- Click here for explanation of classification scheme.

To highlight the rationale and mangement approach in GDM.  The article primarily focuses on the management protocol in use at the University of Texas Health Science Center at San Antonio for a large inner city population.  For all types of diabetes in pregnancy, current approaches call for intensification of treatment to manage glucose levels with the goal of achieving and maintaining near normal glycemia throughout pregnancy.

Article inclusion criteria not described.

Not described.

Recruitment Article selection methods not described.

Design Narrative Review.

Blinding used (if applicable): Not applicable

Intervention (if applicable): Not applicable

Statistical Analysis: Not applicable

 

Timing of Measurements: Not applicable

Dependent Variables:  Not applicable

Independent Variables:  Not applicable

Control Variables:  Not applicable

 

Initial N: 89 citations

Attrition (final N):  89

Age: Not described.

Ethnicity: Not described.

Other relevant demographics: Not described.

Anthropometrics:  Not described.

Location: Not described fully.  Several studies were conducted by the authors in San Antonio, Texas.

 

The principal foundation of the management of the gestational diabetic patient should include

1. verified data using self-monitoring of blood glucose
2. appropriate insulin dose (approximately 90 U) to obtain good glycemic control due to the increased insulin resistance and decreased insulin secretion
3. multiple insulin administration in three daily injections
4. achievement and maintenance of an optimal level of glycemic control with a mean blood glucose ranging between 90 and 100 mg/dL
5. elective delivery for selective indications only and permitting the remainder of patients with GDM to await spontaneous labor until 42 weeks' gestation
6. delivery by cesarean section for infants weighing 4250 g.

 

We believe that the intensified management approach is associated with enhanced perinatal outcomes and with decreased economic cost in comparison with traditional conventional methods of management.

Authors prescribe 25 cal/kg for actual body weight for obese patients (BMI >27), 30 cal/kg for nonobese women (BMI 20-26), and 38 cal/kg for underweight patients (BMI < 20), divided into 3 meals and 3 snacks, 55% carb, 25% protein and 20 % fat. 

Authors discuss whether hypocaloric diets are realistic for patients and suggest that the use of milder caloric restriction (20-25 kcal/kg) may be considered promising because they are not associated with the presence of ketonuria and growth delay of the fetus.

The metabolic rationale for the therapeutic use of cardiovascular conditioning in the gestational diabetic woman is compelling and parallels the argument of the individual with NIDDM.  The metabolic benefits of exercise, in part, seem to be related to the ability to enhance insulin senstivity and improvement in hepatic glucose output.  However, the positive effects of exercise in GDM pregnancies has not been established and requires further research.

Insulin requirements in pregnancy are higher in weeks 20-30 vs. week 30 on.

Pt's with fasting BG of 95 or higher should be assigned to insulin treatment to prevent macrosomia.

The A1C test can be misleading during pregnancy.  Yet, self-monitoring is useful during GDM and is cost-efficient.  The use of verifed blood glucose from values obtained by a memory reflectance meter in conjunction with patient education and positive patient-provider interaction results in high compliance regardless of socioeconomic level and ethnic diversity according to research conducted by authors.

The authors assessed metabolic control and emotional well-being and found no differences between groups using either diet or insulin to manage GDM.  Further, intensified therapy with self-monitoring of blood glucose and liberal use of insulin for GDM is not associated with a negative psychological profile.

Assessment of the likelihood of fetal pulmonary maturation is universally recommended before elective delivery, either by confirmation of gestational age or by identification of other markers of lung maturation.

In the presence of large-for-gestational age, the authors delay elective delivery up to a weight estimation of approximately 4000g.  Induction of labor is then performed, because the daily accelerated growth rate of the large-for-gestational-age infant is approximately 40 to 50 g per day.  This maximizes the possibility for vaginal delivery.

A second indication for delivery of the patient with GDM is poor compliance or poor glycemic control.

University/Hospital:

Unviersity of Texas Health Science Center at San Antonio

The authors do a good job of integrating their own research findings with other available evidence.

Methods for choosing the articles included are not described, however, they do point out that review will draw largely from their own research.