J. Seth Hawkins

Weekly compared with daily blood glucose monitoring in women with diet-treated gestational diabetes.

OBJECTIVE: To estimate whether daily blood glucose self-monitoring reduces macrosomia when compared with weekly office testing in women with gestational diabetes. METHODS: Between January 1991 and December 1997, standard treatment at our hospital for women with diet-treated gestational diabetes included routine office monitoring of fasting blood glucose. Beginning in January 1998, blood glucose self-monitoring (four times daily) became the standard management. Women with diet-treated gestational diabetes who underwent routine office-based monitoring of fasting glucose values were compared with similar women who used blood glucose self-monitoring. The outcomes of interest were birthweight at or above 4,000 g and large for gestational age (LGA) in relation to the method of blood glucose self-monitoring. RESULTS: A total of 315 women used daily blood glucose self-monitoring, and they were compared with 675 women with weekly office-based glucose testing. Women with daily blood glucose self-monitoring had fewer macrosomic (29.5% compared with 21.9%, P=.013) and LGA neonates (34.4% compared with 23.1%, P≤.001) and gained significantly less weight (median 0.56, interquartile range 0.22–1.08 lb per week compared with 0.74, interquartile range 0.33–1.17 lb per week, P=.009). CONCLUSION: Daily blood glucose self-monitoring, compared with weekly office-based testing, is associated with a reduction in the incidence of macrosomia. LEVEL OF EVIDENCE: II

Diet-treated gestational diabetes mellitus: comparison of early vs routine diagnosis

OBJECTIVE The purpose of this study was to compare pregnancy outcomes in women with diet-treated gestational diabetes mellitus (GDM) that was diagnosed at < 24 weeks of gestation to those women who received the diagnosis at > or = 24 weeks of gestation. STUDY DESIGN This was a retrospective cohort study of 2596 women with diet-treated GDM who delivered between December 1999 and June 2005 at Parkland Hospital. Women with risk factors for GDM underwent immediate glucose screening; women without risk factors underwent universal glucose screening between 24 and 28 weeks of gestation. Women with diet-treated GDM that was diagnosed at < 24 weeks of gestation (n = 339; 13.1%) were compared with those women who received the diagnosis at > or = 24 weeks of gestation. RESULTS Women with an earlier diagnosis of diet-treated GDM were at increased risk of preeclampsia and the delivery of large infants. Even after adjustment for differences in maternal characteristics and glycemic control, the risk of preeclampsia persisted (odds ratio, 2.4; 95% CI, 1.5, 3.8). CONCLUSION Women with an early diagnosis of diet-treated GDM have a 2-fold increased risk of preeclampsia.

Current pharmacotherapy options for labor induction

Introduction: Labor induction is now reported to occur in up to 30 – 40% of obstetrical patients. There are a number of pharmacological options available to facilitate labor induction, including oxytocin and analogues of prostaglandins E1 and E2, which have particular utility when labor induction necessitates cervical ripening, as when labor induction occurs in the context of an unfavorable cervix. Areas covered: This paper reviews acceptable pharmacological options for labor induction, especially when cervical ripening is required. These options include oxytocin and a number of prostaglandin formulations using dinoprostone and misoprostol. It also covers several analyses of published clinical trials (Phase-III) describing evidence of effectiveness. Expert opinion: Oxytocin is best used when labor needs to be induced in the context of a favorable cervix. When the cervix is not favorable, cervical ripening using prostaglandins should precede labor induction. Either dinoprostone or misoprostol are superior to oxytocin alone for cervical ripening. However, judicious, careful considerations need to be made at the outset of labor induction so as to balance maternal and fetal risks, and these should be guided by institutional policies that reflect the evidence-base.