A simple approach to improving gestational diabetes management

A study published in Diabetic Medicine outlines a simple approach for the daily titration of insulin under the control of the patient with gestational diabetes (GD). This results in lower fasting blood sugar and lower birth weight, without causing significant hypoglycemia. The authors of the retrospective observational study1 conducted in a clinic in the South West of England, point out that multiple adverse pregnancy outcomes are associated with GD: macrosomia and large babies compared to at gestational age, maternal and infant birth trauma, increased need for obstetric intervention at delivery (e.g., caesarean section), hypoglycaemia, jaundice, respiratory problems and perinatal mortality.2-4 Read: Younger age of diabetes diagnosis linked to greater rates of cardiovascular outcomes, mortality Many women with GD are overweight and therefore have some degree of insulin resistance. However, the guidelines do not recommend any approach for insulin titration in this particular case. The researchers designed an algorithm to achieve rapid control of fasting blood sugar, using a three-pronged decision tree that allowed women to decide whether to increase or decrease their basal insulin doses or leave it unchanged. Methodology Women with GD were divided into two groups for analysis: those who required insulin treatment and a control group who did not. The starting dose of insulin was 14 intermediate-acting units. All patients on insulin were advised to increase their insulin dose by four units each day when their fasting blood glucose was ≥ 5.0 mmol/L (90 mg/dL). They were instructed to continue doing this daily until their fasting blood glucose was consistently < 5.0 mmol/L. Read: Moderate and late preterm birth linked to later cardiometabolic disorders The researchers compared insulin doses and glucose values at 36 weeks of gestation, as well as maternal and neonatal outcomes, in 105 women who had completed their pregnancies before the intervention procedure was implemented (titration of the insulin) and 93 others after this one. The baseline characteristics of the women in the before and after groups were the same. Results Results at 36 weeks show that patients started on insulin after implementation of the algorithm experienced improvements in all primary measures: Higher total daily insulin dose (53.1 units vs 36.4; p = 0.027; 0.56 vs 0.37 units/kg/day; p = 0.029); Lower mean fasting blood glucose (4.6 vs 5.1 mmol/L [83 vs 92 mg/dL]; p = 0.031); Lower birth weight according to the Z score (0.34 vs 0.92; p = 0.005); No significant difference was observed for macrosomia or cesarean sections; None of the women suffered from severe hypoglycaemia. The authors point out that the simplicity and minimal cost of this intervention are major advantages. The patients said they were satisfied with the autonomy they were granted and the results they obtained. This simple and pragmatic approach to insulin therapy during pregnancy gives excellent results in a real setting. However, several aspects of this approach require further evaluation. References 1. McGovern, A.P. et al. (2022). Patient-led rapid titration of basal insulin in gestational diabetes is associated with improved glycaemic control and lower birthweight. Diabetic Medicine https://doi.org/10.1111/dme.14926 2. Metzger B.E. et al. (2008). Hyperglycemia and adverse pregnancy outcomes. N Engl J Med 358(19), 1991-2002. 3. Dodd J.M. et al. (2007). Screening for gestational diabetes: the effect of varying blood glucose definitions in the prediction of adverse maternal and infant health outcomes. Aust N Z J Obstet Gynaecol 47(4), 307-312. 4. Crowther C.A. et al. (2005). Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med 352(24), 2477-2486. This article has been translated from its original French and originally appeared on our sister site Profession Santé. Read: One in five adolescent girls with type 2 diabetes have PCOS

A simple approach to improving gestational diabetes management

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