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		November 2005 Evidence of the Month

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Treatment of Gestational Diabetes Reduces Infant Morbidity and Improves Maternal Quality of Life

Fred Storms, MD, PhD
Diabetes Centrum Bilthoven
Mesos MediCentrum
The Netherlands

Comment on: Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS; Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group. Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. N Engl J Med. 2005;352:2477-2486.

Background

Gestational diabetes mellitus occurs in 2 to 9 percent of all pregnancies and involves risks such as macrosomia, shoulder dystocia, birth injuries like fractures and nerve palsies and hypoglycaemia. Despite these risks, there is still discussion whether or not treatment of this form of metabolic disturbances in pregnancy is beneficial.

Methods

In this study women were screened for gestational diabetes. The group was selected according to World Health Organisation (WHO) criteria for gestational diabetes with a fasting glucose below 7.8 mmol/l and 7.8 to 11.0 mmol/l 2 hours after 75 grams of glucose. This group can be classified as having impaired glucose tolerance. The intervention group (n=490) received diet counselling, were instructed how to do self-glucose monitoring and were prescribed insulin injection when fasting glucose was >5.5 mmol/l and postprandial glucose was >7 mmol/l (before 35 weeks gestation) or >8 mmol/l (after 35 weeks gestation). The control group (n=510) were not told about the diagnosis of glucose intolerance and were treated according to local standard practice.

Key Results

The primary outcome (death, shoulder dystocia, bone fracture and nerve palsy) was found in 1% of the intervention and 4% of the routine care group (P=0.01). This gave a number needed to treat to prevent 1 primary outcome of 34. More infants born to mothers in the intervention group were admitted to the neonatal nursery (71% vs 61%, P=0.01), and more women in the intervention group had induced labour (39% vs 29%, P<0.001). In terms of quality of life, scores in the SF-36 well-being scale were better for the intervention group. Moreover, 8% of the intervention group vs 17% of controls scored positive for the Edinburgh Depression Scale (P<0.001). Infants born in the intervention group weighed a mean of 145 g less at birth (P<0.001 vs control).

Clinical Relevance

This trial proved that screening and treatment for gestational diabetes in all pregnancies, as well as treatment with diet and, when necessary according to self-glucose monitoring data, insulin, is the state of the art of treatment. The number of women needed to treat to avoid 1 primary outcome (death, shoulder distocia, bone fracture and nerve palsy) was 34. All healthcare facilities that handle pregnancies should have a screening program and a treatment program for gestational diabetes.

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