Timing of treatment initiation for mild gestational diabetes mellitus and perinatal outcomes

Abstract

Objective To examine the association between gestational age (GA) at the time of treatment initiation for gestational diabetes (GDM) and maternal and perinatal outcomes. Study Design A secondary analysis of a multicenter randomized treatment trial of mild GDM in which women with mild GDM were randomized to treatment versus usual care. The primary outcome of the original trial, as well as this analysis, was a composite perinatal adverse outcome that included neonatal hypoglycemia, hyperbilirubinemia, hyperinsulinemia, and perinatal mortality. Other outcomes examined included the frequency of large for gestational age (LGA), birth weight, neonatal intensive care unit admission (NICU), gestational hypertension / preeclampsia and cesarean delivery. The interaction between GA at treatment initiation (stratified as 24-26 weeks, 27 weeks, 28 weeks, 29 weeks, ≥30 weeks) and treatment group (treated vs. routine care), with the outcomes of interest, was used to determine whether GA at treatment initiation was associated with outcome differences. Results Of 958 women analyzed, those who initiated treatment at an earlier GA did not gain an additional treatment benefit compared to those who initiated treatment at a later GA (p-value for interaction with the primary outcome is 0.44). Similarly, there was no evidence that other outcomes were significantly improved by earlier initiation of GDM treatment (LGA p=0.76; NICU admission p=0.8; cesarean delivery p=0.82). The only outcome that had a significant interaction between GA and treatment was gestational hypertension/preeclampsia (p=0.04), although there was not a clear cut GA trend where this outcome improved with treatment. Conclusion Earlier initiation of treatment of mild GDM was not associated with stronger effect of treatment on perinatal outcomes.

What we have learned about treating mild gestational diabetes mellitus

“…Interestingly, the effect of treatment on perinatal outcomes, including a composite of neonatal hypoglycemia, hyperbilirubinemia, hyperinsulinemia, and birth trauma, did not vary by the gestational age of initiation of mild GDM treatment, which ranged from 24 to 31 weeks of gestation. 14 This finding however may not be generalizable to women with more severe forms of GDM. 14 The treatment effect on fetal overgrowth did vary according to neonatal sex, with a significant treatment reduction in birthweight percentile and neonatal fat mass observed in the males but not the females.…”

“…14 This finding however may not be generalizable to women with more severe forms of GDM. 14 The treatment effect on fetal overgrowth did vary according to neonatal sex, with a significant treatment reduction in birthweight percentile and neonatal fat mass observed in the males but not the females. 15 One explanation hypothesized for these findings was that there may be gender differences in susceptibility to oxidative stress or in the response to a treatment that might mitigate oxidative stress, however markers of oxidative stress were not measured to evaluate this hypothesis.…”

Identifying risk effectors involved in neonatal hypoglycemia occurrence

“…Accumulated studies have shown that pregnancy complications, such as pregnancy-induced hypertension (PIH), gestational diabetes mellitus (GDM) and intrahepatic cholestasis (ICP), could affect perinatal situations [7][8][9][10][11][12][13]. Glucose plays important roles in brain metabolism and brain development in newborns.…”

Proportion of abnormal second 50‐g glucose challenge test in gestational diabetes mellitus screening using the two‐step method in high‐risk pregnant women

“…In late‐onset GDM, we found that there was insignificant higher cesarean section rate (41.9% vs 25.0%, P = 0.210) and more large for gestational age (LGA) (7.0% vs 2.1%, P = 0.429). Palatnik et al . and Black et al .…”