Current trends in the diagnosis and management of gestational diabetes mellitus in the United States.

OBJECTIVE: To assess current practice patterns among members of the Society for Maternal-Fetal Medicine (SMFM) with respect to the diagnosis and management of gestational diabetes mellitus (GDM). METHODS: A 38 question survey on GDM diagnosis and management was distributed to SMFM members. RESULTS: 2330 SMFM members were surveyed with a 40% response rate. Overall, 90.6% of respondents recommend a 2-step (versus a 1-step) diagnostic test. Cutoff values for the 1-h-50 g glucose challenge test vary from 130-140 mg/dL, but the majority (83%) adopts Carpenter Coustan criteria for the 3-h-100 g oral glucose tolerance test. The majority recommend glucose testing four times a day, with 55% preferring post-prandial testing at 2 h. Glyburide is used by 57% as a first-line agent, while 4% use metformin. Long-acting insulin analogs (glargine and/or detemir) are used by 46% and 33.6% of respondents, respectively. Antenatal testing is recommended by 38.7% for diet-controlled GDM compared to 98.7% for pharmacologically controlled GDM, with 56% starting by 34 weeks gestation. Most respondents recommend delivery of diet-controlled GDM at 40 weeks and pharmacologically controlled GDM at 39 weeks. Most (69%) offer elective cesarean section for an estimated fetal weight of >4500 g. CONCLUSIONS: There is significant variation in the diagnosis and management of GDM among SMFM members.

Randomized controlled trial of insulin detemir versus NPH for the treatment of pregnant women with diabetes.

OBJECTIVE: We sought to determine if insulin detemir (IDet) is noninferior to insulin neutral protamine Hagedorn (NPH) for the treatment of gestational diabetes mellitus (GDM) and type 2 diabetes mellitus (T2DM) in pregnancy. STUDY DESIGN: We conducted a randomized, controlled noninferiority trial of women with GDM and T2DM who entered our Diabetes in Pregnancy Program from March 2013 through October 2014. Exclusion criteria were type 1 diabetes, age <18 years, and insulin allergy. Women who failed to achieve good glycemic control (GC) (mean blood glucose [BG] <100 mg/dL) on diet and/or hypoglycemic agents were randomized to receive either IDet or NPH, with short-acting insulin aspart added as needed. Patients were instructed to test BG 4 times a day (fasting and 2-hour postprandial). Targets of GC were fasting BG <90 mg/dL and postprandial BG <120 mg/dL, and insulin was adjusted as needed to achieve the targets. The primary outcome was overall mean BG during insulin treatment; secondary outcomes included overall mean postprandial and fasting BG, median number of weeks to achieve GC, percent of patients with overall GC, maternal weight gain, perinatal/neonatal outcomes, and number of hypoglycemic events. Power analysis (90% power) determined that 88 patients would need to be randomized, assuming a maximal acceptable difference in overall mean BG of 7 mg/dL (SD ± 10 mg/dL). A per protocol analysis was performed. RESULTS: In all, 105 women were randomized. Eighteen women were excluded leaving 87 participants for analysis (45 NPH, 42 IDet). Maternal characteristics were similar in both groups. The difference in the mean BG of the groups was 2.1 mg/dL with a 1-sided upper 95% confidence limit of 5.5 mg/dL (less than the maximal acceptable difference of 7 mg/dL; P = .2937). There was no significant difference in the primary outcome when an intent-to-treat analysis was performed or when the T2DM patients were excluded. The time to achieve GC was similar in both groups. There were no differences in perinatal outcomes and maternal weight gain among the groups. There were more hypoglycemic events per patient in the NPH group. CONCLUSION: IDet is noninferior to insulin NPH for the treatment of GDM and T2DM in pregnancy.

Labor induction in nulliparous women with an unfavorable cervix: double balloon catheter versus dinoprostone.

OBJECTIVE: We sought to compare the efficacy of the double-balloon catheter and dinoprostone for induction of labor among nulliparous women with an unfavorable cervix. STUDY DESIGN: Nulliparous women with a Bishop score <6 were randomized to receive a 10-mg intra-vaginal dinoprostone insert or a double-balloon catheter. Primary outcome was time to delivery. Statistical analyses were performed by intention to treat using the chi-square, Fisher's exact, and Student's t-test, as appropriate. RESULTS: The mean induction-to-delivery time was shorter in the double-balloon group as compared to the dinoprostone group (17.9±5.8 vs. 26.3±9.7 h) as was the time from induction to vaginal delivery (19.13±5 vs. 24.45±8.7 h, respectively). More women in the catheter group were delivered within 24 h compared to the dinoprostone group (87.1% vs. 47.4%). Approximately 50% of women in both groups delivered by cesarean section. CONCLUSION: Induction of labor with the double-balloon catheter in nulliparous women with an unfavorable cervix is associated with a shorter time to delivery compared to dinoprostone.

Trial of labor versus repeat cesarean: are patients making an informed decision?

OBJECTIVE: Most women eligible for a trial of labor after a cesarean (TOLAC) undergo an elective repeat cesarean section (ERCS). We hypothesized that this is largely because of poor patient education. STUDY DESIGN: This was a prospective study of women who presented to our hospital from November 2010 through July 2011 who were candidates for TOLAC. Women filled out a questionnaire prior to their scheduled ERCS or upon admission for TOLAC. A χ(2) and a Student t test were used, as appropriate. RESULTS: The study included 155 women, 87 for TOLAC and 68 for ERCS. Women in both groups demonstrated a lack of knowledge on the risks and benefits of TOLAC and ERCS. When patients perceived their providers as having a preference for ERCS, very few chose TOLAC, whereas the majority chose TOLAC if this was their provider's preference. CONCLUSION: Candidates for TOLAC appear to know little about the risks and benefits associated with their mode of delivery, and provider preference affects this choice.

The proceedings of the diabetes in pregnancy study group of North America 2009 conference.

The DPSG of North America (DPSG-NA) was inaugurated in 1997, and its initial meeting was commenced in San Antonio, Texas, in 1998. Since then, the DPSG-NA has held annual meetings, which are hosted by the home institution of members of the organizing committee on a rotating basis. This yeas, the DPSG-NA held its 11 annual meeting in Baltimore, Maryland, and focused on the major controversies regarding the detection, diagnosis, and management of gestational diabetes mellitus (GDM). It included the latest information on the maternal and fetal consequences of GDM as well as summaries from the HAPO study, the Australian Carbohydrate Intolerance Study (ACHOIS) in pregnant women, and the National Institute of Child Health and Human Development Maternal Fetal Medicine (NICHD MFMU Network) study. In addition, extensive data were presented on the effectiveness of oral antihyperglycemic agents in managing GDM as well as data from studies examining their transfer across the placenta and effects on the fetus. Strategies for managing hypertensive disorders associated with GDM were also presented. Based on this year's presentations, the DPSG-NA coordinating committee has made recommendations on the screening and management of GDM and priorities for future research.

The glyburide report card.

Over the past decade, several studies have been published describing the use of glyburide for the treatment of women with gestational diabetes (GDM). These studies include randomized prospective trials, prospective studies, and cohort studies. With a total of more than 1000 patients, they encompass a wide range of patient populations and treatment centers and demonstrate the effectiveness of oral treatment in achieving good glycemic control in women with GDM. Taken together, these studies have demonstrated that glyburide is as safe and as useful as insulin for the treament of women with GDM and will likely become universally accepted as the first line drug of choice for treatment of this condition.

Antenatal fetal testing in pregnancies complicated by gestational diabetes mellitus.

Most obstetricians adapt some form of strategy for antenatal fetal testing in pregnancies complicated by gestational diabetes mellitus (GDM). There are, however, wide differences of opinion among providers as to the preferred protocol for such testing. The optimal method of fetal surveillance, the gestational age at which to start testing, the frequency of testing, and even whether all patients with GDM require antenatal testing are all controversial, unresolved issues. Indeed, in the absence of prospective, randomized clinical trials, it is impossible to determine whether antenatal fetal testing is beneficial in uncomplicated GDM. Moreover, it appears that even with the use of well-defined antenatal testing protocols, it is unavoidable that some women with GDM will experience an unexplained third trimester stillbirth. Pending the availability of solid data based on prospective trials, it is prudent to incorporate antenatal fetal testing in the management scheme of women with gestational diabetes.