ACOG Recommendations for Delivery Timing in Gestational Diabetes
ACOG recommends delivery during the 38th week of gestation for patients with gestational diabetes mellitus (GDM), as prolongation of pregnancy beyond 38 weeks increases the risk of fetal macrosomia without reducing cesarean rates. 1
Delivery Timing Based on Glycemic Control
The timing of delivery for patients with GDM depends primarily on glycemic control and whether medication is required:
Diet-controlled GDM:
- Recommended delivery: 39 0/7 to 40 6/7 weeks of gestation 2
- These patients have lower risks of complications when glucose is well-controlled with lifestyle modifications alone
Medication-controlled GDM:
- Recommended delivery: 39 0/7 to 39 6/7 weeks of gestation 2
- Earlier delivery window is recommended due to increased risks of complications
Special Considerations for Delivery Timing
Poorly Controlled GDM
- Increased surveillance is appropriate when fasting glucose levels exceed 105 mg/dl (5.8 mmol/l) or pregnancy progresses past term 1
- These patients are at higher risk for fetal demise and may require earlier delivery
Fetal Growth Abnormalities
- For GDM pregnancies complicated by fetal growth restriction:
Fetal Macrosomia
- When estimated fetal weight exceeds 4,500g, discussion about prelabor cesarean delivery is recommended to reduce risk of shoulder dystocia 3
- Risk of shoulder dystocia increases significantly in GDM pregnancies with macrosomic fetuses (19.9-50% when birth weight >4,500g) 1
Management During Labor and Delivery
- Maternal glucose monitoring during labor is recommended
- For patients on insulin, glucose management during labor can include decreased glucose testing and sliding-scale insulin dosing rather than continuous intravenous insulin 3
- GDM itself is not an indication for cesarean delivery 1
Postpartum Considerations
- Reclassification of maternal glycemic status should be performed at 4-12 weeks postpartum 4, 2
- A 75g oral glucose tolerance test is the recommended screening method postpartum 4, 2
- Breastfeeding should be encouraged to reduce the risk of maternal type 2 diabetes 4
Important Caveats
- Delivery timing should account for other obstetric factors that may necessitate earlier delivery
- Antenatal corticosteroids should be administered if delivery is anticipated before 34 weeks of gestation 1
- Regular obstetric examinations including ultrasound are recommended to monitor fetal growth and well-being 5
The most recent evidence supports delivery during the 38th week for most GDM patients, with adjustments based on glycemic control and presence of complications. This approach balances the risks of continuing the pregnancy (macrosomia, shoulder dystocia) against the risks of earlier delivery (neonatal respiratory issues).