A randomized controlled clinical trial will be conducted in KasrELAiny hospitals, Cairo University and Beni-Suef University Hospital, including 80 uncontrolled diabetic pregnant women (type I) in the 3rd trimester (28-32 weeks of pregnancy) divided equally into study group and control group, to compare the usage of both metformin and insulin instead of using insulin alone. Group assignment will be randomized by computer program.

A total of 80 uncontrolled diabetic pregnant patients in the 3rd trimester seeking medical advice in Beni-Suef University Hospital and meet the eligibility criteria, are approached about participation in the trial and given information pamphlets describing the study. The patients are asked to sign a consent form and will be assigned to one of the 2 groups: Group A (study group); will include 40 patients who will be treated with metformin

(1 gm twice daily (with the 2 main meals)), combined with insulin therapy Group B (control group); will include 40 patients who will be treated with insulin alone. (Insulin dosage will be adjusted according to endocrinological recommendations) All patients will be managed according to NICE guidelines for diabetes with pregnancy (2015) Maternal assessment

• Full history taking Baseline medical history is obtained along with other baseline demographics and concomitant medications including insulin regimen and dose.

• Thorough clinical examination Maternal weight, height and blood pressure measured and recorded.

• Laboratory investigations;

  • Routine labs: CBC, coagulation profile, liver and kidney function at time of participation, 28-32 weeks of gestation especially renal parameter serum Creatinine.
  • HbA1c at time of 1st examination.
  • FBS, 2h post prandial blood sugar will be done weekly from time of participation till time of delivery

• Fundus examination for early detection of retinal affection at Ophthalmology clinic

Follow up:

1. Fetal weight gain weekly
2. Maternal weight gain weekly

Accordingly:

1. Uncontrolled cases will follow up weekly in the High Risk Pregnancy outpatient clinic until 36 weeks and then admitted to High risk pregnancy department for termination of pregnancy

   o Fetal surveillance will be done by ;CTG weekly, Ultrasound weekly and Fetal kick count daily

2. Resistant uncontrolled cases will be admitted to high risk pregnancy department where capillary blood sugar will be measured 7 times daily Fetal surveillance will be done by ; CTG Daily, Ultrasound every 3 days and Fetal kick count daily

Assessment of Patients at time of termination by:

1. Fasting blood sugar , 2 hours post prandial blood sugar and HBA1C
2. Routine preoperative labs. CBC, coagulation profile, liver and kidney function
3. Fetal weight
4. Maternal weight Neonatal assessment after delivery include the following; APGAR score, neonatal weight, incidence of transient tachypnea of newborn (TTN), acute respiratory distress syndrome (ARDS), neonatal hypoglycemia and NICU admission.

Inclusion Criteria:

• Diabetic pregnant patients with type one diabetes and no other chronic disorders
• Patients on insulin in the 3rd trimester of pregnancy (on insulin therapy since start of gestation)
• Patients pregnant in single living fetus with no apparent congenital anomalies
• Haemoglobin A 1 C (HbA1c) level between 7% to 11%
• All patients have done a dating ultrasound to confirm gestational age, viability and rule out any abnormality

Exclusion Criteria:

• Patients with type 2 or gestational diabetes
• Patients with intolerance or hypersensitivity to metformin
• Patients with congestive heart failure or a history of congestive heart failure
• Patients with renal insufficiency
• Patients having current significant gastrointestinal problems such as severe vomiting requiring intravenous fluids or hospitalization
• Presence of acute or chronic metabolic acidosis, including diabetic ketoacidosis, a history of diabetic ketoacidosis or history of lactic acidosis
• Patients with liver impairment
• Patients with known higher order pregnancies (twins, triplets, etc.)
• Patients having a known potentially fetal lethal anomaly