What are the American College of Obstetricians and Gynecologists (ACOG) recommendations for delivery timing in women with gestational diabetes?

ACOG Recommendations for Delivery Timing in Gestational Diabetes

ACOG recommends delivery during the 39th week of gestation for women with well-controlled gestational diabetes, with earlier delivery at 38 weeks for those requiring medication for glucose control. 1

Timing of Delivery Based on Treatment Requirements

Well-Controlled GDM with Diet/Lifestyle Only

• Recommended delivery window: 39 weeks 0 days to 40 weeks 6 days 2
• No data supports routine delivery before 38 weeks in the absence of maternal or fetal compromise 3
• Prolonging pregnancy beyond 40 weeks requires intensified fetal surveillance 3

GDM Requiring Medication (Insulin or Oral Agents)

• Recommended delivery window: 39 weeks 0 days to 39 weeks 6 days 2
• Earlier delivery at 38 weeks may be appropriate as evidence indicates that:
  • Delivery at 38 weeks prevents more stillbirths compared to 39 weeks 4
  • Prolongation beyond 38 weeks increases risk of macrosomia without reducing cesarean rates 1

Indications for Earlier Delivery (<38 weeks)

Earlier delivery may be warranted in the following situations:

• Poor glycemic control despite maximal therapy
• Fetal growth restriction with abnormal umbilical artery Doppler studies
• Preeclampsia or other maternal comorbidities
• Evidence of fetal compromise on antenatal testing

Fetal Surveillance Recommendations

• Women with well-controlled GDM should be taught to monitor fetal movements during the last 8-10 weeks of pregnancy 3
• For GDM requiring medication, antenatal testing should begin at 32 weeks 2
• Intensified fetal surveillance is recommended when:
  • Pregnancy continues beyond 40 weeks
  • Maternal hyperglycemia is severe
  • Other adverse clinical factors are present

Considerations for Mode of Delivery

• GDM alone is not an indication for cesarean delivery 1
• Consider scheduled cesarean delivery when estimated fetal weight exceeds 4,500g due to significantly increased risk of shoulder dystocia (19.9-50%) 1, 2
• Induction of labor should not occur before 39 weeks unless glycemic control is poor or other indications for delivery are present 5

Important Clinical Pitfalls

1. Avoid routine early delivery: There is no evidence supporting delivery before 38 weeks in well-controlled GDM without complications 3

2. Balance risks carefully: When considering timing of delivery, weigh the risks of stillbirth against those of neonatal morbidity from early term delivery 4

3. Consider cervical favorability: In multiparous women with unfavorable cervix, induction before 39 weeks is associated with significantly higher cesarean rates (17.39% vs 2.2%) 6

4. Don't neglect postpartum follow-up: All women with GDM should be screened at 4-12 weeks postpartum with a 75g oral glucose tolerance test to identify persistent glucose abnormalities 1, 7

The evidence clearly supports a balanced approach that considers glycemic control, need for medication, and presence of other complications when determining optimal delivery timing in women with gestational diabetes.