Current Management of Gestational Diabetes Mellitus

Guido Menato; Simona Bo; Anna Signorile; Marie-Laure Gallo; Ilenia Cotrino; Chiara Botto Poala; Marco Massobrio

Disclosures

Expert Rev of Obstet Gynecol. 2008;3(1):73-91. 

In This Article

Intrapartum Management

The goal of intrapartum management is to maintain normoglycemia in order to prevent neonatal hypoglycemia. Patients with diet-controlled diabetes will not require intrapartum insulin and may simply need glucose level monitoring on admission for delivery. During the labor patients with insulin-requiring diabetes need capillary hourly monitoring of blood glucose levels. Target values are 80-110 mg/dl.[110]

Published protocols for intrapartum management of patients with insulin requiring diabetes recommend low-dose insulin infusion. These guidelines are based on small case series and observational studies.[110] The only published comparative trial evaluated intravenous insulin versus CSII for the management of patients with insulin requiring diabetes in labor. The study showed the continuous pump to be superior in achieving and maintaining metabolic control. Golde et al. demonstrated that 48% of diabetic patients did not require insulin in labor.[109]

A study validated these findings and suggests that supplemental 5% dextrose in active labor when the maternal glycemia is below 100 mg/dl is sufficient. For blood glucose concentrations exceeding 100 mg/dl, no dextrose is included in the intravenously administered solution. If the blood glucose level increases above 120 mg/dl, 2-4 U of regular insulin is given by intravenous push every hour that the blood glucose concentration is above 120 mg/dl.[110] A recent randomized clinical trial evaluated that there is no difference in mean maternal intrapartum capillary blood glucose whether patients with insulin-requiring diabetes were placed on maintenance dextrose intravenous fluids and a concurrent adjusted insulin drip or their fluids were rotated between glucose-containing and nonglucose-containing intravenous fluids. Either method seems adequate to control maternal blood sugar in labor or there was no difference in neonatal outcomes.[111]

After birth, the infant of a patient with GDM should be observed closely for hypoglycemia, hypocalcemia and hyperbilirubinemia.[15] Neonatal hypoglycemia occurs more often in pregnancies complicated by GDM, resulting in possible coma or even death if undetected. A study observed a 24% prevalence of neonatal hypoglycemia in infants born from GDM mothers, despite treatment during pregnancy; no cases were observed in a nondiabetic control group.[93]

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