Elective cesarean delivery to avoid brachial plexus injuries in overgrown fetuses is another important issue. The American College of Obstetricians and Gynecologists (2017a) has concluded that data are insuicient to determine whether cesarean delivery in women with gestational diabetes whose fetuses have a sonographically estimated weight �4500 g should be performed to avoid risk of birth trauma. From their systematic review, Garabedian and coworkers (2010) estimated that as many as 588 cesarean deliveries in women with gestational diabetes and an estimated fetal weight of �4500 g would be necessary to avoid one case of permanent brachial plexus palsy. Scifres and colleagues (2015), in their retrospective analysis of 903 women with gestational diabetes who underwent so nographic evaluation within 1 month of delivery, demonstrated that sonographic estimates of fetal weight typically overdiagnosed fetuses as being LGA. Only 22 percent of women estimated to have an LGA fetus actually delivered an overgrown newborn. Still, the American College of Obstetricians and Gynecologists (2016a) acknowledges that prophylactic cesarean delivery may be considered in diabetic women with an estimated fetal weight �4500 g.
Recommendations for postpartum evaluation are based on the 50-percent likelihood of women with gestational diabetes developing overt diabetes within 20 years (O'Sullivan, 1982). The Fifth International Workshop Conference on Gestational Diabetes recommended that women diagnosed with gestational diabetes undergo postpartum evaluation with a 75-g OGTT (Metzger, 2007). These recommendations are shown in Table 57-14 along with the classification scheme of the ADA (20 17b). Eggleston and colleagues (2016) reviewed insurance claim data from 2000 to 2013 and found that only 24 percent of women with a pregnancy complicated by gestational diabetes underwent postpartum screening within a year, and less than half of those underwent a 75-g OGTT. he American College
TABLE 57-14. Fifth International Workshop-Conference: Metabolic Assessments Recommended after Pregnancy with
Fasting or random plasma glucose 75-g, 2-hr OGI 75-g, 2-hr OGTI 75-g, 2-hr OGTI 75-g, 2-hr OGTI
Classification of the American Diabetes Association (2013) 2 hr <140 mg/dL 2 hr �140-199 mg/dL Hemoglobin A1c<5.7% 5.7-6.4%
OGTI = oral glucose tolerance test.
Detect persistent, overt diabetes
Postpartum classification of glucose metabolism Assess glucose metabolism 2 hr �200 mg/dL �6.5%
Data from American Diabetes Association, 2013, 2017a; Metzger, 2007.
of Obstetricians and Gynecologists (2017a) recommends either a fasting glucose or the 75-g, 2-hour OGTT at 4 to 12 weeks postpartum for the diagnosis of overt diabetes. he ADA (2017a) recommends testing at least every 3 years in women with a history of gestational diabetes but normal postpartum glucose screening.