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Obstetrical management of pregnancies complicated by gestational diabetes mellitus

INTRODUCTION

Obstetrical challenges in caring for pregnant women with gestational diabetes mellitus (GDM) include knowledge of the maternal and fetal risks related to the disorder, antepartum maternal and fetal monitoring, use of obstetrical ultrasound to monitor fetal growth and well-being, decisions about timing and route of delivery, intrapartum obstetric and glycemic management, and postpartum assessment.

This topic will address issues related to obstetric management of women diagnosed with GDM after screening at 24 to 28 weeks of gestation. Screening, diagnosis, and glycemic management of women with gestational diabetes are discussed separately. (See "Screening and diagnosis of diabetes mellitus during pregnancy" and "Medical management and follow-up of gestational diabetes mellitus".)

Obstetrical and medical management of pregnant women with type 1 and type 2 diabetes mellitus are also discussed separately. (See "Obstetrical management of pregnancy complicated by pregestational diabetes mellitus" and "Medical management of type 1 and type 2 diabetes mellitus in pregnant women" and "Pregnancy risks in women with type 1 and type 2 diabetes mellitus" and "Prepregnancy evaluation and management of women with type 1 or type 2 diabetes mellitus".)

FOCUS OF PRENATAL CARE

In addition to routine pregnancy issues, the prenatal care of women with GDM focuses upon identifying and managing conditions that are more common among women with glucose impairment. Maintaining good glycemic control is the key intervention for reducing the frequency and/or severity of these conditions. In contrast to women with pregestational diabetes, women with GDM typically do not have overt vasculopathy or an increased risk of infants with congenital malformations.

Conditions more common in GDM include:

            

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Literature review current through: Apr 2013. | This topic last updated: Mar 25, 2013.
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References
Top
  1. HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, et al. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med 2008; 358:1991.
  2. Crowther CA, Hiller JE, Moss JR, et al. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 2005; 352:2477.
  3. Kwik M, Seeho SK, Smith C, et al. Outcomes of pregnancies affected by impaired glucose tolerance. Diabetes Res Clin Pract 2007; 77:263.
  4. Garner P, Okun N, Keely E, et al. 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. Am J Obstet Gynecol 1997; 177:190.
  5. Hillier TA, Pedula KL, Vesco KK, et al. Excess gestational weight gain: modifying fetal macrosomia risk associated with maternal glucose. Obstet Gynecol 2008; 112:1007.
  6. Dooley SL, Metzger BE, Cho NH. Gestational diabetes mellitus. Influence of race on disease prevalence and perinatal outcome in a U.S. population. Diabetes 1991; 40 Suppl 2:25.
  7. Lipscomb KR, Gregory K, Shaw K. The outcome of macrosomic infants weighing at least 4500 grams: Los Angeles County + University of Southern California experience. Obstet Gynecol 1995; 85:558.
  8. Lazer S, Biale Y, Mazor M, et al. Complications associated with the macrosomic fetus. J Reprod Med 1986; 31:501.
  9. Rouse DJ, Owen J. Prophylactic cesarean delivery for fetal macrosomia diagnosed by means of ultrasonography--A Faustian bargain? Am J Obstet Gynecol 1999; 181:332.
  10. Bérard J, Dufour P, Vinatier D, et al. Fetal macrosomia: risk factors and outcome. A study of the outcome concerning 100 cases >4500 g. Eur J Obstet Gynecol Reprod Biol 1998; 77:51.
  11. Stotland NE, Caughey AB, Breed EM, Escobar GJ. Risk factors and obstetric complications associated with macrosomia. Int J Gynaecol Obstet 2004; 87:220.
  12. Cohen BF, Penning S, Ansley D, et al. The incidence and severity of shoulder dystocia correlates with a sonographic measurement of asymmetry in patients with diabetes. Am J Perinatol 1999; 16:197.
  13. Nesbitt TS, Gilbert WM, Herrchen B. Shoulder dystocia and associated risk factors with macrosomic infants born in California. Am J Obstet Gynecol 1998; 179:476.
  14. Casey BM, Lucas MJ, Mcintire DD, Leveno KJ. Pregnancy outcomes in women with gestational diabetes compared with the general obstetric population. Obstet Gynecol 1997; 90:869.
  15. Yogev Y, Xenakis EM, Langer O. The association between preeclampsia and the severity of gestational diabetes: the impact of glycemic control. Am J Obstet Gynecol 2004; 191:1655.
  16. Innes KE, Wimsatt JH, McDuffie R. Relative glucose tolerance and subsequent development of hypertension in pregnancy. Obstet Gynecol 2001; 97:905.
  17. Joffe GM, Esterlitz JR, Levine RJ, et al. The relationship between abnormal glucose tolerance and hypertensive disorders of pregnancy in healthy nulliparous women. Calcium for Preeclampsia Prevention (CPEP) Study Group. Am J Obstet Gynecol 1998; 179:1032.
  18. Carpenter MW. Gestational diabetes, pregnancy hypertension, and late vascular disease. Diabetes Care 2007; 30 Suppl 2:S246.
  19. Hyperglycemia and Adverse Pregnancy Outcome (HAPO) Study Cooperative Research Group. Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study: preeclampsia. Am J Obstet Gynecol 2010; 202:255.e1.
  20. Parretti E, Lapolla A, Dalfrà M, et al. Preeclampsia in lean normotensive normotolerant pregnant women can be predicted by simple insulin sensitivity indexes. Hypertension 2006; 47:449.
  21. Sierra-Laguado J, García RG, Celedón J, et al. Determination of insulin resistance using the homeostatic model assessment (HOMA) and its relation with the risk of developing pregnancy-induced hypertension. Am J Hypertens 2007; 20:437.
  22. Hauth JC, Clifton RG, Roberts JM, et al. Maternal insulin resistance and preeclampsia. Am J Obstet Gynecol 2011; 204:327.e1.
  23. Shoham I, Wiznitzer A, Silberstein T, et al. Gestational diabetes complicated by hydramnios was not associated with increased risk of perinatal morbidity and mortality. Eur J Obstet Gynecol Reprod Biol 2001; 100:46.
  24. Biggio JR Jr, Wenstrom KD, Dubard MB, Cliver SP. Hydramnios prediction of adverse perinatal outcome. Obstet Gynecol 1999; 94:773.
  25. Girz BA, Divon MY, Merkatz IR. Sudden fetal death in women with well-controlled, intensively monitored gestational diabetes. J Perinatol 1992; 12:229.
  26. Aberg A, Rydhström H, Källén B, Källén K. Impaired glucose tolerance during pregnancy is associated with increased fetal mortality in preceding sibs. Acta Obstet Gynecol Scand 1997; 76:212.
  27. Dudley DJ. Diabetic-associated stillbirth: incidence, pathophysiology, and prevention. Obstet Gynecol Clin North Am 2007; 34:293.
  28. Langer O, Rodriguez DA, Xenakis EM, et al. Intensified versus conventional management of gestational diabetes. Am J Obstet Gynecol 1994; 170:1036.
  29. Blank A, Grave GD, Metzger BE. Effects of gestational diabetes on perinatal morbidity reassessed. Report of the International Workshop on Adverse Perinatal Outcomes of Gestational Diabetes Mellitus, December 3-4, 1992. Diabetes Care 1995; 18:127.
  30. Hod M, Merlob P, Friedman S, et al. Gestational diabetes mellitus. A survey of perinatal complications in the 1980s. Diabetes 1991; 40 Suppl 2:74.
  31. Boney CM, Verma A, Tucker R, Vohr BR. Metabolic syndrome in childhood: association with birth weight, maternal obesity, and gestational diabetes mellitus. Pediatrics 2005; 115:e290.
  32. Malcolm JC, Lawson ML, Gaboury I, et al. Glucose tolerance of offspring of mother with gestational diabetes mellitus in a low-risk population. Diabet Med 2006; 23:565.
  33. Gillman MW, Rifas-Shiman S, Berkey CS, et al. Maternal gestational diabetes, birth weight, and adolescent obesity. Pediatrics 2003; 111:e221.
  34. Silverman BL, Metzger BE, Cho NH, Loeb CA. Impaired glucose tolerance in adolescent offspring of diabetic mothers. Relationship to fetal hyperinsulinism. Diabetes Care 1995; 18:611.
  35. American College of Obstetricians and Gynecologists. Gestational Diabetes. ACOG practice bulletin #30, American College of Obstetricians and Gynecologists, Washington, DC 2001.
  36. Kjos SL, Leung A, Henry OA, et al. Antepartum surveillance in diabetic pregnancies: predictors of fetal distress in labor. Am J Obstet Gynecol 1995; 173:1532.
  37. Landon MB, Gabbe SG. Antepartum fetal surveillance in gestational diabetes mellitus. Diabetes 1985; 34 Suppl 2:50.
  38. Gabbe SG, Mestman JG, Freeman RK, et al. Management and outcome of class A diabetes mellitus. Am J Obstet Gynecol 1977; 127:465.
  39. Gonen O, Rosen DJ, Dolfin Z, et al. Induction of labor versus expectant management in macrosomia: a randomized study. Obstet Gynecol 1997; 89:913.
  40. Rouse DJ, Owen J, Goldenberg RL, Cliver SP. The effectiveness and costs of elective cesarean delivery for fetal macrosomia diagnosed by ultrasound. JAMA 1996; 276:1480.
  41. Kjos SL, Schaefer-Graf UM. Modified therapy for gestational diabetes using high-risk and low-risk fetal abdominal circumference growth to select strict versus relaxed maternal glycemic targets. Diabetes Care 2007; 30 Suppl 2:S200.
  42. Engstrom JL, Work BA Jr. Prenatal prediction of small- and large-for-gestational age neonates. J Obstet Gynecol Neonatal Nurs 1992; 21:486.
  43. Humphries J, Reynolds D, Bell-Scarbrough L, et al. Sonographic estimate of birth weight: relative accuracy of sonographers versus maternal-fetal medicine specialists. J Matern Fetal Neonatal Med 2002; 11:108.
  44. Johnstone FD, Prescott RJ, Steel JM, et al. Clinical and ultrasound prediction of macrosomia in diabetic pregnancy. Br J Obstet Gynaecol 1996; 103:747.
  45. McLaren RA, Puckett JL, Chauhan SP. Estimators of birth weight in pregnant women requiring insulin: a comparison of seven sonographic models. Obstet Gynecol 1995; 85:565.
  46. Smith GC, Smith MF, McNay MB, Fleming JE. The relation between fetal abdominal circumference and birthweight: findings in 3512 pregnancies. Br J Obstet Gynaecol 1997; 104:186.
  47. Hackmon R, Bornstein E, Ferber A, et al. Combined analysis with amniotic fluid index and estimated fetal weight for prediction of severe macrosomia at birth. Am J Obstet Gynecol 2007; 196:333.e1.
  48. Scioscia M, Scioscia F, Vimercati A, et al. Estimation of fetal weight by measurement of fetal thigh soft-tissue thickness in the late third trimester. Ultrasound Obstet Gynecol 2008; 31:314.
  49. Cromi A, Ghezzi F, Di Naro E, et al. Large cross-sectional area of the umbilical cord as a predictor of fetal macrosomia. Ultrasound Obstet Gynecol 2007; 30:861.
  50. Higgins MF, Russell NM, Mulcahy CH, et al. Fetal anterior abdominal wall thickness in diabetic pregnancy. Eur J Obstet Gynecol Reprod Biol 2008; 140:43.
  51. Ben-Haroush A, Chen R, Hadar E, et al. Accuracy of a single fetal weight estimation at 29-34 weeks in diabetic pregnancies: can it predict large-for-gestational-age infants at term? Am J Obstet Gynecol 2007; 197:497.e1.
  52. Little SE, Edlow AG, Thomas AM, Smith NA. Estimated fetal weight by ultrasound: a modifiable risk factor for cesarean delivery? Am J Obstet Gynecol 2012; 207:309.e1.
  53. Kjos SL, Henry OA, Montoro M, et al. Insulin-requiring diabetes in pregnancy: a randomized trial of active induction of labor and expectant management. Am J Obstet Gynecol 1993; 169:611.
  54. Lurie S, Insler V, Hagay ZJ. Induction of labor at 38 to 39 weeks of gestation reduces the incidence of shoulder dystocia in gestational diabetic patients class A2. Am J Perinatol 1996; 13:293.
  55. Conway DL, Langer O. Elective delivery of infants with macrosomia in diabetic women: reduced shoulder dystocia versus increased cesarean deliveries. Am J Obstet Gynecol 1998; 178:922.
  56. Lurie S, Matzkel A, Weissman A, et al. Outcome of pregnancy in class A1 and A2 gestational diabetic patients delivered beyond 40 weeks' gestation. Am J Perinatol 1992; 9:484.
  57. Peled Y, Perri T, Chen R, et al. Gestational diabetes mellitus--implications of different treatment protocols. J Pediatr Endocrinol Metab 2004; 17:847.
  58. Witkop CT, Neale D, Wilson LM, et al. Active compared with expectant delivery management in women with gestational diabetes: a systematic review. Obstet Gynecol 2009; 113:206.
  59. Nicholson JM, Kellar LC, Cronholm PF, Macones GA. Active management of risk in pregnancy at term in an urban population: an association between a higher induction of labor rate and a lower cesarean delivery rate. Am J Obstet Gynecol 2004; 191:1516.
  60. Nicholson JM, Parry S, Caughey AB, et al. The impact of the active management of risk in pregnancy at term on birth outcomes: a randomized clinical trial. Am J Obstet Gynecol 2008; 198:511.e1.
  61. Rosenstein MG, Cheng YW, Snowden JM, et al. The risk of stillbirth and infant death stratified by gestational age in women with gestational diabetes. Am J Obstet Gynecol 2012; 206:309.e1.
  62. Committee opinion no. 560: medically indicated late-preterm and early-term deliveries. Obstet Gynecol 2013; 121:908.
  63. Wiznitzer A, Furman B, Zuili I, et al. Cord leptin level and fetal macrosomia. Obstet Gynecol 2000; 96:707.
  64. ACOG Practice Bulletin. Clinical management guidelines for obstetrician-gynecologists. Fetal Macrosomia. Number 22, November, 2000.
  65. Silver RM, Landon MB, Rouse DJ, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006; 107:1226.
  66. Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal outcomes associated with a trial of labor after prior cesarean delivery. N Engl J Med 2004; 351:2581.
  67. Caughey AB, Sandberg PL, Zlatnik MG, et al. Forceps compared with vacuum: rates of neonatal and maternal morbidity. Obstet Gynecol 2005; 106:908.
  68. Demissie K, Rhoads GG, Smulian JC, et al. Operative vaginal delivery and neonatal and infant adverse outcomes: population based retrospective analysis. BMJ 2004; 329:24.
  69. Kozhimannil KB, Pereira MA, Harlow BL. Association between diabetes and perinatal depression among low-income mothers. JAMA 2009; 301:842.
  70. Kjos SL, Peters RK, Xiang A, et al. Contraception and the risk of type 2 diabetes mellitus in Latina women with prior gestational diabetes mellitus. JAMA 1998; 280:533.
  71. Xiang AH, Kawakubo M, Kjos SL, Buchanan TA. Long-acting injectable progestin contraception and risk of type 2 diabetes in Latino women with prior gestational diabetes mellitus. Diabetes Care 2006; 29:613.