The SMFM released a statement on the use of metformin as a first-line alternative to insulin in women with GDM. ACOG has also released an update to the major 2017 Practice Bulletin which also addresses this issue and still considers insulin the preferred option to treat women who are not adequately controlled with appropriate nutritional therapy.
Thus, although metformin may be a reasonable alternative approach to treat gestational diabetes, it is important to counsel women about the lack of superiority when compared with insulin, the placental transfer of the drug, and the absence of long-term data in exposed offspring. Additionally, in the aforementioned prospective trials, between 26% and 46% of women who took metformin alone eventually required insulin.
…this difference is based on the values placed by different experts and providers on the evidence available in the medical literature and is not meant to represent an exclusive course of management.
One abnormal values on the 3 hour OGTT
Clarification of insulin use and dosage
Macrosomia and cesarean section
SMFM Statement Pharmacological treatment of gestational diabetes
ACOG Practice Bulletin 190: Gestational Diabetes Mellitus
The FDA has recently released an official ban on powdered surgeon’s gloves, powdered patient examination gloves, and absorbable powder for lubricating a surgeon’s glove. Many providers have already transitioned to powderless gloves. Powdered gloves are associated with asthma, lung inflammation and surgical adhesions. It is important to note, these products not only pose risks to patients, but providers as well. The rule, published on December 19, 2016, is available in the link below.
Federal Register: Banned Devices; Powdered Surgeon’s Gloves, Powdered Patient Examination Gloves, and Absorbable Powder for Lubricating a Surgeon’s Glove
In 2016, the FDA released a warning stating that repeated or lengthy use of general anesthetic or sedation drugs in children less than 3 years of age or in pregnant women in their 3rd trimester may be harmful to children’s brain development. The FDA issued an update (2017) requiring warnings to be added to labels of these medications. The FDA does point out in the update that the concern relates to procedures >3 hours and that most surgeries in the 3rd trimester are generally well within that time frame. Therefore, the FDA safety communication states
We are advising that in these situations, pregnant women should not delay or avoid surgeries or procedures during pregnancy, as doing so can negatively affect themselves and their infants
In response to the initial warning, ACOG released a practice advisory (2016) making the following important points
As a result of the above and based on current evidence
ACOG continues to recommend that women in any trimester of pregnancy should be counseled regarding evidence-based benefits and risks of any proposed interventions which may involve the use of general anesthetic or sedative agents, and no woman should be denied a medically indicated surgery or procedure which may involve the use of these agents
ACOG and the American Society for Anesthesiologists (2019) confirmed the above in their committee opinion and state that presently there is “no evidence that in utero human exposure to anesthetic or sedative drugs has any effect on the developing fetal brain.”
ACOG / American Society of Anesthesiologists Committee Opinion 775: Nonobstetric Surgery During Pregnancy
FDA Drug Safety Communication: FDA approves label changes for use of general anesthetic and sedation drugs in young children
Does General Anesthesia Exposure in Infancy Impact Neurodevelopment?
Vaginal Seeding describes the practice of using a gauze or swab to “transfer” vaginal fluids to an infant delivered by cesarean section by swabbing the infant’s mouth, face or body. The working theory behind this procedure is based on data suggesting decreased autoimmune disorders, asthma and allergic diseases in infants delivered vaginally. However, presently, there is no evidence to support the use of this practice in the general population due to lack of rigorous studies and outcomes data.
“The American College of Obstetricians and Gynecologists does not recommend or encourage vaginal seeding outside of the context of an institutional review board-approved research protocol, and it is recommended that vaginal seeding otherwise not be performed until adequate data regarding the safety and benefit of the process become available.
The American College of Obstetricians and Gynecologists only supports the performance of vaginal seeding in the context of an institutional review board-approved research protocol.”
Risk stratification is reasonable for such women in the form of testing for infectious diseases and potentially pathogenic bacteria. Serum testing for herpes simplex virus and cultures for group B streptococci, Chlamydia trachomatis, and Neisseria gonorrhea should be encouraged.
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