Gestational Diabetes (3)
INSULIN TREATMENT,
OBSTETRICAL FOLLOW-UP,
AND DELIVERY MODE

Dr. Claude Allouche, Gynecologist,Diabete gestationnel 3 general engl
Ahuza Clinic, Raanana, Israel,
058 726 02 64

WHEN IS INSULIN TREATMENT NECESSARY?

When does insulin treatment become necessary for gestational diabetes?

In the case of gestational diabetes, insulin treatment is required if after 10 days of a hygieno-dietary regimen (balanced diet and physical activity), blood glucose levels are not normalized (less than 0.95 g/L fasting and less than 1.2 g/L after a meal).

This type of treatment is administered in more than one out of four cases of gestational diabetes.

In Israel, in some cases, medications like metformin may also be used if diet alone is not enough to balance the diabetes, but this decision must be made in consultation with a specialized obstetrician-gynecologist and an endocrinologist or diabetologist.

WHAT IS THE OBSTETRICAL FOLLOW-UP?

What is the obstetrical follow-up for gestational diabetes?

In Israel, when gestational diabetes is diagnosed, the patient is referred to a high-risk pregnancy follow-up consultation (in Hebrew, "maakav herayon besicoun מעקב הריון בסיכון") where the gynecologist will decide the monitoring frequency based on the diabetes balance.

However, in general, if the gestational diabetes is well-controlled and there are no other associated risk factors or diseases, your follow-up will resemble that of a healthy pregnancy.

It is therefore essential to diagnose gestational diabetes as early as possible to establish the right plan...

WHAT IS THE MODE OF DELIVERY?

If gestational diabetes is well-controlled, in the absence of other risk factors and fetal macrosomia, delivery is managed like any other pregnancy.
However, in Israel, the Ministry of Health (misrad habriout) recommends inducing labor at 40 weeks of gestation, even if the gestational diabetes is well-controlled, rather than waiting until 41 or 42 weeks, as is usually done in pregnancies without complications.

On the other hand, when diabetes is poorly controlled or there is fetal impact, it is recommended to induce labor at 39 weeks of gestation or even earlier to prevent complications from worsening.

In cases of gestational diabetes, a cesarean section is immediately proposed when the estimated fetal weight exceeds 4,250 - 4,500 g to avoid difficulties in natural delivery, which carries the risk of shoulder dystocia and brachial plexus paralysis.
This arbitrary threshold, set at 4,250 g in Israel and 4,500 g in France, accounts for the imprecision in fetal weight estimation despite current technology, even with experienced sonographers.

WHAT HAPPENS AFTER DELIVERY?

  • In the immediate postpartum period, blood glucose levels should continue to be monitored to verify the return to normal levels.

  • For the newborn, at birth, there is a risk of hypoglycemia, especially for macrosomic babies or when the mother's diabetes was poorly controlled.

  • What about contraception?

    • Contraception should be adapted according to associated risk factors.
    • In the absence of risk factors, a mini-pill or a combined pill can be prescribed.
    • The insertion of an intrauterine device (IUD) can be considered after delivery.

  • What about the prognosis and long-term risks?

    • The risk of recurrence of gestational diabetes in a subsequent pregnancy is estimated at 30 to 80%.
    • The risk of developing type 2 diabetes later in life is multiplied by 7.
    • Screening for type 2 diabetes is recommended through fasting blood glucose testing during the postnatal consultation, before a new pregnancy, and every 3 years thereafter.
    • In Israel, it is even recommended to perform a new 75 g glucose tolerance test, which includes fasting glucose and two glucose levels 1 hour and 2 hours after consuming 75 g of glucose.
      This test is generally prescribed during the postnatal visit 4 to 6 weeks after delivery.
      This is also when future contraception will be discussed based on your preferences and any additional risk factors.

Sources:
Ameli.fr - Gestational Diabetes

Other publications on the subject:

  • Gestational Diabetes (1): What is it? Definition
  • Gestational Diabetes (2): Why screen for it?
  • What complications?
  • Gestational Diabetes (3): Who, when, and how to screen for it?
  • Gestational Diabetes (4): Risk factors
  • Gestational Diabetes (5): Why does gestational diabetes appear during pregnancy?
  • Gestational Diabetes (6): What management? What treatment?
  • Gestational Diabetes (7): What hygieno-dietary advice?
  • Gestational Diabetes (8): How to monitor blood sugar?
  • Gestational Diabetes (9): When is insulin treatment necessary?
  • Gestational Diabetes (10): What obstetrical follow-up?
  • Gestational Diabetes (11): What mode of delivery?
  • Gestational Diabetes (12): And after delivery?
  • Gestational Diabetes (13): Why screen at 24 weeks and not before?

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