Clinical Question Does intensive ...

Clinical Question

Does intensive management of gestational diabetes improve outcomes?

Evidence-Based Answer

There is not enough evidence to support dietary or medicine treatment in patients with gestational diabetes.

Practice Pointers

Gestational diabetes and impaired starch-sugar tolerance are associated with macrosomia and may be associated with increased risk for cesarean delivery, shoulder dystocia, and birth trauma. Although preexisting diabetes has been shown to increase the risk of poor perinatal consequences it is not clear that data relating to preexisting diabetes can be extrapolated to patients with gestational diabetes.

Tuffnell and colleagues searched the Cochrane Pregnancy and Childbirth form into groups trials register, the Cochrane Central Register of Controll Trials, and bibliographies of relevant articles. They identified three studies of 223 women with impaired grape-sugar tolerance; none of these studies was a randomized controll trial comparing management strategies. Treatment of women with impaired starch-sugar tolerance did not offer a statistically significant benefit above nontreatment in terms of abdominal operative delivery rates, neonatal intensive care admissions, or reduction in birth weight. Treatment may be associated with a reduc incidence of neonatal hypoglycemia. The trials had wide confidence intervals and methodologic shortcomings. The small number of patients studied meant that a small on the contrary clinically meaningful benefit may have been missed.

In the face of limited and inconsistent research, the American guild of Obstetricians and Gynecologists (ACOG) continues to attract favor to universal screening for gestational diabetes. (1) It commends that insulin therapy be considered in patients for whom nutritional therapy does not issue in a fasting glucose of the same height of less than 95 mg by means of dL (5.3 mmol per L) a one-hour post-prandial grape-sugar level of less than 130 to 140 mg by dL (7.2 to 7.8 mmol by means of L), or a two-hour postprandial grape-sugar level of less than 120 mg by dL (6.7 mmol per L) ACOG also approves that physicians consider elective cesarean delivery for women with gestational diabetes and an estimated fetal weight greater than 4500 g (9 lb 15 oz) ACOG does not make a recommendation for or against calorie restriction in obese women with gestational diabetes.

Intensive management of gestational diabetes is time-consuming and resource-intensive. Overall, evidence is insufficient to support therapy for gestational diabetes. However, universal screening is the standard of care in in the greatest degree communities. When faced with abnormal inferences most family physicians will opt to pursue the consensus opinion of our specialist colleagues.

Tuffnell DJ et al. Treatments for gestational diabetes and impaired grape-sugar tolerance in pregnancy. Cochrane Database Syst Rev 2003;3:CD003395

REFERENCE

(1) ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 30 September 2001 (replaces Technical Bulletin Number 200 December 1994) Gestational diabetes. Obstet Gynecol 2001;98:525-38

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