Liberal Glucose Management Feasible in GDM

LAS VEGAS — There was no difference in neonatal hypoglycemia among pregnant women with gestational diabetes randomized to tight glucose control versus a more liberalized approach, a researcher said here.

Differences between first neonatal glucose levels in women with tighter glucose control compared with liberalized glucose control were nonsignificant (53 mg/dL vs 56 mg/dL, respectively, P=0.56), reported Maureen S. Hamel, MD, of Brown University in Providence, Rhode Island.

Hamel commented about how increasing maternal age means the prevalence of gestational diabetes will likely increase in the years to come, with gestational diabetes already affecting up to 14% of all pregnancies, Hamel commented in a presentation at the Society for Maternal-Fetal Medicine’s annual meeting.

With incidence of gestational diabetes increasing, neonatal hypoglycemia is also likely to increase, Hamel said, but intrapartum glucose management varies by geography and institution, “from the frequent and conservative to the minimal,” she noted.

“Variations in practice are likely due to lack of recommendations from professional societies such as [the American College of Obstetricians and Gynecologists] and [the American Diabetes Association],” Hamel said.

To shed some light on the subject, researchers hypothesized that neonates born to mothers with tight glucose control would have overall lower rates of hypoglycemia. They performed a randomized trial from February 2016 to April 2018. Participants included women ages ≥18, with a diagnosis of gestational diabetes, with a singleton gestation.

Women were randomized at 36 weeks gestation — to avoid including women who delivered preterm or had a planned cesarean section delivery, Hamel noted — to either tight or liberalized intrapartum glucose control. Protocol for tight glucose control was to check glucose values every hour, while protocol for liberalized glucose control was to check every 4 hours in absence of symptoms. Intervention occurred when women had glucose levels <60 mg/dL or >120 mg/dL.

Overall, 38 women were randomized to tight control and 38 to liberalized control. They were a mean age of about 30, with 55% white and 46% Hispanic. About a third were nulliparous, with an average BMI of 33.

The portion of women who had any glucose value above the threshold and who received insulin for hyperglycemia were both significantly higher in the tight control group versus the liberalized control group, Hamel noted.

Loralei Thornburg, MD, of the University of Rochester in New York, praised the study for showing that liberalized glucose control can work for these patients “in a complex modern world” and keeps women from being “shamed” if their baby is born with hypoglycemia.

“It allows us to say ‘glucose control is important,’ but liberalizing it a little bit — especially for patients whose diets are more carb-based or have food resource issues. It definitely helps us avoid shaming around diabetes care,” Thornburg, who was not involved in the study, told MedPage Today.

Secondary outcomes included neonatal glucose over 24 hours, and the tight glucose group was associated with lower glucose levels versus the liberalized group (54 mg/dL vs 58 mg/dL, respectively, P=0.049). Notably, there was no difference in the portion of infants with glucose <40 mg/dL at birth (24% each, P=0.99).

Limitations to the data include that it only included short-term outcomes and follow-up, and the study was underpowered to assess differences in “infrequent neonatal outcomes,” such as NICU admission.