Treatment Goals of Therapy

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The goals of therapy in GDM are to decrease both maternal and fetal morbidity and mortality attributed to the disease. In particular, to limit macrosomia, intrauterine demise and neonatal morbidity. Preventing macrosomia has been found to decrease birth trauma, and cesarean-section rate (51).

Maternal hyperglycemia conclusively poses a threat to the well-being of the fetus. Fasting hyperglycemia (FPG > 105 mg/dL) is associated with increased risk of fetal death (17,18). Higher postprandial glucose values during weeks 29 to 32 are associated with fetal macrosomia (52). One hour postprandial glucose is a strong predictor of infant birth weight and fetal macrosomia (53). The risk of macrosomia is a continuum that increases further if 1 h postprandial glucose is > 120 mg/dL whole blood capillary glucose (plasma glucose of approximately 140 mg/dL). Despite aggressive treatment with diet, exercise and insulin therapy, which may normalize glycosylated hemoglobin (HbA1c), neonatal morbidities persist. The relative risk of neonatal hypoglycemia remains elevated at 5.7, macrosomia risk is elevated 3.2-fold, and polycythemia, hypocalcemia, and hyperbilirubinemia are increased 2.0-fold (7).

Attaining good glycemic control is the cornerstone of therapy. Treatment is aimed at maintaining normoglycemia, and limiting maternal ketosis. Controlling blood sugars using postprandial glucose monitoring goals (1 h postprandial whole blood glucose <140 mg/dL) in combination with fasting blood glucose measurement (fasting blood glucose 60-90 mg/dL) can optimize glycemic control and significantly improve pregnancy outcomes, by decreasing neonatal hypoglycemia, macrosomia and cesarean-section rates (54). Recent assessments of obstetrician gynecologists by self report noted that 96% routinely screen for GDM, nearly all by using a 50-g glucose 1-h oral test. With medical nutrition therapy (MNT), almost 75% of respondents recommend exercise for patients with GDM. When MNT is ineffective for their patients with GDM, 82% of respondents initially prescribe insulin, whereas 13% begin with glyburide. Nearly 75% of respondents routinely perform a postpartum evaluation of glucose tolerance in the patient with GDM. The targets for blood glucose results were fasting mean 97.3 mg/dL; preprandial mean 103.6 mg/dL; 1-h postprandial mean 134.6 mg/dL; 2-h postprandial mean 122.1 mg/dL (55). This shows a significant improvement in adherence to practice guidelines compared to similar previous survey studies (55).

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