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Gestational diabetes mellitus: Glucose management and

maternal prognosis
Author: Celeste Durnwald, MD
Section Editors: David M Nathan, MD, Erika F Werner, MD, MS
Deputy Editor: Vanessa A Barss, MD, FACOG
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2022. | This topic last updated: Mar 18, 2022.
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INTRODUCTION
Treatment of gestational diabetes mellitus (GDM) can improve pregnancy outcome. Many
patients can achieve glucose target levels with nutritional therapy alone, but up to 30 percent
will require pharmacotherapy [1]. Even patients with mildly elevated glucose levels who do not
meet standard criteria for GDM may have more favorable pregnancy outcomes if treated since
the relationship between glucose levels and adverse pregnancy outcomes such as macrosomia
exists continuously across the spectrum of increasing glucose levels [2-9].
Glucose management in patients with GDM is reviewed here. Screening, diagnosis, and
obstetric management are discussed separately. (See "Gestational diabetes mellitus: Screening,
diagnosis, and prevention" and "Gestational diabetes mellitus: Obstetric issues and
management".)
RATIONALE FOR TREATMENT
Treatment of GDM is important to minimize maternal and neonatal morbidity. In a U S

Preventive Services Task Force meta-analysis of randomized trials, compared with no treatment,
appropriate management of GDM (nutritional therapy, self-blood glucose monitoring,
administration of insulin when target blood glucose concentrations are not met with diet alone)
resulted in reductions in [10]:
https://www.uptodate.com/contents/gestational-diabetes-mellitus-glucose-management-and-maternal-prognosis/print 1/36
● Preeclampsia (7.2 versus 11.7 percent; relative risk [RR] 0.62, 95% CI 0.43-0.89; three trials,
moderate quality)
● Birth weight >4000 g (8.4 versus 17.4 percent; RR 0.50, 95% CI 0.35-0.71; five trials,
moderate quality)
● Shoulder dystocia (1.5 versus 3.5 percent; RR 0.42, 95% CI 0.23-0.77; three trials, moderate
quality)
The only identified potential harm from treatment of GDM was an increased number of
prenatal visits; however, the frequency and consequences of maternal hypoglycemia in patients
treated with insulin were not reported. No statistically significant differences in rates of
cesarean birth, induction of labor, small for gestational age newborns, neonatal hypoglycemia,
neonatal hyperbilirubinemia, neonatal respiratory complications, birth trauma, or neonatal
intensive care unit admission were demonstrated compared with no treatment, although the
quality of evidence was low.
Some authors have suggested that avoiding maternal obesity and excessive gestational weight
gain may be more important than detecting and treating GDM because maternal weight may
be more closely related to adverse outcomes, particularly fetal overgrowth, than glucose
intolerance [11]. However, data from the Hyperglycemia and Adverse Pregnancy Outcome
(HAPO) study refute this hypothesis. In HAPO, both obesity and GDM (International Association
of Diabetes and Pregnancy Study Groups criteria) were independently predictive of
macrosomia, preeclampsia, primary cesarean birth, and neonatal adiposity [2].
Few trials have evaluated long-term effects of maternal treatment of GDM on offspring. In a
study of 500 offspring of treated versus untreated mothers with mild GDM, treatment during
pregnancy did not reduce late adverse metabolic outcomes (eg, obesity, glucose intolerance) in
offspring age 5 to 10 years [12]. This finding may reflect lack of a true treatment effect,
inadequate treatment of hyperglycemia during pregnancy, the mildness of the glucose
intolerance, or inadequate power to show modest differences in outcome because of the low
prevalence of these disorders prior to puberty, and the small numbers of study participants.
(Mild GDM was defined as fasting plasma glucose <95 mg/dL and two of three timed
measurements that exceeded established thresholds [one hour, 180 mg/dL; two hours, 155
mg/dL; three hours, 140 mg/dL]).
MEDICAL NUTRITIONAL THERAPY
Medical nutritional therapy is the process by which the dietary plan is tailored for patients with
diabetes, based on medical, lifestyle, and personal factors. Patients with GDM should receive
medical nutritional counseling by a registered dietitian (when possible) upon diagnosis and be
placed on an appropriate diet. The goals are to [13]:
● Achieve normoglycemia
● Prevent ketosis
● Provide adequate nutrition
● Provide adequate gestational weight gain based on maternal body mass index (BMI)
● Contribute to fetal well-being
Most patients (up to 85 percent) with GDM based on Carpenter and Coustan criteria can achieve
target glucose levels with lifestyle modification alone [3,14]. A detailed review of medical
nutritional therapy for individuals with diabetes can be found separately. (See "Nutritional
considerations in type 1 diabetes mellitus".)
The specific diet that achieves optimum maternal and newborn outcomes in GDM is unclear
[15-17]. A key simple, achievable intervention is to emphasize the benefits of elimination, or at
least reduction, of consumption of sugar-sweetened beverages (eg, soft drinks, fruit drinks) and
encourage drinking water instead. Noncaloric sweeteners may be used in moderation.
Traditionally, restricting carbohydrate intake (particularly simple carbohydrates) has been
favored because it appears to reduce postprandial hyperglycemia [18] and fetal overgrowth
[19,20].
In a systematic review of randomized trials comparing a variety of dietary interventions (eg, low
glycemic index, DASH, low carbohydrate, energy restriction, soy protein, fat modification,
ethnic, high fiber) with conventional dietary recommendations for patients with GDM (18 trials,
1151 participants), dietary intervention overall reduced fasting and postprandial glucose levels
(fasting: -4.07 mg/dL, 95% CI -7.58 to -0.57; postprandial -7.78 mg/dL, 95% CI -12.27 to -3.29),
need for medication (relative risk [RR] 0.65, 95% CI 0.47-0.88), birth weight (-170.62 g, 95% CI
-333.64 to -7.60), and macrosomia (RR 0.49, 95% CI 0.27-0.88) [16]. When analyzed by diet
subtype, low glycemic index, DASH, low carbohydrate, and ethnicity-based diets had beneficial
effects on maternal glucose levels. A limitation of the analysis was that all of the trials had small
sample sizes.
Probiotics and high fiber diets do not appear to improve glycemic control [21,22].
Meal plan — A typical meal plan for patients with GDM includes three small- to moderate-sized
meals and two to four snacks. Ongoing adjustment of the meal plan is based upon results of
self-glucose monitoring, appetite, and weight-gain patterns, as well as consideration for
maternal dietary preferences and work, leisure, and exercise schedules.
Close follow-up is important to ensure nutritional adequacy. Individual assessment and self-
blood glucose monitoring are used to determine and modify specific nutrition/food
recommendations. If insulin therapy is added to nutritional therapy, a primary goal is to
maintain carbohydrate consistency at meals and snacks to facilitate insulin adjustments.
Calories — The caloric requirements of patients with GDM are the same as those for pregnant
patients without GDM [23]. For individuals with a prepregnancy BMI in the healthy range,
caloric requirements in the first trimester are the same as before pregnancy and generally
increase by 340 calories per day in the second trimester and 452 calories per day in the third
trimester [24]. Individuals who are underweight, overweight, or obese should work with a
registered dietician to determine their specific caloric requirements. (See "Gestational weight
gain".)
Carbohydrate intake — Once the caloric needs are calculated, carbohydrate intake is
determined as it is the primary nutrient affecting postprandial glucose levels. The total amount
of carbohydrate consumed, the distribution of carbohydrate intake over meals and snacks, and
the type of carbohydrate consumed can be manipulated to blunt postprandial hyperglycemia.
Dietary Reference Intakes (DRI) for all pregnant people is a minimum of 175 g of carbohydrate
per day and 28 g of fiber [23]. There is sparse evidence from randomized trials as to the ideal
carbohydrate intake for individuals with GDM. We limit carbohydrate intake to 40 percent of
total calories while ensuring that ketonuria does not ensue [25,26]. Adequately powered studies
are needed to evaluate the effect of various dietary interventions on perinatal outcomes in
GDM.
Many patients will need individual adjustment of the amount of carbohydrate by 15 to 30 g at

each meal, depending on their postprandial glucose levels, which are directly dependent upon
the carbohydrate content of the meal or snack [27]. The postprandial glucose rise can be
blunted if the diet is carbohydrate restricted. However, reducing carbohydrates to decrease
postprandial glucose levels may lead to higher consumption of fat, which may have adverse
effects on maternal insulin resistance and fetal body composition.
In a meta-analysis of randomized trials of dietary intervention in patients with GDM, low

carbohydrate diets had a favorable effect on postprandial blood glucose concentrations and
significantly lowered the need for insulin therapy but did not affect other maternal or newborn
outcomes (eg, macrosomia, cesarean birth, gestational weight gain), although the data were
insufficient to detect small or moderate statistical differences in obstetric outcomes between
the patient groups [28]. (See "Nutritional considerations in type 2 diabetes mellitus", section on
'Glycemic index and glycemic load'.)
Protein and fat intake — The remaining calories come from protein (20 percent of total
calories or approximately 71 g per day [23]) and fats (40 percent of total calories; saturated fat
intake should be <7 percent of total calories). Protein intake should be distributed throughout
the day and included in all meals and snacks to promote satiety, slow the absorption of
carbohydrates into the bloodstream, and provide adequate calories.
A bedtime high-protein snack is recommended to prevent accelerated (ie, starvation) ketosis

overnight and maintain fasting glucose levels within the target range.
Gestational weight gain/loss — After prescribing the diet, it is important to pay attention to
subsequent changes in weight. In a retrospective cohort study including over 31,000 patients
with GDM, those with appropriate gestational weight gain ( table 1) had optimal outcomes,
while excessive gestational weight gain was associated with a significantly increased risk of
having a large for gestational age newborn, preterm birth, and cesarean birth [29]. Although
suboptimal weight gain increased the likelihood of avoiding pharmacotherapy of GDM and
decreased the likelihood of having a large for gestational age newborn, there were also more
small for gestational age newborns in this group (7.3 versus 5.6 percent). The data in this study
were not corrected for potential confounders, such as smoking. (See "Obesity in pregnancy:
Complications and maternal management" and "Gestational weight gain", section on
'Recommendations for gestational weight gain'.)
Some patients experience minimal weight loss (one to five pounds) or weight stabilization for
the first few weeks after beginning nutritional therapy, which should be evaluated in the overall
context of gestational weight gain and ongoing surveillance of weight gain in the weeks
thereafter. Weight loss is generally not recommended during pregnancy, although controversy
exists regarding this recommendation for patients with obesity, especially class II or III. For
pregnant people with obesity, a modest energy restriction of 30 percent below the DRI for
pregnant people (175 g carbohydrate, 71 g protein, 28 g fiber [23]) can often be achieved while
meeting gestational weight gain recommendations and without causing ketosis [30]. (See
"Gestational weight gain", section on 'Recommendations for gestational weight gain'.)
EXERCISE
Adults with diabetes are encouraged to perform 30 to 60 minutes of moderate-intensity aerobic

activity (40 to 60 percent maximal oxygen uptake [VO2max]) on most days of the week (at least
150 minutes of moderate-intensity aerobic exercise per week). A program of moderate exercise
is recommended as part of the treatment plan for patients with diabetes as long as they have
no medical or obstetric contraindications to this level of physical activity. Exercise that increases
muscle mass, including circuit training, appears to improve glucose management, primarily
from increased tissue sensitivity to insulin. As a result, exercise can reduce both fasting and
postprandial blood glucose concentrations and, in some patients with GDM, the need for
insulin may be obviated [31]. (See "Exercise during pregnancy and the postpartum period" and
"Effects of exercise in adults with diabetes mellitus".)
GLUCOSE MONITORING
Patients should self-monitor their glucose concentrations. Glucose meters measure capillary
blood glucose, almost all available glucose meters provide plasma equivalent values rather than
whole-blood glucose values. Thus, results from most available glucose meters and venous
plasma glucose measured in a laboratory should be comparable. (See "Glucose monitoring in
the ambulatory management of nonpregnant adults with diabetes mellitus".)
Intermittent self-monitoring of blood glucose — We suggest that patients self-monitor

blood glucose levels [32-35]:
● Before breakfast (ie, fasting glucose level) and

● At one or at two hours after the beginning of each meal
Results should be recorded in a glucose log, along with dietary information. This facilitates
recognition of glycemic patterns and helps to interpret results stored in the memory of glucose
meters.
We prefer the one-hour postprandial measurement as it corresponds more closely to the

maximum insulin peak in patients using rapid-acting insulin analogs. The value of fasting plus
postprandial versus preprandial measurement was suggested by a trial that randomly assigned
66 insulin-treated patients with GDM to management according to results of fasting plus
postprandial monitoring (one hour after meals) or according to preprandial-only blood glucose
concentrations [36]. Postprandial monitoring had several benefits as compared with
preprandial monitoring: better glycemic management (glycated hemoglobin [A1C] value 6.5
versus 8.1 percent), a lower incidence of large for gestational age newborns (12 versus 42
percent), and a lower rate of cesarean birth for cephalopelvic disproportion (12 versus 36
percent).
Can the frequency of self-monitoring be reduced? — When initially diagnosed with GDM,
we ask patients to measure their blood glucose concentration at least four times daily, as
described above (see 'Intermittent self-monitoring of blood glucose' above). Multiple daily
measurements allow recognition of patients who should begin pharmacologic therapy.
There is no strong evidence regarding the frequency of glucose testing, particularly in patients
on nutritional therapy who consistently have glucose levels in the target range (see 'Glucose
target' below) [37,38], but decreasing the frequency of testing to every other day in specific
patients with mild GDM (defined as no more than intermittent glucose elevations that are 5 to
10 mg/dL above targets), no signs of fetal overgrowth (defined as abdominal circumference (AC)
>75th percentile or estimated fetal weight (EFW) ≥90th percentile), and normal amniotic fluid
volume (ie, no polyhydramnios), likely improves the patient's quality of life.
In a randomized trial of patients with GDM on nutritional therapy who demonstrated glucose
levels in the target range after one week of four times daily glucose testing, those assigned to
every other day testing had similar birth weights and frequency of macrosomia as those who
continued to test four times daily [39].
Continuous glucose monitoring — Continuous glucose monitoring (CGM) allows

determination of peak postprandial glucose levels, mean glucose level, episodes of nocturnal
hyperglycemia, and percent time in range for a 24-hour period. We do not routinely use CGM in
patients with GDM because of cost and it has not been proven to improve maternal or fetal
outcome, but few trials have been performed. When CGM was compared with frequent self-
monitoring of blood glucose in a meta-analysis of two small randomized trials, outcomes were
similar for both approaches: cesarean birth (risk ratio [RR] 0.91, 95% CI 0.68-1.20), large for
gestational age newborn (RR 0.67, 95% CI 0.43-1.05), neonatal hypoglycemia (RR 0.79, 95% CI
0.35-1.78) [40]. There were no perinatal deaths. Larger trials may clarify whether the favorable
trends that were observed are real.
Although use of CGM has no clear advantages for most patients, it may be considered in
patients who cannot consistently check fingerstick glucose levels and are willing to wear a
device. Cost may be a barrier to use.
Glucose target — Glucose targets vary among countries and the precise target for optimum
maternal, fetal, and newborn outcome is not well-established. In the United States, the
American Diabetes Association (ADA) and the American College of Obstetricians and
Gynecologists (ACOG) recommend the following upper limits for glucose levels, with insulin
therapy initiated if they are exceeded, but acknowledge that these thresholds have been
extrapolated from recommendations proposed for pregnant patients with preexisting diabetes
[23,41]:
● Fasting and preprandial blood glucose concentration: <95 mg/dL (5.3 mmol/L)
● One-hour postprandial blood glucose concentration: <140 mg/dL (7.8 mmol/L)
● Two-hour postprandial glucose concentration: <120 mg/dL (6.7 mmol/L)
These targets are well above the mean glucose values in pregnant people without diabetes
described in a literature review of studies of the normal 24-hour glycemic profile of pregnant
people [42]. In this review, which had a total of 255 pregnant people without diabetes who were
mostly in the late third trimester and without obesity, the pooled weighted mean glucose
values (±1 SD) were fasting 71±8 mg/dL (3.9±0.4 mmol/L), one-hour postprandial 109±13 mg/dL
(6.0±0.7 mmol/L), two-hour postprandial 99±10 mg/dL (5.5±0.6 mmol/L), and 24-hour glucose
88±10 mg/dL (4.9±0.6 mmol/L). These levels were derived from measurements on whole blood,
plasma, self-monitored capillary glucose measurements, or tissue fluid (CGM). Although
glucose levels in whole blood, plasma, and interstitial fluid differ, there was some consistency in
the results. If two standard deviations are added to the means outlined in the systematic
review, the upper limit of normal fasting glucose would be 87 mg/dL (4.8 mmol/L), the
corresponding one-hour postprandial value would be 135 mg/dL (7.5 mmol/L), and the upper
limit of normal two-hour value would be 119 mg/dL (6.6 mmol/L); while the fasting value is
somewhat lower than the target 95 mg/dL (5.3 mmol/L), the postprandial values are not
dissimilar to the targets described above.
Glycated hemoglobin — A1C may be a helpful ancillary test in assessing glycemic

management during pregnancy [43,44]. It is not clear whether or how often it should be
monitored in patients with GDM with glucose levels are in the target range. If measured and
there is a discrepancy between the A1C and glucose values, then potential causes should be
investigated. (See "Measurements of glycemia in diabetes mellitus", section on 'Racial/ethnic
differences' and "Measurements of glycemia in diabetes mellitus", section on 'Unexpected or
discordant values'.)
High-quality normative data for A1C in each trimester are not available. A1C values tend to be
lower in pregnant compared with nonpregnant people [45] because the average blood glucose
concentration is approximately 20 percent lower in pregnant people, and in the first half of
pregnancy, there is a rise in red cell mass and a slight increase in red blood cell turnover [46,47].
Other factors that have been reported to affect A1C values include race (although it is not clear
whether the higher A1C levels observed in Black persons compared with White persons are due
to differences in glucose levels or racial differences in the glycation of hemoglobin [48]) and
iron status (chronic iron deficiency anemia increases A1C, treatment of iron deficiency anemia
with iron lowers A1C). Sources of variation in A1C levels are discussed in detail separately. (See
"Measurements of glycemia in diabetes mellitus", section on 'Glycated hemoglobin (A1C)'.)
MONITORING FOR KETONURIA
We do not routinely monitor urinary ketones in pregnant people with GDM, as diabetic
ketoacidosis is extremely rare in patients first diagnosed with diabetes during pregnancy
[49,50]. Episodes of physiological ketonemia and ketonuria are not uncommon in pregnancy
and can occur with hypocaloric diets [51]. Studies have reported inconsistent findings regarding
a potential association between ketonuria and impaired cognitive outcome in offspring [52-56].
PHARMACOTHERAPY
Goal — The goal of pharmacotherapy is to manage glucose levels so that the majority are no
higher than the upper limit of the target range, without inducing any episodes of hypoglycemia.
Overly tight metabolic control (average blood glucose levels ≤86 mg/dL [4.8 mmol/L]) has no
additional benefits and increases the risk for iatrogenic growth restriction [57,58].
Indications for pharmacotherapy
● Glucose levels above the target range – If glucose targets cannot be maintained by
medical nutritional therapy, then pharmacotherapy should be initiated, but the degree of
hyperglycemia at which the disadvantages of initiating insulin therapy are clearly
outweighed by the benefits has not been definitively determined and varies among
providers [59].
We initiate pharmacotherapy when over 30 percent of the blood glucose values in a week
are above target glucose thresholds (see 'Glucose target' above). Our general approach is
described in the algorithm ( algorithm 1).
In a retrospective cohort study of patients with GDM, initiating pharmacotherapy when 20

to 39 percent of glucose levels were above goal compared with ≥40 percent above goal
was associated with a reductions in preterm birth (7.4 versus 15.7 percent), neonatal
intensive care unit admission (4.0 versus 11.7 percent), and large for gestational age
newborn (9.1 versus 21.2 percent) [60].
● Fetal overgrowth – Data from some randomized trials suggest that pharmacotherapy,
specifically insulin, in the subgroup of patients with indirect evidence of fetal
hyperinsulinemia (eg, abdominal circumference [AC] >75th percentile or estimated fetal
weight [EFW] ≥90th percentile on the early third-trimester sonogram) can reduce the
occurrence of macrosomia and large for gestational age in newborns, even in patients
with GDM who are not hyperglycemic at the time pharmacotherapy is initiated.
In a meta-analysis including only two trials, compared with conventional hyperglycemia-

based management in patients with a broad GDM severity spectrum, initiation of
pharmacotherapy based on ultrasound findings of a large AC increased the percent of
patients requiring insulin treatment (34 versus 23 percent, relative risk [RR] 1.58, 95% CI
1.14-2.20) and reduced the occurrence of large for gestational age newborns (RR 0.58,
95% CI 0.34-0.99) and macrosomia (RR 0.32, 95% CI 0.11-0.95) without increasing the risk
for small for gestational age newborns [61]. Rates of pregnancy-associated hypertension
and cesarean birth were similar in both groups; data on frequency of maternal
hypoglycemia were not provided.
Based on these and other findings, it is reasonable for patients with sonographic signs of
fetal overgrowth to receive insulin to decrease the risk of large for gestational age and
macrosomia despite having less than 30 percent of glucose values above target threshold.
Choice of pharmacotherapy — The pharmacotherapy options in pregnant patients who

require pharmacotherapy are insulin (and some insulin analogs) or selected oral
antihyperglycemic agents (metformin or glyburide).
We favor insulin because it is effective, easily adjusted based on glucose levels, and safe for the
fetus, whereas data are lacking regarding long-term outcomes of offspring exposed to oral
antihyperglycemic drugs in utero. We believe that oral antihyperglycemic agents are a
reasonable alternative to insulin for patients in whom pharmacotherapy is indicated but who
decline to take, or are unable to comply with, insulin therapy. Our approach is generally
consistent with national and international guidance [1,23,41,62,63]. Some guidelines consider
oral antihyperglycemic drugs an acceptable first-line approach in selected patients, such as
those with normal fasting blood glucose levels and modest postprandial hyperglycemia [62-64].
(See 'Society guideline links' below.)
Meta-analyses comparing use of oral antihyperglycemic agents with insulin therapy have
generally found that both approaches can improve some pregnancy outcomes in patients with
GDM or type 2 diabetes [59,65-70]. There is a trend toward more frequent maternal
hypoglycemia with use of insulin [68], and some patients on oral agents need supplemental
insulin to achieve and maintain glucose levels in the target range [71]. However, it is difficult to
draw firm conclusions about the optimal approach because of inconsistencies in criteria for
GDM, glucose targets, patient adherence to treatment, clinical outcome measures across
studies, and lack of long-term safety data [68].
In randomized trials, compared with insulin, metformin:
● Reduced gestational weight gain (mean difference -1.31 kg, 95% CI -2.34 to -0.27) [69]
● Reduced birth weight (mean difference -74 g, 95% CI -115 to -33) [69]
● Reduced risk for macrosomia (odds ratio [OR] 0.60, 95% CI 0.45-0.79) [69]
● Reduced risk for neonatal hypoglycemia (risk ratio [RR] 0.63, 95% CI 0.45-0.87) [70]
● Reduced risk for pregnancy-induced hypertension (RR 0.56, 95% CI 0.37-0.85) [70]
● Increased offspring body mass index (BMI, by 0.8 kg/m2) and adiposity by mid-childhood
[72]
● Differences in other outcomes were not statistically significant: large for gestational age
newborn (OR 0.87, 95% CI 0.66-1.14) [69], preterm birth (RR 1.18, 95% CI 0.67-2.07), small
for gestational age newborn (RR 1.20, 95% CI 0.67-2.14), perinatal mortality (RR 0.82, 95%
CI 0.17-3.92), cesarean birth (RR 0.97, 95% CI 0.80-1.19) [70].
In randomized trials, compared with insulin, glyburide:
● Increased mean birth weight (mean difference 290 g, 95% CI 68-511) [69]
● Increased risk for macrosomia (OR 1.38, 95% CI 1.01-1.89) [69]
● Increased the frequency of neonatal hypoglycemia (12.2 versus 7.2 percent; difference 5.0,
95% CI 0.5-9.5) [73]
● Showed trends toward an increased risk for a large for gestational age newborn (OR 2.49,
95% CI 0.79-7.81) and less maternal gestational weight gain (mean difference -0.68 kg,
95% CI -1.69 to 0.34 kg) [69].
Insulin
Dose — The insulin dose required to achieve target glucose levels varies among individuals,
but the majority of studies have reported a total dose ranging from 0.7 to 2 units per kg
(current pregnant weight). Dose titration to blood glucose levels is based upon frequent self-
monitoring. At least four daily glucose measurements are required (fasting and one or two
hours postprandial with the addition of pre-lunch and pre-dinner measurements as needed) to
optimize therapy and ensure timely dose increases as insulin requirements increase with
pregnancy progression. The insulin requirement in twin gestations complicated by GDM may
double with pregnancy progression.
We do not use insulin pumps in patients with GDM because there are no data to suggest that
they are necessary or more effective than conventional therapy, and the cost of an insulin pump
is not justified over the relatively short duration of a pregnancy. However, case reports have
described successful use in some pregnant people.
Pragmatic approach to management of hyperglycemia — Hospitalization is not

necessary to initiate insulin therapy; however, if teaching some patients the procedures they
need to know is not possible in the outpatient setting, then an inpatient stay to utilize the
expertise of the hospital's nursing staff may justify the cost of hospitalization.
One principle we have found useful is to start with the simplest regimen and increase the
complexity as needed to address the particular situation. Typically, regardless of body weight,
insulin dosing is based on the glucose levels recorded in the patient's blood glucose log.
The following is our general approach to management of patients diagnosed with GDM after
screening at 24 to 28 weeks who have mostly postprandial hyperglycemia, fetal AC>75th
percentile, or EFW ≥90th percentile. Because any insulin regimen requires serial dosing
adjustments in response to specific fasting or postprandial glucose levels, the starting dose
should be considered just that, a starting point. Weekly glucose log review is recommended so
that insulin doses can be adjusted as needed to meet target glucose levels as the pregnancy
advances. Some patients may be diagnosed with diabetes and therapy initiated early in
pregnancy (prior to 24 to 28 weeks screening); these patients are managed differently and
generally require slightly lower insulin doses since insulin resistance is lower early in pregnancy.
● We begin with a single injection of 10 to 20 units of intermediate-acting basal insulin

(neutral protamine Hagedorn [NPH]) and 6 to 10 units of rapid-acting insulin (lispro or
aspart) in the morning immediately before breakfast; the dose within this range is based
on the degree of elevation above target levels.
● If postprandial glucose levels throughout the day remain high, adjustments in the rapid-
acting insulin dose are typically in the range of 10 to 20 percent. The upper end of this
range is not likely to lead to hypoglycemia in patients with both obesity and GDM unless a
meal is omitted after insulin is given.
● If only the post-dinner glucose level remains elevated, then we add an injection of 6 to 10
units of rapid-acting insulin immediately before dinner.
● If only the post-lunch glucose level remains elevated, we add an injection of 6 to 10 units
of rapid-acting insulin immediately before lunch.
● If the fasting glucose level is elevated after postprandial levels in the target range, we add
an intermediate-acting basal insulin, preferably at bedtime but with dinner is another
option on an individualized basis. The initial dose is 0.2 units/kg body weight.
Dosing based on glucose levels and weight — An alternative approach to insulin

therapy, somewhat more complex and likely most appropriate for individuals whose glucose
levels are not well managed with simpler paradigms, is described below:
● If only the fasting blood glucose concentration is high, an intermediate-acting basal

insulin (NPH) is given before bedtime but before dinner is another option on an
individualized basis; an initial dose of 0.2 unit/kg body weight is utilized. A long-acting
insulin analog (insulin glargine or detemir) may be used instead if NPH insulin is not
available.
● If only postprandial blood glucose concentrations are high, 6 to 10 units of rapid-acting

insulin analogs (aspart or lispro) are given immediately before meals. (See "General
principles of insulin therapy in diabetes mellitus".)
● If both preprandial and postprandial blood glucose concentrations are high or if the
patient's postprandial glucose levels can only be blunted when starvation ketosis occurs,
then a four-injection-per-day regimen is utilized, which improved glycemic control and
perinatal outcome compared with a twice-daily regimen in one randomized trial [74],
although macrosomia rates were not impacted.
The starting dose is calculated by trimester of pregnancy and body weight: 0.9 units/kg in
the second trimester and 1.0 units/kg in the third trimester, split into basal and bolus
dosing. In patients with class II or III obesity, the initial doses of insulin may need to be
increased to 1.5 to 2 units/kg to overcome the combined insulin resistance of pregnancy
and obesity.
Two-thirds of the total daily dose is administered in the morning, with two-thirds of the
morning dose given as basal insulin and one-third given as rapid-acting insulin up to 15
minutes before breakfast. One-third of the total daily dose is administered in the evening,
with half of this dose given as rapid-acting insulin up to 15 minutes before dinner and the
other half given as basal insulin as a nighttime dose (usually at bedtime but before dinner
is another option on an individualized basis). A lunchtime dose of rapid-acting insulin may
be added if there is continued postprandial lunch hyperglycemia.
Management of hypoglycemia — Hypoglycemia in pregnancy is defined as a blood glucose

<60 mg/dL (3.3 mmol/L). Hypoglycemia remote from meal or snack time is rare in patients with
GDM treated with pharmacotherapy, and it is treated by administering 10 to 20 g of a fast-
acting carbohydrate snack immediately. The American Diabetes Association (ADA) suggests the
following options: 4 ounces (1/2 cup) of juice or regular soda, 8 ounces (1 cup) of skim milk, or 5
to 6 hard candies (eg, Life-Savers); glucose tablets can also be used (check package for grams
per tablet as content varies). Since the sugars in milk release more slowly into the bloodstream
than pure sugar options, the glucose pattern seen with pure sugars (ie, rapid elevation of
glucose followed by a rapid decline) may be dampened. (See "Hypoglycemia in adults with
diabetes mellitus", section on 'Reversing hypoglycemia'.)
Patients who are feeling better may recheck their blood glucose 15 to 30 minutes after
treatment. If the glucose remains <60 mg/dL (3.3 mmol/L), repeat treatment may be necessary.
On the other hand, they may need to give themselves extra insulin to compensate for
overtreatment of the symptoms.
If low glucose values are encountered more than once at the same time of day, insulin doses
are adjusted downward accordingly.
Type of insulin — Use of insulin preparations of low antigenicity may minimize transplacental
transfer of insulin antibodies. Human insulin is the least immunogenic of the commercially
available preparations. The three rapid-acting insulin analogs (lispro, aspart, glulisine) are
comparable in immunogenicity to human regular insulin, but only lispro and aspart have been
investigated in pregnancy and shown to have acceptable safety profiles, minimal transfer
across the placenta, and no evidence of teratogenesis. Neonatal outcomes are similar to those
of patients treated with regular insulin [59]. These two insulin analogs both improve
postprandial excursions compared with human regular insulin and are associated with lower
risk of delayed postprandial hypoglycemia.
Long-acting insulin analogs (insulin glargine, insulin detemir) have not been studied as
extensively in pregnancy, but data from patients with preexisting (pregestational) diabetes and
studies of placental transfer suggest that both detemir and glargine are safe and effective for
use in pregnancy [75-81]. (See "Pregestational (preexisting) diabetes mellitus: Antenatal
glycemic control", section on 'Type of insulin'.).
Based on available data, we prefer using human NPH insulin as part of a multiple injection
regimen in pregnant people with GDM, especially given the peak at four to six hours after the
morning dose, which can help decrease lunch postprandial blood glucose levels without an
additional dose of rapid-acting insulin [82]. The body of data support the safety and
effectiveness of NPH in pregnancy, and doses can be adjusted frequently and quickly in
response to changing requirements in pregnant patients.
If a longer-acting insulin analog is used, we prefer detemir insulin because it can be dosed
twice a day, similar to NPH, with the advantage over NPH of more consistent absorption and
less variability in absorption among patients. Insulin detemir is preferred over insulin glargine
because it has been studied more extensively in pregnancy and can be dosed twice per day
more predictably than glargine, as previously mentioned. (See "General principles of insulin
therapy in diabetes mellitus", section on 'Safety'.)
Oral hypoglycemic agents — Metformin and glyburide are the only noninsulin
antihyperglycemic drugs used in pregnancy. Both oral hypoglycemic agents offer the
advantage of significantly decreased cost compared with insulin.
Choosing metformin versus glyburide — Clinically important pregnancy outcomes are

generally similar for metformin and glyburide, with only limited evidence of benefit of one oral
agent over the other.
● Pregnant outcome – When compared with glyburide in meta-analyses of randomized

trials, metformin resulted in:
• Similar rates of perinatal mortality, neonatal hypoglycemia [71], and hypertensive

disorders of pregnancy [83].
• Lower mean birth weight (mean difference -191 g, 95% CI -288 to -95 g; mean birth
weight 3103 to 3360 g versus 3329 to 3463 g with glyburide) [69].
• Less macrosomia (OR 0.32, 95% CI 0.08-1.19) and large for gestational age infants (OR
0.38, 95% CI 0.18-0.78) [69].
• Less gestational weight gain (mean difference -2.22 kg, 95% CI -3.88 to -0.56 kg) [69].
● Need for supplemental insulin – The frequency of treatment failure (inability to maintain
glucose levels in the target range) is similar for glyburide and metformin and ranges from
approximately 15 to 30 percent in most trials directly comparing the two drugs [71,84].
● Placental transfer – Both drugs cross the placenta (in contrast to insulin). Fetal
metformin levels are 200 percent of the maternal level and glyburide levels are 70 percent
of the maternal level, which has unknown long-term consequences [85-87]. Although
metformin and glyburide have not been associated with an increased risk of congenital
anatomic anomalies, when either drug is prescribed, patients should be made aware that
information regarding the long-term effects of transplacental passage, including possible
fetal programming effects, are largely unknown, so caution is warranted until more data
are available [88-93].
Metformin — A typical dosing regimen is to start metformin extended release (XR) 500 mg
orally once daily (with dinner) and, if tolerated, increase by 500 mg (eg, 1000 mg with dinner or
500 mg with dinner plus 500 mg with breakfast) based on the degree of glucose elevations. The
dose can then be increased by 500 to 1000 mg orally per week until reaching the usual effective
dose of 1500 to 2000 mg orally per day divided into two doses (maximum daily dose is 2500
mg) [94]. An immediate release preparation is also available, but we prefer the XR as it may
cause fewer gastrointestinal side effects and fewer daily doses may be needed.
The most common side effects of metformin are gastrointestinal, including a metallic taste in
the mouth, mild anorexia, nausea, abdominal discomfort, and soft bowel movements or
diarrhea. These symptoms are usually mild, transient, and reversible after dose reduction or
discontinuation of the drug. Symptoms can be mitigated by starting at a low dose with slow-
dose escalation as needed. In a clinical trial, only 2 percent of study subjects discontinued
metformin because of gastrointestinal side effects [94].
The ADA recommends avoiding metformin in patients with hypertension, preeclampsia, or at

risk for intrauterine growth restriction because metformin suppresses mitochondrial
respiration, which may adversely affect function, growth, or differentiation of fetal or placental
tissues [23,88]; however, any clinical impact of this effect has not been observed in human
pregnancies. The American College of Obstetricians and Gynecologists (ACOG) and the Society
for Maternal-Fetal Medicine do not include this caveat in their recommendations.
Glyburide — Starting doses of 2.5 to 5 mg once daily are commonly used, increased as
needed to a maximum of 20 mg per day. Twice-daily dosing is often necessary to maintain
glucose levels in the target range. One group that investigated glyburide pharmacokinetics in
pregnancy suggested pregnant patients take the drug 30 to 60 minutes before a meal, rather
than with the meal, to improve efficacy [95]. In this study, plasma glyburide concentrations in
pregnant patients with GDM did not increase until one hour after drug ingestion, peaked at two
to three hours, and returned to baseline by 8 to 10 hours. Thus, the drug took longer to reach
peak concentration and was metabolized more rapidly than in nonpregnant females.
Maternal hypoglycemia is the most common side effect, and the risk was higher than that in
patients with GDM using insulin in a large trial (28.8 versus 3.5 percent; difference 25.3 percent,
95% CI 16.6-34.0) [73].
Patients who fail to achieve glycemic control with oral pharmacotherapy — If oral
pharmacotherapy alone does not adequately manage glucose levels, supplemental insulin can
be prescribed and may be easier for the patient than switching to a multidose insulin only
regimen. In contrast to nonpregnant patients, dual use of oral agents (eg, metformin plus
glyburide) is not recommended in pregnancy because of minimal safety and efficacy data [84]
and concerns about adverse fetal effects since both drugs cross the placenta.
OBSTETRIC MANAGEMENT
Obstetric management of the pregnancy is discussed separately. (See "Gestational diabetes

mellitus: Obstetric issues and management".)
INTRAPARTUM MANAGEMENT
Intrapartum glucose and insulin management are discussed in detail separately. (See
"Pregestational (preexisting) and gestational diabetes: Intrapartum and postpartum glucose
management".)
MATERNAL PROGNOSIS
Most patients with GDM are normoglycemic after giving birth. However, they are at high risk for
recurrent GDM and developing prediabetes (impaired glucose tolerance or impaired fasting
glucose) or overt diabetes over the subsequent five years. Optimum interpregnancy care to
minimize these risks has not been well-studied in randomized trials [96]. Feasibility trials of a
web-based lifestyle intervention and a telephone-based intervention reported less postpartum
weight retention in patients with GDM assigned to the intervention, suggesting this type of
behavioral intervention may have a favorable impact [97,98].
Recurrence — GDM in one pregnancy is a strong predictor of recurrence in a subsequent

pregnancy [99]. In a study including over 65,000 pregnancies, the frequency of GDM in the
second pregnancy among patients with and without previous GDM was 41 and 4 percent,
respectively [100]. Risk factors for recurrence include high birth weight in the index pregnancy,
older maternal age, high parity, high prepregnancy weight, and high weight between
pregnancies [101,102].
Long-term risk — A history of GDM is predictive of an increased risk of developing type 2

diabetes, metabolic syndrome, cardiovascular disease (CVD), and even type 1 diabetes. These
risks appear to be particularly high in patients with both GDM and a hypertensive disorder of
pregnancy [103]. GDM has been called a "marker," "stress test," or "window" for future diabetes
and CVD; it is not considered causal.
● Impaired glucose tolerance – As many as 30 percent of patients with GDM have impaired
glucose tolerance during the early postpartum period [104-106].
● Type 2 diabetes – In a meta-analysis, patients with GDM were at an almost 10-fold higher
risk of developing subsequent type 2 diabetes than patients with normoglycemic
pregnancies (relative risk [RR] 9.51, 95% CI 7.14-12.67; 20 studies including nearly 68,000
patients with GDM and over 1.2 million patients without GDM) [107]. The RR was 17 within
the first five years after delivery and approximately 10 after that. Absolute risks for type 2
diabetes at 1 to 5 years, >5 to 10 years, and >10 years postdelivery follow-up were 9, 12,
and 16 percent, respectively, compared with 1 to 2 percent in the control groups. The
lifetime maternal risk for diabetes has been estimated to be as high as 50 to 60 percent
[107,108].
Waist circumference and body mass index (BMI) are the strongest anthropometric
measures associated with development of type 2 diabetes in patients with GDM [59,109],
as they are in those without GDM. Type 2 diabetes develops in 50 to 75 percent of patients
with obesity (BMI ≥30 kg/m2) and a history of GDM versus fewer than 25 percent of those
with GDM who achieve normal BMI after delivery [110-112].
Other major risk factors are gestational requirement for insulin and early gestational age
at the time of diagnosis (ie, less than 24 weeks of gestation) [109]. Additional risk factors
for impaired glucose tolerance and overt diabetes later in life include autoantibodies (eg,
glutamic acid decarboxylase, insulinoma antigen-2), high-fasting blood glucose
concentrations during pregnancy and early postpartum, higher-fasting plasma glucose at
diagnosis of GDM and high glucose levels in the GTT, the number of abnormal values on
the glucose tolerance test, neonatal hypoglycemia, and GDM in more than one pregnancy
[59,104,105,110,113-117]. In one study, an additional pregnancy increased the rate ratio of
type 2 diabetes threefold compared with individuals without an additional pregnancy (RR
3.34, 95% CI 1.80-6.19) [118]. The authors hypothesized that episodes of insulin resistance
contribute to the decline in beta-cell function that leads to type 2 diabetes in many high-
risk individuals.
Parity, large birth weight, and diabetes in a first-degree relative are less correlated with
later diabetes.
● Type 1 diabetes – GDM also appears to be a risk factor for the development of type 1
diabetes, particularly in populations with a high prevalence of this disorder. Specific
human leukocyte antigen (HLA) alleles (DR3 or DR4) may predispose to the development
of type 1 diabetes postpartum, as does the presence of islet-cell autoantibodies [119-121]
or antibodies against glutamic acid decarboxylase or insulinoma antigen 2. GDM in lean
pregnant people, need for insulin treatment of GDM, diabetic ketoacidosis during
pregnancy, and postpartum hyperglycemia also suggest preexisting unrecognized type 1
diabetes or high risk of developing type 1 diabetes [121]. Although testing for antibodies
is not routinely recommended, it is important for clinicians to be aware of this association.
Distinguishing type 1 from type 2 diabetes, and monogenic forms of diabetes (eg,
maturity-onset diabetes of the young [MODY]) from type 1 and type 2 diabetes, is
reviewed in detail elsewhere. (See "Clinical presentation, diagnosis, and initial evaluation
of diabetes mellitus in adults", section on 'Differentiating the cause' and "Classification of
diabetes mellitus and genetic diabetic syndromes".)
● Metabolic syndrome – At ≥three months postpartum, patients with GDM are more likely
to have metabolic syndrome, an atherogenic lipid profile, and early vascular dysfunction
than those without previous GDM [122-125]. In one study of patients with mild GDM (ie,
normal fasting glucose level on glucose tolerance test [GTT]), approximately one-third
developed metabolic syndrome within 5 to 10 years after giving birth [125].
● Cardiovascular disease – Patients with GDM are at higher risk of developing CVD and
developing it at a younger age than those with no history of GDM [126-129]. Even mild
glucose impairment (defined as an abnormal 50 g one-hour GTT followed by a normal 100
g three-hour GTT) appears to identify individuals at increased risk of future development
of CVD, usually myocardial infarction or stroke [130]. Much but not all of this excess risk is
related to development of type 2 diabetes later in life.
In a pooled analysis of nine studies including over 5 million females and >101,000
cardiovascular events, those with GDM had a twofold higher risk of future CVD compared
with those with no history of GDM (RR 1.98, 95% CI 1.57-2.50) [131]. Meta-regression
analysis showed that the rates of incident type 2 diabetes across the studies did not affect
this risk and when individuals with type 2 diabetes were excluded, GDM was still
associated with an increased risk of future CVD (RR 1.56, 95% CI 1.04, 2.32).
Follow-up
Testing — Long-term follow-up for development of type 2 diabetes is routinely recommended

for individuals with GDM [23,41].
GTT — A common approach is to perform a GTT 4 to 12 weeks after giving birth, using the
75 g GTT, as recommended by the American Diabetes Association (ADA) [23]. Criteria for
diagnosis of diabetes and prediabetes are shown in the tables ( table 2A-B).
Since many obstetrical providers see their patients at four to six weeks postpartum, it makes
sense to order the test prior to this visit so the results are available for counseling or to provide
an opportunity for scheduling/rescheduling if the test was not performed. Compliance with the
4- to 12-week GTT is poor; however, there is increasing evidence that ordering the test when
patients are still hospitalized after birth increases compliance to nearly 100 percent and
provides reliable results [106,132]. In an analysis of over 200 patients with GDM who completed
a postpartum day two 75 g GTT, returned for a GTT at postpartum week 4 to 12, and had a A1C
checked approximately one year after delivery, there were no significant differences between
the day two and the 4- to 12-week postpartum GTTs in predicting impaired glucose metabolism
(A1C ≥5.7 and <6.5 percent) or diabetes (A1C ≥6.5 percent) at one year [132]. At one year
postpartum, the A1C was consistent with impaired glucose metabolism in 35 percent and
diabetes in 4 percent of individuals tested.
● Effect of breastfeeding on the GTT – Breastfeeding during a two-hour 75 gram oral GTT
appears to have a modest lowering effect on the two-hour glucose level (5 percent lower
on average) [133], which could affect interpretation of a borderline test. Patients should be
informed in advance that they might need to repeat the test if this happens so they can
make an informed decision about breastfeeding during the test versus planning the test
at a time/later date when breastfeeding can be avoided. Clinicians should consider
retesting those patients whose results fall within 6 mg/dL of the diagnostic cut points.
Fasting glucose — A fasting plasma glucose level is a reasonable alternative to the GTT
but does not allow for diagnosis of impaired glucose tolerance. A glycated hemoglobin (A1C)
can be performed in patients in whom obtaining a fasting specimen is especially inconvenient
but performs less well for diagnosis of diabetes or prediabetes in postpartum patients because
of increased peripartum red cell turnover [134]. (See "Clinical presentation, diagnosis, and initial
evaluation of diabetes mellitus in adults", section on 'Diagnostic tests'.)
Counseling
● Patients with prediabetes – Patients who meet criteria for prediabetes are counseled
about their subsequent risk for developing overt diabetes and referred for discussion of
management options (eg, lifestyle modification such as medical nutritional therapy, use of
metformin). They should try to achieve a BMI in the normal range through diet and
exercise, and if possible, they should avoid drugs that may adversely affect glucose
tolerance (eg, glucocorticoids). They should have yearly assessment of glycemic status.
(See "Clinical presentation, diagnosis, and initial evaluation of diabetes mellitus in adults",
section on 'Prediabetes' and "Prevention of type 2 diabetes mellitus".)
Breastfeeding may decrease the long-term risk of developing type 2 diabetes. (See
"Gestational diabetes mellitus: Obstetric issues and management", section on
'Breastfeeding'.)
● Patients with diabetes – Patients with overt diabetes mellitus should receive appropriate
education and treatment. They should also be given advice regarding contraception and
the planning of future pregnancies, especially the importance of good glycemic

management prior to conception. (See "Overview of general medical care in nonpregnant
adults with diabetes mellitus" and "Pregestational (preexisting) diabetes: Preconception
counseling, evaluation, and management".)
● Patients with normal test results
• Risk for future diabetes – Patients with a normal GTT should be counseled regarding
their risk of developing GDM in subsequent pregnancies and their future risk of
developing type 2 diabetes. (See 'Recurrence' above and 'Long-term risk' above.)
• Prevention of future diabetes – Patients should be informed that breastfeeding may

decrease their long-term risk of developing type 2 diabetes. (See "Gestational diabetes
mellitus: Obstetric issues and management", section on 'Breastfeeding'.)
Lifestyle interventions are beneficial for reducing the incidence of type 2 diabetes in
persons with prediabetes [135] and these interventions (diet and exercise, achieving a
normal body mass index, avoiding smoking and excessive alcohol intake) also appear
to be beneficial in patients with a history of GDM, whether or not they meet criteria for
prediabetes [136]. The annual incidence of diabetes may be reduced by 30 to 50
percent or more compared with no intervention [137,138].
Drug therapy (eg, metformin, pioglitazone) may also have a role in preventing future
type 2 diabetes. In a multicenter randomized trial, both intensive lifestyle and
metformin therapy reduced the incidence of future diabetes by approximately 50
percent compared with placebo in patients with a history of GDM; metformin was
much more effective than lifestyle intervention in parous patients with previous GDM
[137]. This topic is discussed in detail separately. (See "Prevention of type 2 diabetes
mellitus".)
• Follow-up laboratory testing – Long-term follow-up is essential. Reassessment of

glycemic status should be undertaken at a minimum of every three years [23]. More
frequent assessment may be important in patients who may become pregnant again,
since early detection of diabetes is important to preconception and early prenatal care.
More frequent screening (every one or two years) may also be indicated in patients
with other risk factors for diabetes, such as family history of diabetes, obesity, and
need for pharmacotherapy during pregnancy.
The best means of follow-up testing has not been defined. The two-hour 75 g oral GTT
is the more sensitive test for diagnosis of diabetes and impaired glucose tolerance in
most populations, but the fasting plasma glucose is more convenient, specific, and
reproducible, and less expensive. A1C is convenient and the preferred test for patients
who have not fasted overnight. (See "Screening for type 2 diabetes mellitus", section on
'Screening tests'.)
• Prevention of future cardiovascular disease – Given increasing evidence of an

association between GDM and future CVD [139], even in the absence of progression to
type 2 diabetes, it is reasonable to discuss healthy lifestyle behaviors (eg, heart-healthy
diet, maintenance of a healthy weight, tobacco avoidance, and physical activity) with all
patients who have had GDM [140]. (See "Overview of primary prevention of
cardiovascular disease".)
Follow-up of patients not screened for GDM — For patients who did not undergo screening
for GDM, but diabetes is suspected postpartum because of newborn outcome (eg,
hypoglycemia, macrosomia, congenital anomalies), a postpartum GTT may be considered. A
normal postpartum GTT excludes the presence of type 1 or type 2 diabetes or prediabetes; it
does not exclude the possibility of GDM during pregnancy and the future risks associated with
this diagnosis. Indications for screening and tests used for screening are discussed separately.
(See "Screening for type 2 diabetes mellitus".)
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Diabetes mellitus in
pregnancy".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have about
a given condition. These articles are best for patients who want a general overview and who
prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer,
more sophisticated, and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and are comfortable with
some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)
● Basics topics (see "Patient education: Gestational diabetes (diabetes that starts during
pregnancy) (The Basics)")
● Beyond the Basics topics (see "Patient education: Gestational diabetes (Beyond the
Basics)")
SUMMARY AND RECOMMENDATIONS
● Glucose monitoring – Glucose levels are monitored several times daily in patients with
gestational diabetes mellitus (GDM). We suggest glucose self-monitoring before breakfast
and at one or at two hours after the beginning of each meal. (See 'Glucose monitoring'
above.)
The frequency of testing may be decreased to every other day in specific patients with
mild GDM (defined as no more than intermittent glucose elevations within 5 to 10 points
above targets), no signs of fetal overgrowth (defined as abdominal circumference (AC)
>75th percentile or estimated fetal weight (EFW) ≥90th percentile), and normal amniotic
fluid volume (ie, no polyhydramnios). (See 'Can the frequency of self-monitoring be
reduced?' above.)
● Glucose targets (see 'Glucose target' above)
• Fasting blood glucose concentration: <95 mg/dL (5.3 mmol/L)

• One-hour postprandial blood glucose concentration: <140 mg/dL (7.8 mmol/L)
• Two-hour postprandial glucose concentration: <120 mg/dL (6.7 mmol/L)
● Treatment
• Benefits – A program of medical nutritional therapy, self-monitoring of blood glucose

levels, and pharmacotherapy, when needed, improves some perinatal outcomes
(reduction in preeclampsia, macrosomia, and shoulder dystocia). Moderate exercise
also improves glycemic control and should be part of the treatment plan for patients
with no medical or obstetric contraindications to this level of physical activity. (See
'Rationale for treatment' above and 'Exercise' above.)
• Medical nutritional therapy – Medical nutritional therapy is the initial approach.

Calories are generally divided over three meals and two to four snacks per day and are
composed of approximately 40 percent carbohydrate, 20 percent protein, and 40
percent fat. Gestational weight gain recommendations are shown in the table
( table 1). (See 'Medical nutritional therapy' above.)
• Pharmacotherapy – Pharmacotherapy is prescribed for patients who do not achieve

adequate glycemic control with nutritional therapy and exercise alone (ie, at least 30
percent of glucose levels meet or exceed target thresholds within any one week)
( algorithm 1). We also suggest pharmacotherapy for patients with indirect evidence
of fetal hyperinsulinemia (eg, AC >75th percentile or EFW ≥90th percentile on an early
third-trimester sonogram) regardless of maternal glucose levels (Grade 2C).
Pharmacotherapy can reduce the occurrence of macrosomia and large for gestational
age in newborns. (See 'Indications for pharmacotherapy' above.)
- Insulin – We suggest prescribing insulin rather than noninsulin antihyperglycemic

drugs during pregnancy (Grade 2C). We start with the simplest insulin regimen
likely to be effective based on the glucose levels recorded in the patient's blood
glucose log and increase the complexity as needed. An alternative approach based
on both patient weight and glucose levels is somewhat more complex and likely
most appropriate for individuals whose glucose levels are not well managed with
simpler paradigms. (See 'Insulin' above.)
- Oral antihyperglycemic drugs – Metformin and glyburide are the only oral
antihyperglycemic drugs used in pregnancy and either is a reasonable alternative
for patients who decline to take, or are unable to comply with, insulin therapy. The
long-term effects of transplacental passage of noninsulin antihyperglycemic
agents are not known. (See 'Oral hypoglycemic agents' above.)
● Prognosis – Most patients with gestational diabetes mellitus are normoglycemic after
giving birth but are at high risk for developing recurrent gestational diabetes mellitus,
prediabetes (impaired glucose tolerance or impaired fasting glucose), and overt diabetes.
(See 'Recurrence' above and 'Long-term risk' above.)
● Postpartum testing – Patients with GDM should be tested for type 2 diabetes mellitus
after pregnancy ( table 2A-B). Testing is performed 4 to 12 weeks postpartum and, if
results are normal, at least every three years thereafter. Lifestyle interventions (eg,
achieving a healthy weight, appropriate level of physical activity/exercise) are beneficial for
reducing the incidence of type 2 diabetes and related comorbidities such as cardiovascular
disease (CVD). (See 'Maternal prognosis' above.)
ACKNOWLEDGMENTS
The UpToDate editorial staff acknowledges Lois Jovanovic, MD, Donald R Coustan, MD, and
Michael Greene, MD, who contributed to earlier versions of this topic review.
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Gestational diabetes mellitus: Glucose management and

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RATIONALE FOR TREATMENT

Treatment of GDM is important to minimize maternal and neonatal morbidity. In a U S

MEDICAL NUTRITIONAL THERAPY

Many patients will need individual adjustment of the amount of carbohydrate by 15 to 30 g at

In a meta-analysis of randomized trials of dietary intervention in patients with GDM, low

A bedtime high-protein snack is recommended to prevent accelerated (ie, starvation) ketosis

Adults with diabetes are encouraged to perform 30 to 60 minutes of moderate-intensity aerobic

Intermittent self-monitoring of blood glucose — We suggest that patients self-monitor

● Before breakfast (ie, fasting glucose level) and

We prefer the one-hour postprandial measurement as it corresponds more closely to the

Continuous glucose monitoring — Continuous glucose monitoring (CGM) allows

Glycated hemoglobin — A1C may be a helpful ancillary test in assessing glycemic

MONITORING FOR KETONURIA

Indications for pharmacotherapy

In a retrospective cohort study of patients with GDM, initiating pharmacotherapy when 20

In a meta-analysis including only two trials, compared with conventional hyperglycemia-

Choice of pharmacotherapy — The pharmacotherapy options in pregnant patients who

In randomized trials, compared with insulin, metformin:

In randomized trials, compared with insulin, glyburide:

Pragmatic approach to management of hyperglycemia — Hospitalization is not

● We begin with a single injection of 10 to 20 units of intermediate-acting basal insulin

Dosing based on glucose levels and weight — An alternative approach to insulin

● If only the fasting blood glucose concentration is high, an intermediate-acting basal

● If only postprandial blood glucose concentrations are high, 6 to 10 units of rapid-acting

Management of hypoglycemia — Hypoglycemia in pregnancy is defined as a blood glucose

Choosing metformin versus glyburide — Clinically important pregnancy outcomes are

● Pregnant outcome – When compared with glyburide in meta-analyses of randomized

• Similar rates of perinatal mortality, neonatal hypoglycemia [71], and hypertensive

The ADA recommends avoiding metformin in patients with hypertension, preeclampsia, or at

Obstetric management of the pregnancy is discussed separately. (See "Gestational diabetes

Recurrence — GDM in one pregnancy is a strong predictor of recurrence in a subsequent

Long-term risk — A history of GDM is predictive of an increased risk of developing type 2

Testing — Long-term follow-up for development of type 2 diabetes is routinely recommended

the planning of future pregnancies, especially the importance of good glycemic

● Patients with normal test results

• Prevention of future diabetes – Patients should be informed that breastfeeding may

• Follow-up laboratory testing – Long-term follow-up is essential. Reassessment of

• Prevention of future cardiovascular disease – Given increasing evidence of an

SOCIETY GUIDELINE LINKS

INFORMATION FOR PATIENTS

SUMMARY AND RECOMMENDATIONS

● Glucose targets (see 'Glucose target' above)

• Fasting blood glucose concentration: <95 mg/dL (5.3 mmol/L)

• Benefits – A program of medical nutritional therapy, self-monitoring of blood glucose

• Medical nutritional therapy – Medical nutritional therapy is the initial approach.

• Pharmacotherapy – Pharmacotherapy is prescribed for patients who do not achieve

- Insulin – We suggest prescribing insulin rather than noninsulin antihyperglycemic

1. Society of Maternal-Fetal Medicine (SMFM) Publications Committee. Electronic address:

7. Uvena-Celebrezze J, Fung C, Thomas AJ, et al. Relationship of neonatal body composition to

27. Peterson CM, Jovanovic-Peterson L. Percentage of carbohydrate and glycemic response to

61. Balsells M, García-Patterson A, Gich I, Corcoy R. Ultrasound-guided compared to

Child Fetal Neonatal Ed 2016.

This generalized information is a limited summary of diagnosis, treatment, and/or medication

Topic 6790 Version 144.0

Conflict of interest policy

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