Indication and results of insulin therapy for gestational diabetes mellitus Gestational impaired glucose tolerance does not increase perinatal mortality in a developing country: cohort study 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. Toward universal criteria for gestational diabetes: relationships between seventy-five and one hundred gram glucose loads and between capillary and venous glucose concentrations. A randomized controlled trial using glycemic plus fetal ultrasound parameters versus glycemic parameters to determine insulin therapy in gestational diabetes with fasting hyperglycemia. Randomized trial of diet versus diet plus cardiovascular conditioning on glucose levels in gestational diabetes. Low energy diets in the treatment of gestational diabetes. Intensified versus conventional management of gestational diabetes. Management of women with one abnormal oral glucose tolerance test value reduces adverse outcome in pregnancy. Usefulness of a Breakfast Test in the Management of Women With Gestational Diabetes A randomised controlled pilot study of the management of gestational impaired glucose tolerance Jet-Injected Insulin Is Associated With Decreased Antibody Production and Postprandial Glucose Variability When Compared With Needle-Injected Insulin in Gestational Diabetic Women A randomised controlled trial of dietary energy restriction in the management of obese women with gestational diabetes Exercise in Gestational Diabetes: An Optional Therapeutic Approach? Medical Treatment of the Gestational Diabetic Exercise fails to improve postprandial glycemic excursion in women with gestational diabetes. Treatment of women with an abnormal glucose challenge test (but a normal oral glucose tolerance test) decreases the prevalence of macrosomia. Treatment of gestational diabetes with short‐ or long‐acting insulin and neonatal outcome: a pilot study Gestational Diabetes Mellitus (GDM): Comparative Evaluation of Two Treatment Regimens, Diet Versus Insulin and Diet Insulin therapy for gestational diabetes. A comparison of glyburide and insulin in women with gestational diabetes mellitus.
The aim of this study was to determine whether amniotic fluid insulin concentration ( AFI ) is a better parameter than mean maternal blood glucose values ( MBG ) for deciding about insulin therapy in patients with gestational diabetes . MBG 's were calculated on the base of 9 blood glucose levels during a 24 hour period after one week of diet therapy . In a prospect i ve trial between 1987 and 1989 in Karlsburg , 123 gestational diabetic patients were r and omized into two groups . Treatment was either based on the concentration of AFI or MBG levels . In a second series in Berlin , 103 patients were offered amniocentesis . 81 patients agreed and 22 refused . Treatment was then analogous to that in Karlsburg . In both groups of the r and omized population , strict metabolic control was achieved . There was no difference regarding pregnancy complications . Earlier labor induction and higher cesarean section rates were seen in the non-invasive group ( p < 0.05 ) . The incidence of diabetic fetopathy and neonatal hypoglycemia was significantly lower in the invasive group ( p < 0.01 ) , even though the metabolic control parameters did not differ between the two groups . The results in Berlin correspond to these findings . In conclusion , AFI enables the recognition of any hyperinsulinism reaction to the maternal metabolic situation . We recommend the additional measurement of the AFI concentration between 28 and 36 weeks as the direct fetal parameter for deciding about insulin treatment The high prevalence of diabetes and impaired glucose tolerance in women of childbearing age in Mauritius provides an opportunity to assess prospect ively the risks of adverse outcome in pregnancy of these conditions , whether the conditions are known to be present at conception or diagnosed during pregnancy.1 The findings are likely to have consequences for healthcare planning in developing countries . View this table : Outcome of pregnancy in Mauritius , 1993 - 6 , according to diagnostic category of glucose intolerance . Values are number ( percentage ) unless otherwise indicated The study hospital ( catchment population 250 000 ; 4500 deliveries a year ) accounts for 22 % of deliveries of babies in Mauritius , hospital deliveries being 80 % of all deliveries on the isl and .1 Cases were registered in 1993–6 at a joint obstetric and medical service for diabetes , and were also found by monitoring admissions to the obstetric wards , and by monitoring all requests for  obstetric oral glucose tolerance tests . Data were collected from the mother and from hospital and national records . Diabetes and impaired glucose 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 OBJECTIVES Replacement of the two-step , 100 gm , 3-hour National Diabetes Data Group procedure by the one-step , 75 gm , 2-hour World Health Organization oral glucose tolerance test has been hindered by a paucity of data comparing the two tests during pregnancy . The current series compared 100 gm and 75 gm glucose loads and glucose measurements in venous plasma or capillary blood . STUDY DESIGN After a 75 gm oral glucose tolerance test  30 gestational diabetics and 30 metabolically healthy pregnant women were r and omly assigned to a second 75 or 100 gm test within 3+/-1.3 ( mean+/-SD ) days . Glucose levels at both tests was measured in capillary blood and venous plasma , as were insulin and C peptide . RESULTS In controls 1-hour maternal glucose levels ( 112 vs 128 mg/dl ) and 2-hour levels ( 104 vs 113 mg/dl ) differed significantly after a 75 or 100 gm load ( paired t test ) . In gestational diabetes mellitus , however , there was no difference ( 176 vs 178 mg/dl ) but a low insulin/glucose quotient at 1 hour . Only 2-hour levels differed significantly ( 133 vs 149 mg/dl ) . In controls glucose measurement in capillary blood and venous plasma differed significantly at 1 hour ( 126 vs 115 mg/dl ) and 2 hours ( 111 vs 104 mg/dl ) independently of the glucose load . In gestational diabetes mellitus , however , glucose measurement in capillary blood and venous plasma differed neither in 1-hour levels ( 179 vs 174 mg/dl ) nor in 2-hour levels ( 142 vs 139 mg/dl ) . CONCLUSION In metabolically healthy women both different loading and different blood fractions lead to statistically different blood glucose levels at 1 and 2 hours . In gestational diabetes mellitus , however , 1-hour glucose levels do not differ after a 75 or 100 gm load or after glucose measurement in capillary blood or venous plasma . This is due to elevated insulin resistance shown by a low insulin/glucose quotient at 1 hour . For comparison of tests in gestational diabetes mellitus only , 2-hour values must be adjusted by 16 mg/dl after different loading OBJECTIVE To compare management based on maternal glycemic criteria with management based on relaxed glycemic criteria and fetal abdominal circumference ( AC ) measurements in order to select patients for insulin treatment of gestational diabetes mellitus ( GDM ) with fasting hyperglycemia . RESEARCH DESIGN AND METHODS In a pilot study , 98 women with fasting plasma glucose ( FPG ) concentrations of 105 - 120 mg/dl were r and omized . The st and ard group received insulin treatment . The experimental group received insulin if the AC , measured monthly , was > or = 70th percentile and /or if any venous FPG measurement was > 120 mg/dl . Power was projected to detect a 250-g difference in birth weights . RESULTS Gestational ages , maternal glycemia , and AC percentiles were similar at r and omization . After initiation of protocol , venous FPG ( P = 0.003 ) and capillary blood glucose levels ( P = 0.049 ) were significantly lower in the st and ard group . Birth weights ( 3,271 + /- 458 vs. 3,369 + /- 461 g ) , frequencies of birth weights > 90th percentile ( 6.3 vs 8.3 % ) , and neonatal morbidity ( 25 vs. 25 % ) did not differ significantly between the st and ard and experimental groups , respectively . The cesarean delivery rate was significantly lower ( 14.6 vs. 33.3 % , P = 0.03 ) in the st and ard group ; this difference was not explained by birth weights . In the experimental group , infants of women who did not receive insulin had lower birth weights than infants of mothers treated with insulin ( 3,180 + /- 425 vs. 3,482 + /- 451 g , P = 0.03 ) . CONCLUSIONS In women with GDM and fasting hyperglycemia , glucose plus fetal AC measurements identified pregnancies at low risk for macrosomia and result ed in the avoidance of insulin therapy in 38 % of patients without increasing rates of neonatal morbidity We studied the impact of a training program on glucose tolerance in gestational diabetes mellitus . Women with gestational diabetes mellitus ( N = 19 ) were r and omized into either group I , a 6-week diet alone group ( 24 to 30 kcal/kg/24 hours ; 20 % protein , 40 % carbohydrate , 40 % fat ) , or group II , which followed the same diet plus exercise ( 20 minutes three times a week for 6 weeks ) . An arm ergometer was used to maintain heart rate in the training range . Glycemic response was monitored by glycosylated hemoglobin , a 50 gm oral glucose challenge with a fasting and 1-hour plasma glucose , and blood glucose self-monitoring , fasting and 1 hour  after meals .  Week 1 glycemic parameters were the same for both groups . Week 6 data ( mean + /- SD ) were as follows : group I glycosylated hemoglobin , 4.7 % + 0.2 % versus group II , 4.2 % + /- 0.2 % ; p less than 0.001 . The group I glucose challenge fasting value was 87.6 + /- 6.2 versus 70.1 + /- 6.6 mg/dl , p less than 0.001 for group II . The group I 1-hour plasma glucose challenge result was 187.5 + /- 12.9 mg/dl versus 105.9 + /- 18.9 mg/dl for group II , p less than 0.001 . The glycemic levels diverged between the groups at week 4 . We conclude that arm ergometer training is feasible in women with gestational diabetes mellitus and results in lower glycosylated hemoglobin , fasting , and 1-hour plasma glucose concentrations than diet alone . Arm ergometer training may provide a useful treatment option for women with gestational diabetes mellitus and may obviate insulin treatment A r and omised prospect i ve study of treatment with dietary restriction alone or insulin therapy with dietary advice was performed in 15 women with glucose intolerance diagnosed early in the third trimester of pregnancy . Twenty-four hour profiles of plasma glucose and 3-hydroxybutyrate were performed before and four weeks after commencing treatment . The effect on neonatal outcome was assessed . The case history of one of the patients in the study was sent to British physicians with a special interest in diabetes to obtain their opinion about the appropriate initial treatment of women with gestational diabetes OBJECTIVE We tested the hypothesis that intensified management of gestational diabetes mellitus on the basis of stringent glycemic control , verified glucose data , and adherence to an established criterion for insulin initiation results in near normoglycemia control and reduction of adverse outcomes . STUDY DESIGN A prospect i ve , population -based study compared the effect on perinatal outcome of conventional  ( n = 1316 )  and intensified  ( n = 1145 )  management . Group assignment was based on availability of memory-based reflectance meters at entry to the program . A contemporaneous r and omized control group ( nondiabetic , n = 4922 ) was selected . RESULTS The diabetic groups were comparable in demographic characteristics and in factors associated with higher risk for adverse pregnancy outcome , such as  previous macrosomia , previous gestational diabetes mellitus , and family history of diabetes . The control group was younger , less obese , and had a lower rate of previous macrosomia .  The intensified management group had rates of macrosomia , cesarean section , metabolic complications , shoulder dystocia , stillbirth , neonatal intensive care unit days , and respiratory complications lower than those in the conventional management group and comparable to those of the nondiabetic controls . Other maternal complication rates , such as for preeclampsia , chronic hypertension , and infection , were similar for the three groups . Mean blood glucose levels were a good predictor of perinatal outcome . Gestational age at delivery , previous history of macrosomia , and overall mean blood glucose levels were the only significant predictors of birth weight percentile in both diabetic groups ( logistic regression ) . CONCLUSION The intensified management approach is significantly associated with enhanced perinatal outcome . This management strategy clarifies the relationship between glycemic control and neonatal outcome In this study we sought to test the hypothesis that treatment of women with one abnormal oral glucose tolerance test value will result in reduction of adverse outcome .  One hundred twenty-six women with one abnormal oral glucose tolerance test value and 146 women in the control group ( normal oral glucose tolerance test values ) participated in a prospect i ve study during the third trimester of pregnancy . The subjects with one abnormal test result were r and omized into treated ( group 1 ) and untreated groups ( group II ) . Group 1 subjects were treated with a strict diabetic protocol to maintain tight glycemic control by means of diet and insulin therapy . Group 2 subjects tested their capillary blood glucose for a baseline period . The study revealed that the level of glycemic control was similar before initiation of therapy ( mean capillary blood glucose 118 + /- 14 vs. 119 + /- 15 mg/dl , p = NS ) for groups 1 and 2 , respectively . There was a significant difference in mean capillary blood glucose ( 95 + /- 10 vs. 119 + /- 15 mg/dl , p less than 0.0001 ) , prepr and ial , and postpr and ial determinations between the treated and untreated groups . The overall incidence of neonatal metabolic complications ( 4 % vs. 14 % , p less than 0.05 ) and large infants ( 6 % vs. 24 % , p less than 0.03 ) was significantly lower in the treated group . Comparison between the control ( normal oral glucose tolerance test ) and the untreated groups showed a significantly higher incidence of large infants and metabolic complications . No difference was found between the normal and treated groups . Thus we conclude that treatment of individuals with one abnormal oral glucose tolerance test value will result in significant reduction in adverse outcome in pregnancy 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 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 OBJECTIVE To eluci date the glycemic response and antibody formation in gestational diabetic women treated with insulin injected by a needle or a jet . The American Diabetes Association 's position statement on jet injectors raised the concern that “ insulin could be denatured as a result of forceful injection through a tiny port , which could lead to an increase in antibody formation ” ( Diabetes Care11:600 , 1988 ) . However , the pharmacokinetics of jet-injected insulin suggest that it might be useful in controlling postpr and ial glucose levels . METHODS We r and omized 20 women with gestational diabetes mellitus ( < 34 wk gestation ) who required insulin to receive either jet-injected or needle-injected human NPH and regular insulin .  Variables of interest were evaluated at the start of therapy , weekly until delivery , and 6-wk postpartum that included : 1 ) insulin antibodies in the mother and her infant , 2 ) HbA1c , 3 ) insulin dose , 4 ) fasting and postpr and ial glucose levels , and 5 ) subject acceptance and preference . RESULTS Of the 10 women in the needle group , 6 developed significant insulin antibodies compared with 1 of 10 in the jet group ( P < 0.001 ) . HbA1c and insulin doses were the same in both groups . During the test meal , glucose levels in the jet group were significantly lower ( P < 0.01 ) , yet none of the women in the jet group experienced blood glucose 70 mg/dl ( 3.89 mM ) at 3–4 h after the meal , compared with 5 in the needle group ( P < 0.001 ) . Jet injection was associated with less variability ( P < 0.001 ) in postpr and ial glucose values but slightly greater variability ( P < 0.05 ) in fasting glucose .  Jet-injected insulin was more readily accepted by subjects than needle injections . CONCLUSIONS Jet injection is associated with a diminished antibody response and postpr and ial variability compared with needle-injected insulin . Thus , this warrants consideration as a therapeutic option for women with gestational diabetes mellitus and may also be applicable to nonpregnant , insulin-requiring diabetic patients 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 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 The outcome of pregnancy  in control and treated gestational diabetics was not significantly different . The decreased loss rate among the insulin- and diet-treated gestational diabetics , however , did become significant when the data were reanalyzed with consideration of two important influencing variables . The high-risk group of gestational diabetics aged 25 years and older who received  insulin therapy  before the 32nd week of gestation had fewer fetal losses . Documentation of the critical role played by both maternal age and the gestational age at which insulin therapy is commenced now makes the institution of a conclusive prospect i ve study feasible . The adequately established hypothesis that insulin management of gestational diabetics favorably affects the outcome of their pregnancies can then be finally resolved The effect of an acute period of moderate intensity exercise on maternal glycemic excursion following a mixed nutrient meal was studied . Five normal ( NL ) and six gestational diabetic ( GDM ) subjects were enrolled . A r and omized crossover design was used to compare fasting glucose and insulin levels , peak glucose and insulin levels and incremental area of the glycemic and insulin curves following a mixed nutrient meal with or without an exercise stress that took place 14 h earlier . Exercise consisted of upright stationary cycling for 30 min at a heart rate consistent with 60 % VO2max . The clinical characteristics of normal and gestational diabetic subjects were comparable . Mean values ( + /-SEM ) with , versus without , exercise for fasting glucose ( NL : 78.9 + /- 2.6 vs. 80.0 + /- 2.6 mg/dl ; GDM : 86.4 + /- 2.0 vs. 82.1 + /- 3.5 mg/ dl ) , peak glucose ( NL : 132.3 + /- 10.4 vs. 139.1 + /- 15.6 mg/dl ; GDM : 165.8 + /- 5.5 vs. 160.3 + /- 7.8 mg/dl ) , the area under the glycemic curve ( NL : 5758 + /- 1038 vs. 6393 + /- 1281 mg/dl.min ; GDM : 8,178 + /- 890 vs. 8,331 + /- 563 mg/dl.min ) did not differ . Similarly , plasma insulin levels did not differ between protocol s for either group of subjects . Exercise has been proposed as a treatment to reduce glycemia in gestational diabetes . Results from this study indicate a single bout of exercise did not blunt the glycemic response observed following a mixed nutrient meal 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 Major problems with gestational diabetes ( GDM ) have been the high frequency of fetal macrosomia , and perinatal complications , especially among mothers needing  insulin  in addition to diet therapy ( 1 ) . Both long-acting insulin ( LAI ) and shortacting insulin ( SAI ) are used , the former to reduce the basal glucose level and the latter to control postpr and ial glucose peaks after meals . Despite many improvements , insulin therapy has not solved the above-mentioned problems . We compared the effects of SAI and LAI on perinatal outcome in insulin-requiring GDM . We hypothesized that SAI therapy and postpr and ial glucose monitoring would lead to better glycemic control than LAI and therefore reduce fetal macrosomia . After obtaining approval by the Ethics Committee of the Helsinki University Central Hospital , department of Obstetrics and Gynecology and given information to all study participants , we included 23 consecutive women with insulin-requiring GDM in a prospect i ve r and omized trial . A 2-hr oral glucose tolerance test ( OGTT ) with 75 g of glucose was performed at 24–28weeks of gestation in women 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 Seventy-two patient with gestational diabetes were r and omly treated with insulin ( 20 units NPH and 10 units regular ) and diabetic diet , diet alone , or neither . Of the 27 patients treated with insulin and diet , 2 ( 7 % ) had babies weighing more than 8 1/2 pounds . Of the 11 patients treated with diet alone , 4 ( 36.4 % ) had babies weighing more than 8 1/2 pounds . Of the 34 patients treated with neither diet nor insulin , 17 ( 50 % ) had babies weighing more than 8 1/2 pounds . These data support the hypothesis that treatment of the gestational diabetic with insulin will reduce the incidence of fetal macrosomia BACKGROUND Women with gestational diabetes mellitus are rarely treated with a sulfonylurea drug , because of concern about teratogenicity and neonatal hypoglycemia . There is little information about the efficacy of these drugs in this group of women . METHODS We studied 404 women with singleton pregnancies and gestational diabetes that required treatment . The women were r and omly assigned between 11 and 33 weeks of gestation to receive glyburide or insulin according to an intensified treatment protocol . The primary end point was achievement of the desired level of glycemic control . Secondary end points included maternal and neonatal complications . RESULTS The mean ( + /-SD ) pretreatment blood glucose concentration as measured at home for one week was 114+/-19 mg per deciliter ( 6.4+/-1.1 mmol per liter ) in the glyburide group and 116+/-22 mg per deciliter ( 6.5+/-1.2 mmol per liter ) in the insulin group ( P=0.33 ) . The mean concentrations during treatment were 105+/-16 mg per deciliter ( 5.9+/-0.9 mmol per liter ) in the glyburide group and 105+/-18 mg per deciliter ( 5.9+/-1.0 mmol per liter ) in the insulin group ( P=0.99 ) . Eight women in the glyburide group ( 4 percent ) required insulin therapy . There were no significant differences between the glyburide and insulin groups in the percentage of infants who were large for gestational age ( 12 percent and 13 percent , respectively ) ; who had macrosomia , defined as a birth weight of 4000 g or more ( 7 percent and 4 percent ) ; who had lung complications ( 8 percent and 6 percent ) ; who had hypoglycemia ( 9 percent and 6 percent ) ; who were admitted to a neonatal intensive care unit ( 6 percent and 7 percent ) ; or who had fetal anomalies ( 2 percent and 2 percent ) . The cord-serum insulin concentrations were similar in the two groups , and glyburide was not detected in the cord serum of any infant in the glyburide group . CONCLUSIONS In women with gestational diabetes , glyburide is a clinical ly effective alternative to insulin therapy
BACKGROUND Gestational diabetes and impaired glucose tolerance ( IGT ) in pregnancy affects between 3 and 6 % of all pregnancies and both have been associated with pregnancy complications .
A lack of conclusive evidence has led clinicians to equate the risk of adverse perinatal outcome with pre-existing diabetes .
Consequently , women are often intensively managed with increased obstetric monitoring , dietary regulation , and in some cases insulin therapy .
However , there has been no sound evidence base to support intensive treatment .
The key issue for clinicians and consumers is whether treatment of gestational diabetes and IGT will improve perinatal outcome .
OBJECTIVES The objective of this review was to compare alternative policies of care for women with gestational diabetes and IGT in pregnancy .