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

Expert Commentary & Five-year View

Approximately 5-10% of pregnancies are complicated by gestational diabetes, with short- and long-term repercussions for both mother and child. During pregnancy, a suitable therapy of this disease, maintaining adequate blood glucose levels, reduces morbidity of both mother and child.[90]

Diet represents the mainstay for glycemic control, eventually in association with physical exercise not recommended routinely.[31] It is suitable to resort to pharmacologic therapy when diet is not sufficient.

Insulin is the key to treatment. In the last few years, new types of synthetic insulins have been introduced beside traditional insulins; the use of insulin aspart and lispro has been approved during pregnancy[14,51] for insulin glargine, even if the existing limited studies in pregnancy do not show any contraindications. Finally, for insulin glulisine and detemir there is as yet, no data regarding use in pregnancy.[53]

The use of the rapidly acting insulin analogues seems more effective in post-prandial hyperglycemia control and in the reduction of hypoglycemic episodes compared with the use of traditional insulin.[49] Conventionally, there are two methods to administer insulin: subcutaneous MDI and CSII. There is no strong evidence to support the use of a particular form of insulin administration over another for pregnant women with diabetes.[61,62]

Even if some studies report the use of oral antidiabetic agents during pregnancy with an effectiveness similar to the one of insulin therapy, the routine use is not recommended because of the necessity of randomized clinical trials with long-term follow-up for both mother and child.[14] At present the use of acarbose, thiazolidinediones, glinides and glucagon-like peptide 1 agonists is contraindicated during pregnancy.[14,64] There are no indications to induce the labor before 40 weeks of gestation in cases of good glycemic control and without maternal or fetal complications.[37]

Some studies suggest the induction of the labor at 38-39 weeks in the case of insulin-treated GDM patients or when the ultrasound exam shows signs of fetal macrosomia, even if there is no universal recommendation.[100] At present there is only one study that recommends the use of amniocentesis in the third-trimester to highlight the presence of a possible fetal hyperinsulism. The identification of fetal hyperinsulism involves the intensification of maternal insulin therapy.[106,107] There is no evidence to recommend amniocentesis in order to value the fetal lung maturity.[14]

In the case of diet-controlled GDM it is not necessary to monitor blood glucose levels periodically during labor and delivery, but when insulin treatment was previously established, it is necessary to control the glycemic values periodically in order to maintain them between 80 and 110 mg/dl.[108] Women with gestational diabetes rarely require insulin in the postpartum period and approximately 15% of those remain glucose intolerant or demonstrate overt diabetes in the postpartum state. Published studies show that after GDM, 10-50% of women develop Type 2 diabetes within 5 years.[113] Therefore, accurate diagnosis of glucose abnormalities permits the beginning of strategies for primary prevention of diabetes, hypertension and CVD, a primary goal of follow-up care.[14]

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