ACOG released updated guidance on gestational diabetes (GDM), which has become increasingly prevalent worldwide. Class A1GDM refers to diet-controlled GDM. Class A2GDM refers to the clinical scenario where medications are required. Highlights and changes from the previous practice bulletin include the following:
Consider early screening in pregnancy if patient is overweight with BMI of 25 (23 in Asian Americans), and one or more of the following
The argument against the one-step approach has been that it increases the incidence of GDM significantly, without proven improvement in maternal and/or perinatal outcomes
Our meta-analysis of RCTs, however, provides level-1 evidence that the one-step approach significantly improves perinatal outcomes
In particular, we found a 54% reduction in the risk of LGA
Screening for gestational diabetes mellitus: one step versus two step approach. A meta-analysis of randomized trials
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
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