Intravenous infusion of normal saline is begun.
Once active labor begins or glucose levels decrease to less than 70 mg/dL, the infusion is changed from saline to 5% dextrose and delivered at a rate of 100-150 cc/h (2.5 mg/kg/min) to achieve a glucose level of approximately 100 mg/dL.
Glucose levels are checked hourly using a bedside meter allowing for adjustment in the insulin or glucose infusion rate.
Regular (short-acting) insulin is administered by intravenous infusion at a rate of 1n.25 U/h if glucose levels exceed 100 mg/dL.
Data from Coustan DR. Delivery: timing, mode, and management. In: Reece EA, Coustan DR, Gabbe SG, editors. Diabetes in women: adolescence, pregnancy, and menopause. 3rd ed. Philadelphia (PA): Lippincott Williams & Wilkins; 2004; and Jovanovic L, Peterson CM. Management of the pregnant, insulin-dependent diabetic woman. Diabetes Care 1980;3:63-8.
stimulate women to seek further testing postpartum. The most important perinatal correlate is excessive fetal growth, which may result in both maternal and fetal birth trauma. he likelihood of fetal death with appropriately treated gestational diabetes is not diferent from that in the general population. Importantly, more than half of women with gestational diabetes ultimately develop overt diabetes in the ensuing 20 years. And, as discussed on page 1097, evidence is mounting for long-range complications that include obesity and diabetes in their ofspring.
Despite almost 50 years of research, there is still no agreement regarding optimal gestational diabetes screening. The diiculty in achieving consensus is underscored by the controversy following publication of the single-step approach espoused by the International Association of Diabetes and Pregnancy Study Groups Consensus Panel (2010) and shown in Table 57-11. his strategy was greatly influenced by results of the Hypoglycemia and Pregnancy Outcomes (HAPO) Study, described later. Although the ADA (2017 a) supports this new scheme, the American College of Obstetricians and Gynecologists (2017a) continues to recommend a two-step approach to screen and diagnose gestational diabetes. Similarly, the NIH Consensus Development Conference in 2013 concluded that evidence is insuicient to adopt a one-step approach.
he recommended two-step approach begins with either universal or risk-based selective screening using a 50-g, I-hour oral glucose challenge test. Participants in the Fifth International
TABLE 57-1 1. Threshold Values for Diagnosis of Gestational Diabetes be equaled or exceeded for the diagnosis of gestational diabetes.
bin addition, 1.7% of participants in the initial cohort were unblinded because of fasting plasma glucose levels >5.8 mmol/L (105 mg/dL) or 2-hr OGTI values > 11n.1 mmollL (200 mg/dL), bringing the total to 17.8%.
OGI = oral glucose tolerance test.
Data from International Association of Diabetes and
Pregnancy Study Groups, 2010.
Workshop Conferences on Gestational Diabetes endorsed use ofselective screening criteria shown in Table 57-12. Conversely, the American College of Obstetricians and Gynecologists (2017a) recommends universal screening of pregnant women using a laboratory-based blood glucose test. It is suggested that attempts to identiy the 10 percent of women who should not be screened would add unnecessary complexity. Screening should
TABLE 57-12. Risk-Based Recommended Screening Strategy for Detecting GDMa
GDM risk assessment: should be ascertained at the first prenatal visit