Journal of Perinatology (2008) 28, 657664

r 2008 Nature Publishing Group All rights reserved. 0743-8346/08 $30

www.nature.com/jp

STATE-OF-THE-ART

Gestational diabetes: diagnosis and management

YW Cheng and AB Caughey
Department of Obstetrics and Gynecology, University of California, San Francisco, CA, USA

Purpose: To review the diagnosis and management of gestational diabetes.

Epidemiology: In the United States, approximately 2 to 5% of all

pregnant women have gestational diabetes. Those women with a family
history of type 2 diabetes mellitus, Asian or native American race, Latina
ethnicity or obesity are at higher risk for developing gestational diabetes.
Conclusion: Women with gestational diabetes who are treated
appropriately can achieve good outcomes in the majority of pregnancies.
Frequent blood glucose monitoring, nutrition counseling and frequent
physician contact allow for individualized care to achieve optimal
outcomes. Such treatment includes diet, exercise and insulin. The use of
oral hypoglycemic agents is controversial and there is some concern
about worse maternal and neonatal outcomes as compared to treatment
with insulin. Evolving technologies promise to provide more therapeutic
options.
Journal of Perinatology(2008) 28, 657664; doi:10.1038/jp.2008.62;
published online 17 July 2008
Keywords: gestational diabetes mellitus; screening; diagnosis;
management

Introduction
In the United States, approximately 2 to 7% of all pregnant women
have gestational diabetes mellitus (GDM).1 However, challenges
remain in caring for the pregnant patients with diabetes,
particularly those with poor glycemic control. Thus, effective
management of both the pregnancy and diabetes is essential. This
article reviews current recommendations for the diagnosis and
management of GDM.
Even in women without diabetes, pregnancy induces insulin
resistance and reduced sensitivity to insulin action resulting from
hormones produced by the placenta, in particular, human
placental lactogen or human chorionic somatomammotropin as
well as growth hormone and corticotropin releasing hormone.2,3 In
women with marginal insulin secretory capacity, decreased insulin
Correspondence: Dr AB Caughey, Department of Obstetrics and Gynecology, Division of
Maternal-Fetal Medicine, University of California, San Francisco, 505 Parnassus Avenue,
Box 0132, San Francisco, CA 94143, USA.
E-mail: abcmd@berkeley.edu
Received 12 November 2007; revised 18 March 2008; accepted 14 April 2008; published online
17 July 2008

suppression of hepatic glucose production, and/or already impaired

insulin sensitivity, a hyperglycemic syndrome resembling type 2
diabetes ensues GDM.4,5 As levels of the diabetogenic placental
hormones increase with placental size, gestational diabetes is
usually not present until well into the second or third trimester of
pregnancy. Of note, because of increased placental mass, women
with multiple gestations have both a higher risk of gestational
diabetes and it may present earlier.

Gestational diabetes mellitus

Gestational diabetes mellitus is defined as glucose intolerance with
the onset or first detection during pregnancy.6,7 Most commonly, it
has been reported that gestational diabetes complicates approximately
5 to 7% of all pregnancies, thus accounting for more than 200 000
pregnancies annually in the United States.1,8 Major risk factors for
developing GDM include increasing maternal age, family history of
diabetes, history of GDM in a prior pregnancy, history of macrosomia
and increased pregravid body mass index.9 GDM is more common
among Asian, Hispanic/Latina and native American women.9
Although early studies demonstrated an increased risk among AfricanAmerican women,10 these differences appeared to dissipate when
confounders, such as obesity, were controlled for.11
Gestational diabetes mellitus has been associated with increased
maternal perinatal morbidity (resulting from increases in cesarean
deliveries and forceps or vacuum extraction, as well as third- and
fourth-degree perineal lacerations), principally through its
association with fetal macrosomia.1214 Macrosomia is also
associated with an increased risk of adverse neonatal outcomes,
such as shoulder dystocia, brachial plexus injuries and clavicular
fracture.12,15 Additionally, because of differences in biometrics,
infants of pregnancies complicated by diabetes are at increased risk
of shoulder dystocia when compared to infants with same
birthweight but of pregnancies not complicated by diabetes.
Such risk of shoulder dystocia is particularly present if fetal
head-to-abdominal asymmetry is noted by sonographic estimates.16
They appear to carry the same risk as an infant from a nondiabetic
pregnancy who weighs 250 g more.17
In addition to the adverse outcomes associated with
macrosomia, women with gestational diabetes have a higher rate
of developing preeclampsia.18,19 In pregnancies truly complicated

Gestational diabetes
YW Cheng and AB Caughey

658

by GDM, as opposed to pregestational diabetes, neonates should not

have a higher risk of congenital anomalies. However, because of
the metabolic effects of hyperglycemia in the third trimester, they
do carry increased risk of hypoglycemia, respiratory distress
syndrome, neonatal jaundice and hypocalcemia.20,21
Besides the immediate adverse neonatal outcomes associated
with hyperglycemia in pregnancies complicated by unrecognized or
poorly controlled gestational diabetes, long-term impact of GDM on
early childhood and beyond is evident. The prevalence of metabolic
syndrome, defined by the presence of obesity, hypertension,
dyslipidemia and glucose intolerance, was evaluated in a
longitudinal cohort of children from age 6 through 11. The
prevalence of having three or more components of metabolic
syndrome by age 11 was 15% for those children born large for
gestational age in women with gestational diabetes, compared to
3.0 to 5.3% when born average for gestational age in women with
or without GDM as well as large for gestational age without GDM.22
Other studies have also validated that childhood obesity and
impaired glucose tolerance is associated with increased birth
weight, maternal obesity and gestational diabetes.2325
Screening for GDM
The concept of screening for GDM in pregnant women using an
oral glucose load was first introduced by OSullivan and Mahan in
1973.26,27 Although the original goal was to identify a subset of
pregnant women at increased risk for developing type 2 diabetes
later in life, it was observed that gestational diabetes may be
associated with perinatal mortality.28
Currently, the American College of Obstetricians and
Gynecologists (ACOG) recommends that all pregnant women
should be screened for GDM, either by clinical history or by
laboratory testing.6 Clinical screening involves the evaluation of
patients clinical history and risk factors and then administration
of oral glucose challenge test only to those who are at increased
risk. However, it has been reported that screening for GDM based
on risk factors alone only captures approximately 50% of the cases
of GDM,29 and thus, most clinicians practice universal screening of
prenatal patients. The 50 g oral glucose challenge test is the most
commonly used laboratory screening modality for GDM in the
United States. Depending on the screening threshold utilized,
varying sensitivities can be achieved. For example, using 130 mg
per 100 ml achieves a 99% sensitivity with a 22% screen-positive
rate, whereas a 140 mg per 100 ml threshold achieves an 80%
sensitivity with a 13% screen-positive rate.6
While the ACOG advocates universal screening, the American
Diabetes Association (ADA) recommends risk-based screening, with
those at high risk of GDM (marked obesity, personal history of
GDM, glycosuria, high-risk racial/ethnic groups or a strong family
history of diabetes) receiving glucose challenge test as soon as
feasible; those with average risk should be screened between 24 to
28 weeks gestation and those with low risk need not be tested.8 To
Journal of Perinatology

be considered low risk, a women has to meet all of these

characteristics: age <25 years, weight normal before pregnancy,
members of an ethnic group with a low prevalence of GDM, no
known diabetes in first-degree relatives, no history of abnormal
glucose tolerance and no history of poor obstetric outcomes.8,30 In
1999, a study demonstrated that if only pregnant patients meeting
these ADA criteria were screened, 97% of GDM would be diagnosed.
However, only 10% of patients would go unscreened.31 In another
study that directly compared the detection rate and false-positive
rate of universal versus risk-based screening using a complex
screening strategy in which risk scores for GDM were assigned
based on age, body mass index, and race, the detection rate of GDM
remained approximately 80% for both strategies with a minimal
reduction in false-positive rate using the complex algorithm of
selective screening that may be impractical in clinical setting.32
Although the US Preventive Services Task Force indicates that
better quality evidence is needed to support universal screening,33
currently 94% of providers in the United States screen all pregnant
women.34 Whereas the selective screening may be appropriate for a
population with a low prevalence of GDM, a 2001 Practice Bulletin
from the ACOG notes that only a small percentage of patients meet
criteria as low risk in the United States. Thus, universal screening
using 50 g 1-h glucose loading test (GLT) may be a more practical
approach.6
Establishing a threshold for further confirmatory testing of GDM
has been a matter of some controversy. Coustan et al.35
demonstrated that by using the 50-g 1-h GLT with a threshold of
140 mg per 100 ml, only 80% of GDM would be diagnosed, with a
13% screen-positive rate. However, if a threshold of 135 mg per
100 ml is used, 98% of GDM is diagnosed, but up to one in five
patients will be subjected to the 3-h test.33 Near 100% sensitivity
can be achieved utilizing a screen of 130 mg 100 ml, but this
would be with 22% of individuals having a positive screening test.
Another area of controversy is whether the same screening test
should be used for all patients. One recent study that examined the
screening test properties of the 50 g 1-h glucose challenge test for
GDM among various ethnic groups found that the testing
characteristics varied among women from different races/
ethnicities (Table 1).36 For example, if the goal was to achieve a
95% sensitivity, a screen-positive threshold of 135 mg per 100 ml
could be used among African-American women, but 132 or 133 mg
per 100 ml would be used in other ethnicities. If the goal was to
keep false positives to <10%, 140 mg per 100 ml would be an
adequate threshold for Caucasians, 135 mg per 100 ml for African
Americans, but the threshold would need to be higher for Latinas
and Asians.36
One question that clinicians often encounter is whether there
exists a threshold of GLT high enough that the diagnosis of GDM
can be assumed without performing the 3-h glucose tolerance test
(GTT). Despite a markedly elevated 1-h GLT >180 or >200 mg per
100 ml, nearly one in five women may still be ruled out for GDM

Gestational diabetes
YW Cheng and AB Caughey

659
Table 1 Gestational diabetes: screening21
GLT (mg per
100 ml)
Caucasian
African American
Latina
Asian

130 sensitivity%
(specificity%)
99.5
98.8
98.3
98.5

(82.5)
(88.4)
(80.9)
(75.9)

135 sensitivity%
(specificity%)
93.9
96.5
94.1
93.0

(87.1)
(91.1)
(85.5)
(81.1)

140 sensitivity%
(specificity%)
89.2
92.9
89.9
88.8

145 sensitivity%
(specificity%)

(90.7)
(93.8)
(88.7)
(86.0)

75.6
81.2
78.2
79.8

(92.9)
(96.0)
(91.1)
(89.0)

150 sensitivity%
(specificity%)
66.2
70.6
65.6
69.0

(95.0)
(97.0)
(93.5)
(91.8)

Abbreviation: GLT, glucose loading test.

Esakoff et al.36

Table 2 Two diagnostic criteria of gestational diabetes using a 75 g 2-h oral

glucose tolerance test

Table 3 Two diagnostic criteria of gestational diabetes using a 100 g 3-h oral
glucose tolerance test

Status

World Health Organization (WHO)

American Diabetes Association

Status

Carpenter/Coustan
(mg per 100 ml)

National Diabetes Data Group

(mg per 100 ml)

Fasting
1h
2h

126 mg per 100 ml

F140 mg per 100 ml

95 mg per 100 ml
180 mg per 100 ml
155 mg per 100 ml

Fasting
1h
2h
3h

95
180
155
140

105
190
165
145

Abbreviations: ADA, American Diabetes Association; GDM, gestational diabetes mellitus

WHO diagnosis of GDM: fasting or 2-h value exceeding thresholds.
ADA diagnosis of GDM: two or more values exceeding thresholds.

with a negative 100 g 3-h oral GTT. However, these women have
been demonstrated to experience worse perinatal outcomes.37,38
Perhaps, the more important question becomes who is at risk for
perinatal morbidity, and treating women with a markedly elevated
GLT as if they have a diagnosis of GDM without further
administration of the confirmatory 3-h GTT may actually lead to
better outcomes.
Diagnosis of GDM
Gestational diabetes mellitus can be diagnosed with a fasting blood
glucose of 126 mg per 100 ml and greater or a random blood
glucose of 200 mg per 100 ml and greater, similar to type 2
diabetes mellitus.8,30 Outside the United States, a 75 g 2-h GTT is
widely used, with two different diagnostic criteria established by the
ADA as well as the World Health Organization (Table 2).8,39 Despite
the differences in diagnostic criteria established by the ADA or the
World Health Organization, however, both are able to identify
women at risk of complications associated with GDM.40
In the United Sates, the 100 g 3-h oral GTT is often used
following a positive screening test. Two different diagnostic criteria
were established, the Carpenter/Coustan (based on venous plasma
glucose values) and the more stringent National Diabetes Data
Group (NDDG) thresholds (based on whole blood; Table 3).6,41 The
ADA and various experts on GDM both recommend using the more
inclusive Carpenter/Coustan diagnostic criteria for the diagnosis of
GDM.30,42 As the Carpenter/Coustan criteria are more inclusive, it
captures more of the women at risk for perinatal complications
associated with GDM.43 To examine whether the 100 g 3-h GTT
could be simplified by omitting the third-hour value, two studies

Two or more of the venous plasma concentrations must be met or exceeded for a positive
diagnosis. The test should be carried out in the morning after an overnight fast of
between 8 and 14 h and after at least 3 days of unrestricted diet (X150 g carbohydrate/
day) and unlimited physical activity. The subject should remain seated and should not
smoke throughout the test.

report the sensitivity of the 3-h GTT was reduced to approximately

90%, misclassifying some women with GDM as normal glucose
tolerance.37,44
What about those women with a positive GLT who subsequently
ruled out for GDM? Are they truly risk-free? Two recent studies
found that women with an abnormal GLT but negative GTT still
had higher risk of preeclampsia, cesarean delivery, macrosomia,
shoulder dystocia, and neonatal morbidities that are often
associated with poor glycemic control.45,46 As Carpenter and
Coustan so eloquently stated, the relationship between carbohydrate
intolerance and adverse perinatal outcome is a continuous one,
and no single cutoff can truly separate those at high risk and those
at no risk at all.47 Thus, the cost of screening and diagnosis of
GDM must be weighed against the benefits of treatment to achieve
optimal perinatal outcomes for women with or at risk for GDM.
Management of GDM
The initial management of women with GDM includes education,
diet modifications, light exercise, and assessment of plasma glucose
with self-monitored blood glucose measurements. The glucose levels
should be assessed four times a day (fasting and postprandial) with
the goal of maintaining glycemic levels <95 mg per 100 ml in the
fasting state and <140 mg per 100 ml when 1-h postprandial.48 Of
note, some clinicians utilize 2-h postprandial evaluations with a goal
of <120 mg per 100 ml.49,50 Carbohydrate counting is an important
component of management and should be utilized to obtain a daily
Journal of Perinatology

Gestational diabetes
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660

carbohydrate distribution of 30 to 45 g at breakfast, 45 to 60 g at

lunch and dinner and 15 to 30 g for mid-morning, afternoon, and
evening snacks. Light exercise after each meal, as simple as a 15-min
walk, can help reduce postprandial values to the normal range.
Utilizing a combination of these management schemes has been
demonstrated to reduce maternal and neonatal morbidity, even in
GDM patients with mild insulin resistance.51 In addition, an
ultrasound examination at 36 weeks gestation for an estimated fetal
weight (EFW) may be obtained. Depending on these findings in
women who have not required medical intervention with insulin or
oral agents, commonly, such pregnancies are managed expectantly
until the due date. With a finding of impending macrosomia, some
clinicians will offer induction of labor. Whereas such an intervention
has not been shown to change the risk of cesarean delivery, earlier
induction has been associated with lower birth weight.52
If diet and exercise fail to maintain self-monitored glycemia at
<95 mg per 100 ml (fasting plasma glucose) and <140 mg per
100 ml (1 h postprandial), standard of care is to initiate subcutaneous
insulin therapy. Free insulin does not cross the placenta, therefore, no
particular risks of such therapy need to be considered other than
accidental insulin overdose leading to maternal hypoglycemia.6 In
fact, patients can be counseled that the glucose does cross the
placenta leading to metabolic problems in the fetus and neonate,
which is precisely what is being prevented by insulin therapy. There is
no particular data comparing the efficacy of the multitude of feasible
insulin regimens. Most commonly, we utilize neutral protamine
hagedorn (NPH) insulin at bedtime to control elevated fasting blood
glucose values and fasting acting humalog (Lispro) insulin to control
breakfast and dinner hyperglycemia. For lunchtime hyperglycemia,
either a pre-lunch humalog insulin dose can be used or a dose of
NPH insulin given at the same time as the prebreakfast humalog
insulin dose. The former carries no risk of mid-morning hypoglycemia,
but lacks the convenience of not having to give a midday injection.
Regular insulin, which has a 30 min onset of action that peaks
at approximately 2 h, is less efficient in the management of
diabetes mellitus. Particularly in gestational diabetes, regular
insulin should not be used as it is quite onerous to schedule
injections precisely before meal times. Glargine insulin, which has
an attractive serum profile, one that lacks a peak, has little safety
data in pregnancy in women with gestational diabetes, limited to
one case report of four patients.53 As many gestational diabetics will
have primarily problems with postprandial hyperglycemia, such
insulin probably has only a small role at best in most patients with
gestational diabetes. However, for those women who also require
basal insulin, glargine insulin may lead to better control
throughout the day with less hypoglycemia.
Use of oral agents contraindicated
The use of oral hypoglycemic agents in GDM should still be
considered investigational as there has not been overwhelming
Journal of Perinatology

confirmatory evidence that these agents are either as safe or even

lead to the same level of glycemic control as insulin. While insulin
administration may be time consuming and requires teaching of
insulin injections, oral hypoglycemic agents offer the convenience
of ease-of-use, which may improve compliance. Whereas oral
hypoglycemic agents generally have not been used during
pregnancy due to concerns of teratogenicity and potential neonatal
hypoglycemia associated with their use, studies have shown that
newer generation sulfonylurea crosses the placenta in trace
amount and may be safe during pregnancy.54,55 A study by Langer
et al.56 compared glyburide with conventional insulin therapy in
404 patients with GDM and found that there was no difference in
neonatal outcomes. However, the study was underpowered to
demonstrate a difference between these two groups and actually
demonstrated a trend toward an increase in neonatal complications
in the glyburide-treated group. Since the initial study, several
subsequent retrospective studies have further investigated the use of
glyburide in GDM. The most recent and largest was a study of 584
women reported by Jacobson et al.57 The study compared women
initially managed with insulin versus glyburide. Whereas the study
demonstrated no differences in neonatal birth weight, it did report
higher rates of preeclampsia and higher rates of phototherapy use
in the neonates delivered in the glyburide group. Another recent
study found higher rates of macrosomia and neonatal
hypoglycemia in the neonates whose mothers were treated with
glyburide.58 Further, it appears that approximately 20% of women
treated with glyburide will fail this management resulting in less
time to optimally achieve control with insulin.56,59,60
Given the lack of further confirmation on the findings
regarding the safety and efficacy of glyburide by large, randomized
controlled studies and the limitations of observational studies, the
ACOG has designated the use of glyburide in pregnancy to be
experimental.6 Thus, awaiting further evidence on the efficacy of
glyburide, its use for the current treatment of GDM should not be
routine. Additionally, experts recommend that metformin should be
avoided during pregnancy as it does cross the placenta and its use
in pregnancy has not been well studied.48,61 63 Again, the use of
oral hypoglycemia agents in pregnancy should be considered
experimental and reserved for research protocols in which women
undergo formal informed consent. At our institution, the ability of
all women with A2 GDM to self-administer insulin is assessed. We
have found that the vast majority of women, even those with poor
education, lower socioeconomic status, or who do not speak
English are able to safely and adequately utilize insulin to control
their blood glucose levels. However, in women who are homeless,
with otherwise unstable housing and social situations, or simply
too needle-phobic to safely store and inject insulin, we will suggest
beginning glycemic management with glyburide. In this setting,
these women are counseled regarding the investigational nature of
the medication and why it might be a reasonable mode of
treatment to start with in their particular case.

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Antepartum pregnancy management

The protocol at our institution calls for management of A2 GDM
patients, those requiring medical therapy, similar to the
management of patients with pregestational type 2 diabetes.
Antenatal testing is initiated starting at 32 weeks and induction of
labor scheduled at 39 weeks of gestation. As women with A1 GDM,
those on diet control only, without other pregnancy complications
are presumed to have satisfactory glycemic control and thus not at
risk for complications associated with persistent hyperglycemia,
antenatal testing is initiated at 40 weeks and delivery is
recommended by 41 weeks. Again, this is based on the ability to
maintain adequate glycemic control and a normal EFW on
ultrasound obtained at 36 weeks of gestation. There is only one
prospective randomized trial in such women that demonstrated no
difference in cesarean delivery, but less macrosomia, in women
induced at 38 to 39 weeks of gestation.64 Thus, we have utilized
this protocol to guide our counseling of women with respect to the
risks and benefits of induction of labor versus expectant
management of the pregnancy in this setting.
Labor and delivery
Insulin requirements usually decrease during labor as the patient
may be fasting and exerting significant energy. A1 GDM patients
who have not required medical therapy in their pregnancy rarely
require insulin during labor and delivery, unless they were simply
noncompliant and had undiagnosed A2 GDM. For women with A2
GDM, an insulin infusion during labor and delivery is commonly
used to maintain tight regulation of plasma glucose. A sample
regimen for a patient with A2 GDM is shown in Table 4. In
general, during labor, blood glucose values through self-monitored
blood glucose measurements are checked every 2 h and if the
values rise above 120 mg per 100 ml, an insulin drip is begun.
Table 4 Gestational diabetes: labor and deliveryFinsulin drip
A2 GDMa

Follow BS q 12 h
When BS <90 start D5W,
100 cc h
1
When BS >120 start insulin
drip 1.0 U h
1

BS
(mg per 100 ml)

Action (U h
1)

<100

No insulin

100120

0.5

120140
141160
161180
181200
>200

1.0
2.0
3.0
4.0
X5.0 , recheck BG in
30 min, check urine ketones

Abbreviations: BS, blood sugar; GDM, gestational diabetes mellitus; q, every; U unit(s).
a
This regimen will work for a majority of patients, but may need to be individualized.

When labor is induced in the morning, A2 GDM diabetic

patients can take their NPH insulin the prior night. If labor is
induced with prostaglandins, they may take their usual NPH
insulin dose in the morning. If labor is induced with oxytocin, they
should skip the morning NPH dose. The reason for this is that
when in active labor, having a long-acting insulin on board can
lead to hypoglycemia, which can be much harder to correct than
hyperglycemia. Thus, if uncertain, it is usually better to hold longacting insulin in favor of using an insulin drip. In the setting of a
cesarean delivery, patients may take their usual dose of NPH
insulin in the prior evening, but nothing by mouth and no insulin
after midnight.
Postpartum management
Women who experience GDM, particularly those who are
overweight, have a 50% lifetime risk for developing type 2
diabetes.65 Risk factors include obesity, gestational age at diagnosis
of GDM and the degree of abnormality of postpartum glucose tests.
Patients determined to be at risk should be counseled regarding
diet, exercise and weight reduction to delay or prevent the onset of
type 2 diabetes.8
Owing to the high risk of type 2 diabetes in GDM patients,
diagnostic testing for diabetes is appropriate at the time of the 6week postpartum visit.6 It is unclear whether the traditional 75 g 2h oral glucose challenge test or simply a fasting serum glucose
may be more useful at this time. Whereas the oral glucose
challenge test may identify more patients with abnormal
carbohydrate tolerance, it is uncertain that such a test has added
benefit.66 As the ADA is currently using fasting glucose >125 mg
per 100 ml to define type 2 diabetes, and values between 95 and
125 mg per 100 ml to indicate a pre-diabetic condition, this is the
test we recommend. Of note, the ACOG indicates that there may be
advantages in performing the oral GTT as the initial diagnostic test
after pregnancy complicated by GDM.6 Again, it is not entirely clear
what these advantages are other than reinforcing the idea that
these women are at increased risk for eventually developing type 2
diabetes.
Elective cesarean
There is much debate over whether elective cesarean delivery
should be employed in the setting of pregestational or gestational
diabetes for the prevention of birth trauma, specifically shoulder
dystocia and brachial plexus injury. Of note, it has been estimated
that with a threshold of 4500 g in diabetic patients, 443 cesarean
would need to be performed to prevent one brachial plexus
injury.67 Whether this trade-off is worth the increased risks of
cesarean delivery is unclear. The most recent ACOG bulletin on the
topic of macrosomia suggests that in women without diabetes, an
elective cesarean is reasonable with an EFW at 5000 g or above.68,69
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However, they are less clear about what to do in the setting of

macrosomia and diabetes. If one were to utilize the information
that a diabetic patient has an equal risk of shoulder dystocia in a
nondiabetic patient with a birth weight of 250 g higher, then it
seems reasonable to offer an elective cesarean with an EFW of
4750 g or higher. In the technical bulletin itself, ACOG states that a
prophylactic cesarean may be considered in diabetic patients with
an EFW of 5000 g or above. This is not a ringing endorsement of
such a practice pattern, and it is important to stress the impact of
the prophylactic cesarean not only on the current pregnancy, but
on all future pregnancies as well.
At our institution, we offer, but do not recommend, a cesarean
with an EFW of 4500 g or above. In our counseling, we address the
following issues: (1) problems with predicting birth weight using
obstetric ultrasound; (2) the risks of a cesarean delivery in the
current pregnancy including increased bleeding, wound infection
and prolonged recovery time and (3) the risks of a trial of labor in
future pregnancies as well as the increased risk of placenta previa,
accrete and even hysterectomy with multiple cesareans. If a woman
with an EFW of 4500 g or greater decides to undergo a trial of
labor, we follow the labor curve closely and perform operative
vaginal deliveries only if the fetal vertex has descended normally in
the second stage of labor.
Areas for future research
In the future, hopefully larger randomized controlled studies will
be conducted to examine the efficacy of glyburide and other oral
agents such as metformin. Such studies will need to avoid the prior
problems of lack of statistical power and type 2 error. Although it is
common that most institutions utilize universal screening, future
research is also necessary to examine whether there are low-risk
populations that may not require screening. Further, such risk
examination should also determine which groups of women
(stratified by age, race/ethnicity, body mass index and family
history) will benefit from diabetes screening early in pregnancy.
Prospective cohort studies designed to follow-up both women and
neonates after pregnancies complicated by diabetes may also help
to characterize the long-term medical issues in women and their
children. Finally, examination of both the screening test and
diagnostic test thresholds to make certain that all of the higher risk
women are identified with respect to carbohydrate intolerance
should continue with larger, multicenter studies powered to identify
differences in more severe neonatal morbidities.
Regarding technological advances, studies of inhaled insulin
have been conducted and this may become a marketed reality
in the very near future.70 Continuous glucose monitoring systems
are currently used by some patients with type 1 diabetes, and
it remains to be seen whether their use will improve glycemic
control. Meters capable of beaming information to pumps and
regulating insulin injections are being developed. On the surgical
Journal of Perinatology

front, pancreatic transplantation continues to be investigated.71

However, short-term survival is reported to better with the use of
exogenous insulin.72
Conclusion
It is clear that GDM does appear to carry increased risk of perinatal
complications to both the parturient and her fetus/neonate. Such
risks appear to be reduced by glycemic control, which can be
accomplished with diet, exercise or pharmaceutical intervention.
The evolution of technologies and clinical knowledge has made it
possible for such patients to experience pregnancies similar to those
of the normal population, but patient management can be
clinically challenging. Further advances in the near future are
likely to offer physicians and patients more options for achieving
optimal outcomes.
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