What is the recommended management approach for gestational diabetes?

From the Guidelines

The recommended management approach for gestational diabetes involves a combination of lifestyle modifications and medication when necessary, with insulin as the preferred medication for treating hyperglycemia, as stated in the most recent guidelines 1.

Key Components of Management

• Initial management should focus on dietary changes, including a carbohydrate-controlled diet with approximately 175g of carbohydrates daily, distributed across three meals and 2-3 snacks, as recommended by previous studies 1.
• Regular physical activity of 30 minutes daily is also recommended, as it can help lower fasting and postprandial plasma glucose concentrations 1.
• Blood glucose monitoring should be performed 4 times daily: fasting (target <95 mg/dL) and 1-hour postprandial after each meal (target <140 mg/dL), as outlined in the latest standards of care 1.

Medication Therapy

• If glucose targets aren't achieved after 1-2 weeks of lifestyle modifications, medication therapy should be initiated, with insulin as the first-line medication, as recommended by the latest guidelines 1.
• Insulin regimens typically start with long-acting insulin (such as insulin glargine 0.2 units/kg/day) at bedtime for elevated fasting glucose, or rapid-acting insulin (such as insulin aspart or lispro 2-4 units) before meals for postprandial hyperglycemia.
• Oral agents like metformin or glyburide may be alternatives, though insulin remains preferred due to its safety profile and effectiveness, as noted in several studies 1.

Fetal Monitoring

• Regular fetal monitoring is essential, including ultrasounds to assess growth and non-stress tests starting at 32 weeks, to prevent complications such as macrosomia, neonatal hypoglycemia, and birth trauma, while minimizing maternal hypoglycemia risk, as recommended by the latest guidelines 1.

Telehealth Visits

• Telehealth visits for pregnant people with gestational diabetes mellitus have been shown to improve outcomes compared with standard in-person care, as demonstrated in a meta-analysis of 32 RCTs 1. This comprehensive approach aims to maintain normal glucose levels and prevent complications associated with gestational diabetes, while also considering the latest evidence and guidelines in the field 1.

From the Research

Management Approach for Gestational Diabetes

The recommended management approach for gestational diabetes involves a combination of lifestyle modifications and medical treatment.

• Nutrition therapy is the first option for the majority of pregnancies, with light to moderate physical activity recommended in the absence of obstetrical contraindications 2.
• Medical treatment is recommended if glycemic control is not achieved or if excessive fetal growth is detected by ultrasound 2.
• Insulin is the standard treatment, although oral antidiabetic drugs such as metformin and glyburide have been considered as effective and safe options 2, 3, 4.

Insulin Management

Insulin is preferred as the first-line agent for glucose management of gestational diabetes mellitus when nutritional and lifestyle modifications are unable to achieve pregnancy-specific glucose targets 5.

• Newer insulin preparations have been developed to mimic the physiologic release of endogenous insulin, maintaining appropriate basal levels to cover hepatic gluconeogenesis and simulate the rapid, meal-related, bolus rise of insulin 5.
• Physiologic basal-bolus dosing of insulin can be administered safely, achieving tighter glycemic control while reducing episodes of hypoglycemia 5.

Oral Antidiabetic Drugs

Metformin and glyburide are two oral antidiabetic drugs that have been studied as alternatives to insulin for the management of gestational diabetes.

• A study found that metformin and glyburide were equivalent in terms of maternal glucose levels, birth weight, and neonatal outcomes 3.
• Another study found that glyburide and metformin appear to be safe and effective to manage blood glucose in patients with gestational diabetes who prefer to not utilize insulin or who cannot afford insulin therapy 4.

Monitoring and Treatment

Monitoring of gestational diabetes treatment includes capillary glucose measurements and evaluation of fetal abdominal circumference by ultrasound performed around the 28th gestational week 2.

• Management strategies increasingly emphasize optimal management of fetal growth and weight, with monitoring of glucose, fetal stress, and fetal weight through ultrasound combined with maternal weight management, medical nutritional therapy, physical activity, and pharmacotherapy 6.