Glucose tolerance of offspring of mother with gestational diabetes mellitus in a low-risk population. The Impact of Self-Monitoring of Blood Olucose on Self-Efficacy and Pregnancy Outcomes in Women With Diet-Controlled Gestational Diabetes Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy. A randomized controlled trial of strict glycemic control and tertiary level obstetric care versus routine obstetric care in the management of gestational diabetes: a pilot study. Glycemic control in gestational diabetes mellitus--how tight is tight enough: small for gestational age versus large for gestational age? Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. Costs and consequences of treatment for mild gestational diabetes mellitus – evaluation from the ACHOIS randomised trial Use of an internet-based telemedicine system to manage underserved women with gestational diabetes mellitus. Usefulness of a Breakfast Test in the Management of Women With Gestational Diabetes Continuous glucose monitoring versus self-monitoring of blood glucose in the treatment of gestational diabetes mellitus. Pharmaceutical care of patients with gestational diabetes mellitus. A randomised controlled pilot study of the management of gestational impaired glucose tolerance A randomised controlled trial of dietary energy restriction in the management of obese women with gestational diabetes The Potential Diabetic and Her Treatment in Pregnancy How should clinicians interpret results reflecting the effect of an intervention on composite end points: should I dump this lump? A comparison of glyburide and insulin in women with gestational diabetes mellitus. Exercise in Gestational Diabetes: An Optional Therapeutic Approach? Therapeutic exercise for insulin-requiring gestational diabetics: effects on the fetus — results of a randomized prospective longitudinal study Treatment of women with an abnormal glucose challenge test (but a normal oral glucose tolerance test) decreases the prevalence of macrosomia. Gestational Diabetes Mellitus (GDM): Comparative Evaluation of Two Treatment Regimens, Diet Versus Insulin and Diet
AIMS To describe the prevalence of impaired glucose tolerance and obesity in offspring of mothers whose pregnancies were complicated by gestational diabetes mellitus ( GDM ) in a low-risk population and to investigate the effect on these outcomes of minimal intervention compared with tight control for management of GDM . METHODS Eighty-nine children ( mean age 9.1 years , 93 % Caucasian ) were recruited through a follow-up study of women previously involved in a r and omized controlled trial of minimal intervention ( control group ) vs. tight glycaemic control ( treatment group ) for GDM . Fasting blood glucose ( FBG ) and 2-h glucose tolerance tests ( 2hGTT ) were performed on offspring and body mass index ( BMI ) calculated . Glucose tolerance and BMI of treatment groups were compared using non-inferiority tests ( non-inferiority margin -15 % ) . RESULTS Of those offspring , 6.9 % ( 5/72 ) had abnormal glucose metabolism [ four children had impaired glucose tolerance ( IGT ) and one had Type 2 diabetes mellitus ( DM ) ( all Caucasian ) ] . Of the four children with IGT , three were male , three had normal BMI , and three had a family history of Type 2 diabetes . Of the 71 offspring who underwent 2hGTT , 25/25 ( 100 % ) of the control offspring and 46/46 ( 100 % ) of the treatment offspring had normal FBG ( FBG < 5.7 mmol/l ) . Twenty-five of 25 ( 100 % ) of control and 42/46 ( 91.3 % ) of the treatment offspring had normal glucose tolerance ( 2hGTT < 7.8 mmol/l ) ( % difference 8.7 , 95 % CI -5.6 , 20.3 ) . BMI < 85th percentile was found in 25/33 ( 75.8 % ) of the treatment group and 44/52 ( 84.6 % ) of the control group ( difference in percentage -8.9 , 95 % CI -27.2 , 7.8 ) . CONCLUSIONS School-age children of mothers with GDM are at risk of IGT and overweight , even if from a low-risk ethnic population . FBG was not adequate for screening this population . Minimal intervention for glycaemic control in GDM pregnancies appears to be as effective as tight control for preventing IGT in childhood but not for preventing obesity PURPOSE The purpose of this study was to examine the effects of self-monitoring of blood glucose ( SMBG ) on feelings of self-efficacy , dietary compliance , and pregnancy outcomes in women with diet-controlled gestational diabetes mellitus ( GDM ) . METHODS Fifty-eight women with GDM and a fasting blood glucose level < 95 mg/dL were r and omly assigned to 2 groups . The experimental group measured their blood glucose levels 4 times daily using a reflectance meter with memory . Metabolic status  was assessed in the control group by periodic monitoring at prenatal visits . Otherwise the management protocol was identical for both groups . The Diabetes Empowerment Scale was completed at study entry and at 37 weeks gestation to assess feelings of self-efficacy .  Dietary compliance was assessed at each visit . RESULTS Both groups of women achieved excellent glucose control ; only 1 woman in each group required insulin therapy . There were no significant differences with regard to feelings of self-efficacy , dietary compliance , birth weight , gestational age at delivery , Apgar scores , and neonatal complications . Rates of macrosomia , delivery by cesarean section , and occurrence of birth trauma were similar . CONCLUSIONS SMBG appears to have little effect on maternal feelings of self-efficacy , dietary compliance , or pregnancy outcomes in women with diet-controlled GDM BACKGROUND The fetuses of women with gestational diabetes mellitus are at risk for macrosomia and its attendant complications . The best method of achieving euglycemia in these women and reducing morbidity in their infants is not known . We compared the efficacy of postpr and ial and prepr and ial monitoring in achieving glycemic control in women with gestational diabetes . METHODS We studied 66 women with gestational diabetes mellitus who required insulin therapy at 30 weeks of gestation or earlier . The women were r and omly assigned to have their diabetes managed according to the results of prepr and ial monitoring or postpr and ial monitoring ( one hour after meals ) of blood glucose concentrations . Both groups were also monitored with  fasting blood glucose measurements . The goal of insulin therapy was a prepr and ial value of 60 to 105 mg per deciliter ( 3.3 to 5.9 mmol per liter ) or a postpr and ial value of less than 140 mg per deciliter ( 7.8 mmol per liter ) . Obstetrical data and information on neonatal outcomes were collected . RESULTS The prepregnancy weight , weight gain during pregnancy , gestational age at the diagnosis of diabetes and at delivery , degree of compliance with therapy , and degree of achievement of target blood glucose concentrations were similar in the two groups . The mean ( + /- SD ) change in the glycosylated hemoglobin value was greater in the group in which postpr and ial measurements were used ( -3.0 + /- 2.2 percent vs. 0.6 + /- 1.6 percent , P < 0.001 ) and the infants ' birth weight was lower ( 3469 + /- 668 vs. 3848 + /- 434 g , P = 0.01 ) . Similarly , the infants born to the women in the postpr and ial-monitoring group had a lower rate of neonatal hypoglycemia ( 3 percent vs. 21 percent , P = 0.05 ) , were less often large for gestational age ( 12 percent vs. 42 percent , P = 0.01 ) and were less often delivered by cesarean section because of cephalopelvic disproportion ( 12 percent vs. 36 percent , P = 0.04 ) than those in the prepr and ial-monitoring group . CONCLUSIONS Adjustment of insulin therapy in women with gestational diabetes according to the results of postpr and ial , rather than prepr and ial , blood glucose values improves glycemic control and decreases the risk of neonatal hypoglycemia , macrosomia , and cesarean delivery OBJECTIVES The purpose of this study was to determine whether strict maternal glycemic control for the treatment of gestational diabetes lessened the risk of fetal macrosomia , birth trauma , neonatal hypoglycemia , and operative delivery . The aim of the pilot study was to prepare for a multicenter trial by assessing patient acceptance of the study , by determining realistic accrual rates , and by detecting any major adverse outcomes in the control group that received routine obstetric care . STUDY DESIGN The study was a prospect i ve r and omized controlled trial comparing fetal-neonatal and maternal outcomes in 300 women with gestational diabetes . Women r and omized to the treatment arm were managed by strict glycemic control and tertiary level obstetric care , and women in the control arm received routine obstetric care . RESULTS Three hundred women with gestational diabetes mellitus were studied . There was no difference in maternal age , weight , or length of gestation between groups . The treatment mean birth weight was 3437 + /- 575 gm compared with 3544 + /- 601 gm in the control group , a difference of 107 gm ( not significant ) . Macrosomia rates were similar . There was no birth trauma in either group . The frequency of neonatal hypoglycemia and other metabolic complications was the same . The mode of delivery also showed similar patterns . The treatment group had significantly lower prepr and ial and postpr and ial glucose levels by 32 weeks ' gestation , which continued to term . CONCLUSION This pilot study suggests that intensive treatment of gestational diabetes mellitus may have little effect on birth weight , birth trauma , operative delivery , or neonatal metabolic disorders . It has demonstrated the safety of proceeding to a multicenter trial of sufficient sample size to confirm these findings The relationship between optimal levels of glycemic control and perinatal outcome was assessed in a prospect i ve study of 334 gestational diabetic women and 334 subjects matched for control of obesity , race , and parity . All women with gestational diabetes mellitus were instructed in the use of a memory-based reflectance meter . They were treated with the same metabolic goal according to a predetermined protocol . Three groups were identified on the basis of mean blood glucose level throughout pregnancy ( low , less than or equal to 86 mg/dl ; mid , 87 to 104 mg/dl ; and high , greater than or equal to 105 mg/dl ) . The low group had a significantly higher incidence of small-for-gestational-age infants ( 20 % ) . In contrast , the incidence of large-for-gestational-age infants was 21-fold higher in the mean blood glucose category than in the low mean blood glucose category ( 24 % vs. 1.4 % , p less than 0.0001 ) . An overall incidence of 11 % small-for-gestational-age and 12 % large-for-gestational-age infants was calculated for the control group . A significantly higher incidence of small-for-gestational-age infants ( 20 % vs. 11 % , p less than 0.001 ) was found between the control and the low category . In the high mean blood glucose category an approximate twofold increase was found in the incidence of large-for-gestational-age infants when compared with the control group ( p less than 0.03 ) . No significant difference was found between the control and mean blood glucose categories ( 87 to 104 mg/dl ) . Our data suggest that a relationship exists between level of glycemic control and neonatal weight . This information is helpful in targeting the level of glycemic control while optimizing pregnancy outcome in gestational diabetes comparable to the general population BACKGROUND We conducted a r and omized clinical trial to determine whether treatment of women with gestational diabetes mellitus reduced the risk of perinatal complications . METHODS We r and omly assigned women between 24 and 34 weeks ' gestation who had gestational diabetes to receive dietary advice , blood glucose monitoring , and insulin therapy as needed ( the intervention group ) or routine care . Primary outcomes included serious perinatal complications ( defined as death , shoulder dystocia , bone fracture , and nerve palsy ) , admission to the neonatal nursery , jaundice requiring phototherapy , induction of labor , cesarean birth , and maternal anxiety , depression , and health status . RESULTS The rate of serious perinatal complications was significantly lower among the infants of the 490 women in the intervention group than among the infants of the 510 women in the routine-care group ( 1 percent vs. 4 percent ; relative risk adjusted for maternal age , race or ethnic group , and parity , 0.33 ; 95 percent confidence interval , 0.14 to 0.75 ; P=0.01 ) . However , more infants of women in the intervention group were admitted to the neonatal nursery ( 71 percent vs. 61 percent ; adjusted relative risk , 1.13 ; 95 percent confidence interval , 1.03 to 1.23 ; P=0.01 ) . Women in the intervention group had a higher rate of induction of labor than the women in the routine-care group ( 39 percent vs. 29 percent ; adjusted relative risk , 1.36 ; 95 percent confidence interval , 1.15 to 1.62 ; P<0.001 ) , although the rates of cesarean delivery were similar ( 31 percent and 32 percent , respectively ; adjusted relative risk , 0.97 ; 95 percent confidence interval , 0.81 to 1.16 ; P=0.73 ) . At three months post partum , data on the women 's mood and quality of life , available for 573 women , revealed lower rates of depression and higher scores , consistent with improved health status , in the intervention group . CONCLUSIONS Treatment of gestational diabetes reduces serious perinatal morbidity and may also improve the woman 's health-related quality of life Background Recommended best practice is that economic evaluation of health care interventions should be integral with r and omised clinical trials . We performed a cost-consequence analysis of treating women with mild gestational diabetes mellitus by dietary advice , blood glucose monitoring and insulin therapy as needed compared with routine pregnancy care , using patient-level data from a multi-centre r and omised clinical trial . Methods Women with a singleton pregnancy who had mild gestational diabetes diagnosed by an oral glucose-tolerance test between 24 and 34 weeks ' gestation and their infants were included . Clinical outcomes and outpatient costs derived from all women and infants in the trial . Inpatient costs derived from women and infants attending the hospital contributing the largest number of enrolments ( 26.1 % ) , and charges to women and their families derived from a sub sample of participants from that hospital ( in 2002 Australian dollars ) . Occasions of service and health outcomes were adjusted for maternal age , ethnicity and parity . Analysis of variance was used with bootstrapping to confirm results . Primary clinical outcomes were serious perinatal complications ; admission to neonatal nursery ; jaundice requiring phototherapy ; induction of labour and caesarean delivery . Economic outcome measures were outpatient and inpatient costs , and charges to women and their families . Results For every 100 women with a singleton pregnancy and positive oral glucose tolerance test who were offered treatment for mild gestational diabetes mellitus in addition to routine obstetric care , $ 53,985 additional direct costs were incurred at the obstetric hospital , $ 6,521 additional charges were incurred by women and their families , 9.7 additional women experienced induction of labour , and 8.6 more babies were admitted to a neonatal nursery . However , 2.2 fewer babies experienced serious perinatal complication and 1.0 fewer babies experienced perinatal death . The incremental cost per additional serious perinatal complication prevented was $ 27,503 , per perinatal death prevented was $ 60,506 and per discounted life-year gained was $ 2,988 . Conclusion It is likely that the general public in high-income countries such as Australia would find reductions in perinatal mortality and in serious perinatal complications sufficient to justify additional health service and personal monetary charges . Over the whole lifespan , the incremental cost per extra life-year gained is highly favourable . Trial Registration Australian Clinical Trials Registry BACKGROUND Internet technology has been proven to be a successful tool for the management of patients with multiple medical conditions . The purpose of this study was to demonstrate the feasibility of monitoring glucose control in indigent women with gestational diabetes mellitus ( GDM ) over the Internet . METHODS Women with GDM were r and omized to either the Internet group ( n = 32 ) or the control group ( n = 25 ) . Patients in the Internet group were provided with computers and /or Internet access if needed . A website was established for documentation of glucose values and communication between the patient and the health care team . Women in the control group maintained paper logbooks , which were review ed at each prenatal visit . Maternal feelings of diabetes self-efficacy were assessed at study entry and again before delivery . RESULTS Women in the Internet group accessed the system and sent on average 21.8 ( + /- 16.9 ) sets of data . There was no difference between the two groups in regards either fasting or post-pr and ial blood glucose values , although more women in the Internet group received insulin therapy ( 31 % vs. 4 % ; P < 0.05 ) . There were also no significant differences in pregnancy and neonatal outcomes between the two groups . Women in the Internet group demonstrated significantly higher feelings of self-efficacy at the study 's end . CONCLUSIONS The benefit of monitoring blood glucose in indigent women with GDM via the Internet was limited by their infrequent use of the telemedicine system . Although system use was not associated with improved pregnancy outcomes , women in the telemedicine group did experience enhanced feelings of diabetes psychosocial self-efficacy Objective To assess the usefulness of a breakfast test in determining which women with gestational diabetes do not need self-monitoring of  blood glucose levels ( home monitoring ) . Methods a 1-hour post-st and ardized breakfast blood glucose below 7.8 mmol/L ( 140 mg/dL ) was measured in 227 women and at or above 7.8 mmol/L in 115 . Within each group , women were r and omized to home monitoring with a meter or to clinic follow-up . Target glucose values were 5.3 mmol/L ( 95 mg/dL ) fasting , 5.6 mmol/L ( 101 mg/dL ) before meals , and 7.8 mmol/L ( 140 mg/dL ) 1 hour postpr and ial . Up to these thresholds women on clinic follow-up were transferred to home monitoring . Insulin therapy was started on the same thresholds in women r and omized or transferred to home monitoring .  Large ofr gestational age ( LGA ) newborns  represented the main outcome , with the transfer rate to home monitoring and need of insulin therapy the secondary ones . Results The LGA delivery rate was not significantly different in the two follow-up groups in women with a breakfast result below 7.8 mmol/L ( 9.8 versus 4.3 % ) but was higher in the clinic follow-up among women with a breakfast result at or above 7.8 mmol/L ( 13.3 % versus 30.9 % ; P < .05 ) . Fewer women with a breakfast result below 7.8 mmol/L were transferred to home monitoring ( 2.6 versus 52.7 % ; P < .001 ) or started on insulin therapy ( 3.6 versus 25.2 % ; P < .001 ) . The breakfast test cutoff of 7.8 mmol/L predicted insulin need with a sensitivity of 91.0 % and a specificity of 72.0 % . Conclusion A breakfast test is useful in identifying a low-risk population in which clinic follow-up may be used safely OBJECTIVE To compare Continuous Glucose Monitoring System ( CGMS ) with self-monitoring of plasma glucose ( SM ) in detecting patients with gestational diabetes mellitus ( GDM ) needing antidiabetic drug treatment . RESEARCH DESIGN AND METHODS Pregnant women at 22 - 34 gestational weeks had at least two abnormal high values out of three in OGTT . Patients were r and omly allocated to have CGMS ) ( n=36 ) or SM ( n=37 ) . Dietary counselling was similar in both groups . Patients tested their plasma glucose 5 times per day . Need of  antidiabetic treatment  was determined using the following cut-off values : fasting plasma glucose > 5.5mmol/L twice or > 5.5mmol/l once and postpr and ial value>7.8mmol/l , or postpr and ial value at least twice above 7.8mmol/l . RESULTS In 11 out of 36 patients ( 31 % ) monitored with CGMS )  antihyperglycemic drug therapy was introduced ( 8/36 insulin only , 2/36 metformin only , 1/36 insulin+metformin ) whereas only 3/37 ( 8 % ) in the self-monitoring group were drug-treated ( difference between groups , p=0.0149 ) . There were no statistically significant differences between the groups regarding maternal age , pre-pregnancy BMI , HbA1c , gestational weeks at delivery , rate of pregnancy-induced hypertension , rate of caesarean section , infant birth weight or neonatal hypoglycaemia . CONCLUSIONS Continuous glucose monitoring system detects a markedly higher proportion of GDM mothers needing antihyperglycemic medication compared with self-monitoring of plasma glucose . Further large-scale studies are needed to evaluate whether CGMS ) guided initiation of antihyperglycemic therapy results in less macrosomia and perinatal complications related to GDM RATIONALE , AIMS AND OBJECTIVE To investigate whether the introduction of a programme of optimising drug treatment , intensive education and self-monitoring of patients diagnosed with gestational diabetes mellitus ( GDM ) at an early stage ( < 20 gestational weeks ) , will improve management outcomes as determined by objective measures of patient knowledge about diabetes , glycaemia control , maternal/neonatal complications , and health-related quality of life . METHODS The study was a r and omized , controlled , longitudinal , prospect i ve clinical trial performed at Al-Ain Hospital , Al-Ain , United Arab Emirates . Over an 18-month period , patients diagnosed with GDM were recruited and were r and omly assigned to either an intervention or a control group , in a ratio of 3:2 . Intervention patients received a structured pharmaceutical care service ( including education and introduction of intensive self-monitoring ) while control patients received traditional services . Patients were followed up from time of recruitment until 6 months postnatally at scheduled outpatient clinics . A range of clinical and humanistic outcome measures , including maternal and neonatal complications , were used to assess the impact of the intervention . RESULTS A total of 165 patients ( 99 intervention , 66 control ) completed the study . The intervention patients exhibited a range of benefits from the provision of the programme when compared with control group patients . Statistically significant ( P < 0.05 ) improvements were shown in the intervention group for knowledge of diabetes , health-related quality of life ( as determined by the SF36 ) , control of plasma glucose and HbA(1c ) , maternal complications [ e.g. decreased incidence of pre-eclampsia ( 5.1 % vs. 16.7 % ) , eclampsia ( 1.0 % vs. 7.6 % ) , episodes of severe hyperglycaemia ( 3.0 % vs. 19.7 % ) and need for Caesarean section ( 7.1 % vs. 18.2 % ) ] , and neonatal complications [ e.g. decreased incidence of neonatal hypoglycaemia ( 2.0 % vs. 10.6 % ) , respiratory distress at birth ( 4.0 % vs. 15.2 % ) , hyperbilirubinaemia ( 1.0 % vs. 12.1 % ) and large for gestational age ( 9.0 % vs. 22.7 % ) ] . CONCLUSION The research provides clear evidence that provision of pharmaceutical care adds value to the management of GDM as exemplified by improved maternal and neonatal outcomes Objective To determine whether a study of a less intensive form of management for impaired glucose tolerance in pregnancy is feasible and whether women would accept r and omisation Summary : A r and omised controlled trial was design ed to determine the effect of moderate 30 % maternal dietary energy restriction on the requirement for maternal insulin therapy  and the incidence of macrosomia in gestational diabetes .  Although the control group restricted their intake to a level similar to that of the intervention group ( 6845 kiloJoules ( kJ ) versus 6579 kJ ) , the result ing cohort could not identify any adverse effect of energy restriction in pregnancy . Energy restriction did not alter the frequency of insulin therapy ( 17.5 % in the intervention group and 16.9 % in the control group ) . Mean birth weight  ( 3461 g in the intervention group and 3267 g in the control group ) was not affected . There was a trend in the intervention group towards later gestational age at commencement of insulin therapy ( 33 weeks versus 31 weeks ) and lower maximum daily insulin dose ( 23 units versus 60 units ) which did not reach statistical significance . Energy restriction did not cause an increase in ketonemia The purpose of this study was to examine pregnancy outcome in women with abnormal oral glucose tolerance tests , in relation to treatment with diet and insulin . Glucose tolerance tests , done because of well-known historical risk factors , were considered abnormal if two or more readings exceeded the following : fasting , 110 ; 1 hour , 170 ; 2 hours , 120 ; and 3 hours , 110 ( all in mg/100 mL , measured as total reducing substances in whole venous blood ) . Those with positive tests were divided r and omly into a “ positive-control ” group ( n 308 ) that received  st and ard prenatal care or a “ positive-treated ” group ( n 307 ) that received dietary instructions ( 30 kcal/kg ideal body weight , 40 % as carbohydrate , and 1.5–2 g protein/kg body weight ) and insulin ( initial dose 10 U per day of intermediate-acting insulin , adjusted subsequently as directed by blood and urine studies ) , beginning at usually about 32 weeks . A third group ( n 328 ) , termed “ negative controls , ” had exhibited normal glucose tolerance testing . The three groups were similar , except that those with abnormal glucose tolerance tended to be older and heavier , as expected . With respect to outcome , infants with birth weights exceeding 9 lb were three times as frequent in positive-control subjects as in either positive-treated subjects or negative controls ( 13.1 % , 4.3 % , and 3.7 % , respectively ) . Perinatal deaths ( 28 weeks ’ gestation through 14 days after birth ) were similar in the two positive groups ( 4.9 % in control and 4.3 % in treated ) and significantly higher than in negative controls ( 1.9 % ) , with the increase involving both fetal and neonatal components . The conclusions were 1 ) abnormal glucose tolerance during pregnancy leads to larger infants and higher perinatal mortality and 2 ) treatment with diet and insulin ameliorates the former but not the latter . This study concerned what O’Sullivan called potential diabetes and others at the time termed latent or chemical diabetes or prediabetes , but what today we refer to as gestational diabetes . Acceptance of it as a pathologic entity was far from unanimous in 1966 . O’Sullivan resolved the controversy with this large , well- design ed , and well-analyzed clinical trial . The immediate influence was two-fold . In the first place , it settled the existing disagreement as to whether or not impaired glucose tolerance adversely influences pregnancy outcome ; large infants occurred three times as frequently and perinatal deaths were more than doubled in women with abnormal carbohydrate metabolism . Second , the findings of the intervention trial indicated clearly that treatment of gestational diabetes with diet and insulin in late gestation normalizes birth weight ( although it did not seem to influence perinatal mortality ) , a finding confirmed a number of times by subsequent investigators . Incidentally , the frequencies of both fetal and neonatal deaths may seem high , but it needs to be remembered that this experience ante date d the advent of modern fetal surveillance and neonatal intensive care . John B. O’Sullivan , a pioneer in clinical research in gestational diabetes , was an internist . He defined st and ards for the oral glucose tolerance test in pregnancy that , though modified slightly by subsequent investigators , are basically those in use today . Born in 1926 , he received his medical education in his native Irel and before immigrating to the United States in 1955 . After further training in internal medicine at the Lahey Clinic , he took a faculty position at the Boston University School of Medicine , where he did his original work on early diabetes as medical director of the Prenatal Metabolism Clinic at Boston City Hospital and chief of medicine at St. Margaret ’s Hospital . In addition to his position as Associate Professor at Boston University , he also served on the faculties of the Harvard and Yale medical schools . Later he was director of employee health for the Liberty Mutual Insurance Company . He died of cancer in August 2001 In this issue , Evidence -Based Medicine highlights and comments on a l and mark r and omised trial , the ACHOIS trial.1 In this trial , Crowther and her colleagues enrolled 1000 pregnant women with mild gestational diabetes who were either informed of their diagnosis and received treatment  ( including individual dietary advice , instruction on self monitoring of blood glucose concentrations , and insulin therapy as needed ) or informed that they did not have gestational diabetes and assigned routine prenatal care unless subsequent findings suggested diabetes . The ACHOIS trial was design ed to determine the extent to which aggressive treatment of mild gestational diabetes affects outcomes in the mothers ( induction of labor and caesarean section ) and in the infants ( a composite of death , shoulder dystocia , bone fracture , and nerve palsy dubbed “ any serious perinatal complications ” ) . For the maternal outcomes , 189 of 490 ( 39 % ) of mothers in the intervention group and 150 of 510 ( 29 % ) in the routine care group required induction of labour ; 152 ( 31 % ) and 164 ( 32 % ) required caesarean delivery . We will examine the implication s of these results using numbers needed to treat ( NNTs ) under the assumption that all women with mild gestational diabetes are at the same risk of adverse outcomes and that their risk approximates that of the average woman enrolled in the ACHOIS trial ( women at identifiably higher risk of these outcomes would have smaller NNTs , and vice versa ) . While the trial evidence suggests no difference in the rate of caesarean sections , it tells us that for every 11 ( 95 % CI 7 to 31 ) women screened and managed for gestational diabetes , 1 additional woman will require induction of labour . Furthermore , clinicians admitted 357 of 506 ( 71 % ) and 321 of 524 ( 61 % ) infants in the intervention and routine care groups to the neonatal nursery , respectively . Thus , for every 11 Objective To compare the use of glyburide and insulin in the treatment of gestational diabetes . Design R and omized controlled trial . Setting Maternal health clinics in San Antonio , Texas . Patients Women with mild gestational diabetes ( n = 404 ) at 11 - 33 weeks gestation . Only women with a singleton pregnancy were eligible . Intervention Glyburide ( starting dose 2.5 mg , increased as necessary to achieve target glycaemic control to a maximum of 20 mg ) or insulin ( 0.7 U per kg body weight , three times daily , increased as necessary ) . If blood glucose goals were not met after 2 weeks of treatment with the maximal dose of glyburide , treatment was switched to insulin . Main outcome measures Primary outcome was achievement of a desirable level of glycaemic control ( strict target ranges were set for mean , fasting , prepr and ial and postpr and ial blood glucose , measured by frequent home monitoring ) . Neonatal outcomes were also assessed . Main results Eighty-two percent of women in the glyburide group and 88 % of women in the insulin group achieved the target blood glucose values ( difference = -6 % , 95 % confidence interval ( CI ) -13 % to + 1 % , P = 0.07 ) . Considerably less women in the glyburide group had blood glucose values below 40 mg ( 2.2 mmol/l ) per decilitre ( 2 % vs. 20 % , difference -18 % , 95 % CI -24 % to -13 % , P < 0.0001 ) . In the glyburide group , 4 % of women were switched to insulin as the maximal dose failed to produce target blood glucose values . There were no significant differences in neonatal outcomes , including cord serum insulin . Conclusion Treatment of women with gestational diabetes , after the first trimester of pregnancy , with glyburide rather than insulin can achieve similar glycaemic control , with less hypoglycaemia Forty-one patients with gestational diabetes requiring insulin were enrolled in a r and omized study to investigate the efficacy of an exercise program in normalizing glucose tolerance . Seventeen of 21 patients completed the exercise program while maintaining normoglycemia and obviating  insulin therapy . Maternal and neonatal complications did not differ between the study and control groups . The type of program described appears to be safe and can serve as a model for exercise prescription for pregnant diabetic women to attain improved glucose tolerance Regular physical activity is an established therapeutic adjunct in diabetes , but has not been offered to pregnant diabetics in the past ; for sports might induce significant cardiovascular and hormonal changes that are able to reduce blood flow to the uterus and thus limit oxygen transfer to the fetus . Study ing the impact of a medically supervised exercise program on gestational diabetes mellitus [ GDM ) in a r and omised prospect i ve longitudinal study , this paper aims to assess the effects of maternal moderate and strenuous exercise on the fetus . By evaluating shortterm fetal responses as reflected in heart rate patterns ( FHR ) and longterm-pregnancy complications and neonatal outcome , our results suggest that -- in absence of ominous FHR changes or significant changes in uterine activity following the exercise sessions or increased diabetes-related peri- and neonatal morbidity --  regular physical activity seems to be a safe therapeutic option for the fetus of GDM mothers Infant macrosomia is a serious medical concern . Pregnant women who do not meet the specific diagnosis for gestational diabetes may still have glucose-mediated macrosomia . In Santa Barbara County all pregnant women are screened for gestational diabetes at 24 - 28 weeks with a 50-g , 1-hr glucose challenge test ( GCT ) . All patients who fail this test are placed on a st and ard euglycemic diet ( 40 % carbohydrate , 20 % protein , 40 % fat ) and perform home glucose monitoring of fasting and postpr and ial glucose levels . The objective of this study was to examine the effectiveness of this treatment program in decreasing infant macrosomia , maternal and infant morbidity , maternal complications , and operative delivery . We studied 103 women who had a positive GCT , but a negative 100-g , 3-hr oral glucose tolerance test ( OGTT ) . The women were r and omly assigned to either experimental or control groups with experimental women receiving dietary counseling and home glucose monitoring instruction ( HBGM ) . HBGM diaries were review ed weekly by clinic nurses . All women had hemoglobin A1c ( HbA1c ) tests at 28 and 32 weeks . Maternal and fetal charts were review ed to determine delivery type and complications , indications for cesarean section ( C-section ) , and infant gestational age , gender , Apgar scores , birth weight , morbidities , and congenital anomalies . Of the 103 women , 5 women required insulin treatment , 1 woman had an abortion , and 14 women were indeterminate regarding compliance or were control women who received diet counseling and HBGM . The results are based on 83 women--48 control and 35 experimental . There were no significant differences between the groups for age , parity , or weight at 28 - 30 weeks or 37 weeks to delivery , or HbA1c at 28 weeks . HbA1c was significantly higher in control women at 32 weeks . Birth weight expressed in grams or as a percentile specific for gender , ethnicity , and gestational age was significantly higher in control infants . Birth weight was significantly correlated with maternal intake weight , weight at 28 - 30 weeks , and weight at delivery and with HbA1c at 32 weeks ' gestation . There were no significant differences between groups for maternal complications . Groups were significantly different for mode of delivery with experimental women having more induced vaginal deliveries but fewer repeat C-sections than control women . Groups were not different for primary C-sections . Women who fail the GCT , but not the OGTT and thus do not receive the diagnosis of GDM are still at risk for delivering a macrosomic infant and operative delivery . Our program of treatment for all women who fail the GCT improves outcome by reducing infant birth weight and the number of cesarean sections Two-hundred and two pregnant women with impaired glucose tolerance were r and omized to treatment with diet or diet and insulin by stratified selection . Self-monitoring of blood glucose was performed six times a day , 3 days/wk . Dietary treatment was considered inappropriate if fasting and postpr and ial blood glucose values exceeded 7 and 9 mmol/L , respectively , in which case insulin therapy was instituted . Insulin doses were adjusted according to blood glucose values , aim ing at fasting and postpr and ial values below 5 and 6.5 mmol/L , respectively . There were no perinatal deaths . The two treatment regimens disclosed no differences regarding achieved degree of maternal blood glucose control , hemoglobin A1c at delivery , obstetric or neonatal complications , infant 's size at birth including skinfold thickness , or C-peptide concentration in cord serum . Routine treatment of pregnant women with mild carbohydrate intolerance with insulin seems unnecessary . However , 15 patients ( 14 % ) in the diet group needed insulin to achieve acceptable blood glucose control , underlining the importance of monitoring blood glucose to detect those who are at risk of developing overt diabetes
OBJECTIVE To summarise the benefits and harms of treatments for women with gestational diabetes mellitus .