Obstetric Management in Gestational Diabetes

doi:10.2337/dc07-s212

Obstetric Management in Gestational Diabetes

Deborah L. Conway, MD

From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center–San Antonio, San Antonio, Texas

Address correspondence and reprint requests to Deborah Conway, Assistant Professor, Director, Diabetes in Pregnancy Program, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center–San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78229. E-mail: conway{at}uthscsa.edu

Optimizing outcomes for women with gestational diabetes mellitus (GDM) and their fetuses requires not only careful metabolic management, but also appropriately applied fetal surveillance techniques and thoughtful selection of the most advantageous timing and route of delivery. Whenever possible, these clinical decisions should be based on the highest level of evidence available and should weigh the likelihood and seriousness of both maternal and fetal/neonatal morbidity. In areas where high-level evidence is lacking, resources should be channeled to designing and implementing clinical studies to get at good answers. In this review, we examine what new information exists in the area of obstetric care of women with GDM since the time of the Fourth International Workshop-Conference in 1997 and highlight areas where there remains a need for sound evidence on which to base practice guidelines.

The summary statement from the 1997 Workshop-Conference remarked that “the lack of data from controlled clinical studies on which management recommendations can be based was a prominent theme of discussion regarding antepartum management of GDM” (1). In the end, consensus was reached in the following areas of obstetric management:

Fetal surveillance:

All women with GDM should monitor fetal movements during the last 8–10 weeks of pregnancy and report immediately any reduction in the perception of fetal movements.
Non-stress testing should be “considered” after 32 weeks’ gestation in women on insulin and “at or near” term in women requiring only dietary management.
Biophysical profile testing and Doppler velocimetry to assess umbilical blood flow “may be considered” in cases of excessive or poor fetal growth, or when there are comorbid conditions, such as preeclampsia.
Ultrasound should be used to detect fetal anomalies in women with GDM diagnosed in the first trimester or with fasting glucose levels >120 mg/dl.
Amniocentesis to determine fetal lung maturity in preparation for delivery is not necessary …