ACOG Issues New Guidelines for Management of Gestational Diabetes
WESTPORT, CT (Reuters Health) Sept 07 - The American College of Obstetricians and Gynecologists (ACOG) has issued new clinical guidelines to replace those issued in December 1994 regarding the management of gestational diabetes mellitus (GDM).
Lead author Dr. Donald R. Coustan told Reuters Health that "ACOG educational bulletins get reviewed on a regular basis." The result in this case wasn't a drastic change in guidelines, he said, but some change in emphasis and clarification of some issues.
ACOG recommends in the September issue of Obstetrics and Gynecology that all pregnant patients be screened for GDM. In the absence of known risk factors for GDM, a personal history may be sufficient. However, the authors point out, many physicians choose to screen all pregnant patients.
Dr. Coustan, who is affiliated with Brown University in Providence, Rhode Island, pointed out, "One problem is that there's not good solid evidence that screening a population is of benefit. Most believe it to be, but it's not malpractice not to."
The laboratory screening test should use a 50-gram, 1-hour glucose challenge at 24 to 28 weeks' gestation, with a threshold of 130 or 140 mg/dL. "In our bulletin we gave both sets of thresholds because either would be reasonable," Dr. Coustan said. "One of the problems is that the relationship between glucose intolerance and macrosomia is probably not a step function, but a continuous function. So there's no one place above which you're absolutely abnormal, and no place below which you're guaranteed to be normal."
Office-based glucose testing using capillary blood is generally not recommended.
The guidelines do not specifically recommend daily self-monitoring. However, if this is instituted, postprandial glucose values appear to be more informative than fasting levels in determining the likelihood of adverse pregnancy outcomes.
"This issue involves some controversy," Dr. Coustan said, "because people who have pre-existing diabetes usually monitor their preprandial glucose measurements outside of pregnancy. However, new data uncovered since the last issue of the bulletin caused us to change our view on postprandial glucose levels."
In its document, ACOG cautions that if the patient uses caloric restriction, the restriction should not exceed 33% of calories. Use of insulin should be considered if medical nutritional therapy fails. Failure would include fasting glucose levels >95 m/dL, 1-hour postprandial values greater than 130 to 140 mg/dL, or 2-hour postprandial values >120 mg/dL.
If the estimated fetal weight exceeds 4500 grams, cesarean delivery may reduce the likelihood of brachial plexus injury in the infant.
Obstet Gynecol 2001;98:525-538.
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