What is the initial treatment for gestational diabetes?

Initial Treatment for Gestational Diabetes

Lifestyle modification is the essential first-line treatment for gestational diabetes mellitus (GDM) and may suffice for 70-85% of women diagnosed with this condition. 1

Lifestyle Interventions

Medical Nutrition Therapy

• An individualized nutrition plan should be developed between the patient and a registered dietitian familiar with GDM management 1
• The food plan should provide adequate calories to promote fetal/neonatal and maternal health, achieve glycemic goals, and promote appropriate gestational weight gain 1
• Dietary recommendations include:
  • Minimum 175 g of carbohydrate daily 1
  • Minimum 71 g of protein daily 1
  • 28 g of fiber daily 1
  • Emphasis on monounsaturated and polyunsaturated fats while limiting saturated fats and avoiding trans fats 1
• The amount and type of carbohydrate significantly impact glucose levels, especially postprandial excursions 1

Physical Activity

• Regular physical activity should be incorporated into the treatment plan 1
• Generally healthy pregnant women should aim for at least 150 minutes of moderate-intensity aerobic activity weekly, preferably spread throughout the week 1
• Exercise interventions have been shown to improve glucose outcomes and reduce insulin requirements 1, 2

Blood Glucose Monitoring

• Self-monitoring of blood glucose is essential with targets of:
  • Fasting < 95 mg/dL (5.3 mmol/L) and either 1
  • One-hour postprandial < 140 mg/dL (7.8 mmol/L) or 1
  • Two-hour postprandial < 120 mg/dL (6.7 mmol/L) 1

Pharmacological Therapy

If glycemic targets are not achieved with lifestyle modifications alone, pharmacological therapy should be initiated:

Insulin Therapy

• Insulin is the preferred medication for treating hyperglycemia in GDM as it does not cross the placenta to a measurable extent 1
• Insulin is recommended as the first-line pharmacological agent in the United States 1, 3

Oral Agents

• Metformin and glyburide should not be used as first-line agents as both cross the placenta to the fetus 1
• In two randomized controlled trials, glyburide and metformin failed to provide adequate glycemic control in 23% and 25-28% of women with GDM, respectively 1
• Long-term safety data for offspring exposed to oral agents are not available 1

Common Pitfalls and Caveats

• Failure to recognize that most women (70-85%) can achieve glycemic targets with lifestyle modifications alone 1
• Delayed initiation of pharmacological therapy when lifestyle modifications are insufficient 1, 3
• Women with greater initial degrees of hyperglycemia may require earlier initiation of pharmacological therapy 1
• Inadequate monitoring of blood glucose levels to assess treatment effectiveness 1
• Not considering the long-term risks for both mother and child:
  • Women with GDM have increased risk of developing type 2 diabetes after pregnancy 3, 4
  • Children exposed to maternal hyperglycemia have increased risk of obesity and abnormal glucose metabolism 1, 5

Telehealth Considerations

• Telehealth visits for pregnant people with GDM have been shown to improve outcomes compared with standard in-person care 1
• A meta-analysis of 32 RCTs demonstrated that telehealth visits for GDM reduced incidences of cesarean delivery, neonatal hypoglycemia, and other complications compared with standard in-person care 1