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Gestational diabetes
1 Introduction
2 Risks of gestational diabetes
3 Therapy in gestational diabetes
4 Effects of glucose-tolerance testing
5 Conclusions
1 Introduction
The concept of gestational diabetes evolved from the earlier concept of
prediabetes, which held that much of the pathology associated with
overt diabetes develops before the appearance of insulin dependency.
The glucose-tolerance test became the mainstay of this diagnosis, as it
was believed to uncover a defect in glucose homeostasis that could only
be demonstrated after a glucose challenge. It was not until 1973
that an attempt was made to link prediabetes (an abnormal glucose-
tolerance test in the absence of overt disease) to perinatal outcome.
Although this link is remarkably tenuous, it gave rise to the concept of
gestational diabetes as a disease entity, to be searched for and treated.
Caregivers and women became anxious lest gestational diabetes
develop, and various forms of glucose-challenge screening were intro-
duced and carried out to identify the condition.
2 Risks of gestational diabetes
From the evidence available, the small increase in perinatal mortality
associated with abnormal glucose tolerance appears to be predicted as
much by the indication for glucose-tolerance testing (such as obesity,
large fetus, previous stillbirth, or malformation) as by the test result.
The glucose intolerance thus is simply a marker for other underlying
conditions that adversely influence perinatal outcome.
Even as only a marker for increased perinatal mortality, the glucose-
tolerance test could still be a useful indicator of risk. The question
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SOURCE: Murray Enkin, Marc J.N.C. Keirse, James Neilson, Caroline Crowther, Lelia Duley, Ellen Hodnett, and
Justus Hofmeyr. A Guide to Effective Care in Pregnancy and Childbirth, 3rd ed. Oxford, UK: Oxford University
Press, 2000.
DOWNLOAD SOURCE: Maternity Wise website at www.maternitywise.org/prof/
Oxford University Press 2000
remains as to whether or not identification and treatment of women
with gestational diabetes can prevent some of the associated adverse
perinatal outcomes (see Chapter 7).
The adverse outcome most frequently associated with gestational
diabetes is fetal macrosomia (a larger than average baby). The adverse
outcomes of cesarean section, shoulder dystocia, and trauma, derive
from this primary outcome. Up to 30% of mothers with an abnormal
glucose-tolerance test have a baby with a birthweight of more than 4000
g. Clinical judgement, however, based on assessment of prepregnant
weight, weight gain, and a pregnancy past 42 weeks, without any refer-
ence to glucose tolerance, is more predictive of fetal macrosomia than
is the glucose-tolerance test. Wide application of glucose-tolerance
testing to pregnant women would thus be of limited value in identi-
fying women at increased risk of fetal macrosomia.
3 Therapy in gestational diabetes
There is no convincing evidence that treatment of women with an
abnormal glucose-tolerance test will reduce perinatal mortality or
morbidity. Trials of dietary regulation for gestational diabetes do not
demonstrate a significant effect on any outcome, with the possible
exception of macrosomia. Trials comparing the use of insulin plus diet
with diet alone, show a decrease in macrosomia but no significant
effect on other outcomes, such as use of cesarean section, the incidence
of shoulder dystocia, or perinatal mortality. There is also no evidence
that such treatment reduces the incidence of neonatal jaundice or
hypoglycemia. One trial actually assessed the use of elective cesarean
section for gestational diabetes. The result was a statistically signifi-
cant increase in maternal morbidity, with no benefit shown for the
baby. In one trial, no significant differences were found in maternal or
neonatal outcome by use of elective early induction of labor.
4 Effects of glucose-tolerance testing
The diagnosis of gestational diabetes, as currently defined, is based
on an abnormal glucose-tolerance test. This test is not reproducible at
least 5070% of the time, and the increased risk of perinatal mortality
and morbidity said to be associated with this condition has been
considerably overemphasized. As no clear improvement in perinatal
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mortality has been demonstrated with insulin treatment for gestational
diabetes, screening of all pregnant women with glucose-tolerance
testing is unlikely to make a significant impact on perinatal mortality
or morbidity.
An abnormal glucose-tolerance test is associated with a two- or
threefold increase in the incidence of macrosomia, but the majority of
macrosomic infants will be born to mothers with a normal glucose-
tolerance test.
There is, in addition, a great potential for doing more harm than
good by performing a glucose-tolerance test. A positive test labels the
woman as having a form of diabetes. Her pregnancy is likely to be
considered as high-risk, invoking an extensive and expensive program
of tests and interventions of unproven benefit. A negative glucose-
tolerance test, on the other hand, also has a potential for harm by falsely
reassuring the physician and the woman that the risk, engendered by
the indication for the test, has been removed.
As no benefit has yet been established for glucose screening during
pregnancy, the method used for this screening is irrelevant. However,
for those who use this test of unproven value, it should be noted that
a glucose polymer has been shown to be more acceptable than glucose
to women undergoing such screening, and is associated with less
nausea and headache. If any value for screening for minor degrees of
glucose intolerance during pregnancy should ever be demonstrated,
the possible advantages of using a glucose polymer rather than glucose
for this screening should be reviewed.
5 Conclusions
All forms of glucose-tolerance testing should be reviewed. Women in
whom overt diabetes is suspected should be followed with fasting or
blood glucose estimations 2 h after meals, throughout pregnancy.
The available data provide no evidence to support the wide recom-
mendation that all pregnant women should be screened for gestational
diabetes, let alone that they should be treated with insulin. Until the
risk of minor elevations of glucose during pregnancy have been estab-
lished in appropriately conducted trials, therapy based on this diag-
nosis must be critically reviewed. The use of injectable therapy on the
basis of the available data is highly contentious and in many other fields
of medical practice, such aggressive therapy without proven benefit
would be considered unethical.
coxciusioxs
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Sources
Effective care in pregnancy and childbirth
Hunter, D.J.S. and Keirse, M.J.N.C., Gestational diabetes.
Cochrane Library
Walkinshaw, S.A., Dietary regulation for gestational diabetes.
Pre-Cochrane reviews
Walkinshaw, S.A., Glucose polymer vs glucose for screening/diag-
nosing gestational diabetes. Review no. 06652.
Elective caesarean for gestational diabetes. Review no. 06648.
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