Volume 76, Number 6

OBSTETRICAL AND GYNECOLOGICAL SURVEY

Copyright © 2021 Wolters Kluwer Health,
Inc. All rights reserved. CME REVIEW ARTICLE
CHIEF EDITOR'S NOTE: This article is part of a series of continuing education activities in this Journal through which up to
18
36 AMA PRA Category 1 Credits™ can be earned in 2021. Instructions for how CME credits can be earned appear on the last page
of the Table of Contents.

Diagnosis and Management of Gestational

Diabetes Mellitus: An Overview of
National and International Guidelines
Ioannis Tsakiridis, PhD,* Sonia Giouleka, MSc,† Apostolos Mamopoulos, PhD,‡
Anargyros Kourtis, PhD,§ Apostolos Athanasiadis, PhD,‡
Dionysia Filopoulou, MD,† and Themistoklis Dagklis, PhD¶
*Clinical Fellow in Maternal-Fetal Medicine, †Resident, ‡Professor, §Consultant Endocrinologist, and ¶Assistant Professor,
Third Department of Obstetrics and Gynaecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece

Importance: Gestational diabetes mellitus (GDM) represents one of the most frequent complications of preg-
nancy and is associated with increased maternal and neonatal morbidity. Its incidence is rising, mostly due to an
increase in maternal age and maternal obesity rate.
Objective: The aim of this study was to review and compare the recommendations of the most recently pub-
lished guidelines on the diagnosis and management of this condition.
Evidence Acquisition: A descriptive review of guidelines from the National Institute for Health and Care Excel-
lence (NICE), the International Federation of Gynecology and Obstetrics, the Australasian Diabetes in Pregnancy
Society (ADIPS), the Society of Obstetricians and Gynecologists of Canada (SOGC), the American College of Ob-
stetricians and Gynecologists (ACOG), the American Diabetes Association, and the Endocrine Society on gesta-
tional diabetes mellitus was carried out.
Results: The NICE guideline recommends targeted screening only for women with risk factors, whereas the
International Federation of Gynecology and Obstetrics, ADIPS, SOGC, and the ACOG recommend screening
for all pregnant women at 24 to 28 weeks of gestation in order to diagnose and effectively manage GDM; they
also state that women with additional risk factors should be screened earlier (ie, in the first trimester) and retested
at 24 to 28 weeks, if the initial test is negative. These guidelines describe similar risk factors for GDM and suggest
the same thresholds for the diagnosis of GDM when using a 75-g 2-hour oral glucose tolerance test. Of note, the
NICE only assesses the fasting and the 2-hour postprandial glucose levels for the diagnosis of GDM. Moreover,
the SOGC and the ACOG do not recommend this test as the optimal screening method. The Endocrine Society
alone, on the other hand, recommends the universal testing of all pregnant women for diabetes before 13 weeks
of gestation or as soon as they attend the antenatal service and retesting at 24 to 28 weeks if the initial results are
normal. In addition, there is a general consensus on the appropriate ultrasound surveillance of pregnancies com-
plicated with GDM, and all the medical societies, except the ADIPS, recommend self-monitoring of capillary glu-
cose to assess the glycemic control and set the same targets for fasting and postprandial glucose levels. There is
also agreement that lifestyle modifications should be the first-line treatment; however, the reviewed guidelines
disagree on the medical management of GDM. In addition, there are controversies regarding the timing of delivery,
the utility of hemoglobin A1c measurement, and the postpartum and lifelong screening for persistent hyperglycemia
and type 2 diabetes. However, all the guidelines state that all women in pregnancies complicated by GDM should

All authors, faculty, and staff in a position to control the content of Correspondence requests to: Ioannis Tsakiridis, PhD,
this CME activity have disclosed that they have no financial relation- Konstantinoupoleos 49, 54642, Thessaloniki, Greece. E-mail:
ships with, or financial interests in, any commercial organizations rel- [email protected].
evant to this educational activity.

www.obgynsurvey.com | 367

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368 Obstetrical and Gynecological Survey

undergo a glycemic test at around 6 to 12 weeks after delivery. Finally, there is a universal consensus on the impor-
tance of breastfeeding and preconception screening before future pregnancies.
Conclusions: As GDM is an increasingly common complication of pregnancy, it is of paramount importance
that inconsistencies between national and international guidelines should encourage research to resolve the is-
sues of controversy and allow uniform international protocols for the diagnosis and management of GDM, in or-
der to safely guide clinical practice and subsequently improve perinatal and maternal outcomes.
Target Audience: Obstetricians and gynecologists, family physicians
Learning Objectives: After participating in this activity, the learner should be better able to identify all available
screening methods for gestational diabetes mellitus; describe diagnostic procedures for gestational diabetes
mellitus; and explain appropriate management issues during the antenatal, intrapartum, and postpartum period
in pregnancies complicated by gestational diabetes mellitus.

Gestational diabetes mellitus (GDM) is defined as Institute for Health and Care Excellence (NICE 2015),14
hyperglycemia or carbohydrate intolerance that is first the International Federation of Gynecology and Obstetrics
detected during pregnancy and does not meet the (FIGO 2015),1 the Australasian Diabetes in Pregnancy
criteria of preexisting diabetes.1,2 Furthermore, GDM Society (ADIPS 2013),15 the Society of Obstetricians and
is classified as A1GDM when glycemic control is Gynecologists of Canada (SOGC 2019),16 the American
achieved with diet and exercise and as A2GDM when College of Obstetricians and Gynecologists (ACOG
it requires medication.3 Diabetes affects approximately 2018),3 the American Diabetes Association (ADA
7% of pregnancies worldwide, and it is estimated that 2020),17 and the Endocrine Society (ES 2013).18 Of
84% of these cases involve GDM.4 The incidence of note, the ADIPS makes no recommendation on the
GDM has doubled over the last 14 years, mainly due management of GDM. An overview of the recommen-
to the parallel increase of obesity and age of pregnant dations is presented in Table 1 (screening and diagnosis
women.5 for GDM) and Table 2 (management of GDM during
Gestational diabetes mellitus is associated with sig- pregnancy, labor, and postpartum period).
nificant maternal morbidity, including cesarean delivery,
preeclampsia, and high-risk of developing type 2 diabe-
tes or cardiovascular disease later in life.6–9 Moreover, RISK FACTORS FOR GDM
numerous studies have shown that the in utero exposure Five of the reviewed guidelines (NICE, FIGO, ADIPS,
to maternal hyperglycemia leads to several fetal and SOGC, and ACOG) mention risk factors for the oc-
perinatal complications, such as congenital malfor- currence of GDM, including ethnicity (African, Asian,
mations, macrosomia, stillbirth, shoulder dystocia, birth Hispanic, Native American, Aboriginal), maternal age
trauma, neonatal hypoglycemia, polycythemia, and (>35 years), obesity (body mass index [BMI] >25–30-
hyperbilirubinemia. Moreover, it increases the offspring's kg/m2), family history of diabetes (first-degree relative
long-term cardiometabolic risk.10–13 with diabetes or sister with GDM), and previous GDM
Although congenital malformation rates associated or delivery of a macrosomic neonate.19 Other risk factors
with maternal hyperglycemia appear to decline over reported are preeclampsia or hypertension, exces-
the recent years, perinatal mortality rates remain stable, sive weight gain during pregnancy, low height, high
and the risk of both these conditions is still significantly parity, multiple gestation, acanthosis nigricans, physi-
elevated compared with nondiabetic women.5 Thus, the cal inactivity, hemoglobin A1c (HbA1c) of 5.7% or
development of consistent international evidence-based greater, high-density lipoprotein cholesterol less than
algorithms for the prevention, diagnosis, and manage- 35 mg/dL, triglyceride level greater than 250 mg/dL,
ment of this disease will hopefully lower its incidence and history of cardiovascular disease.19,20 The ADIPS
and optimize the pregnancy outcomes. Hence, the aim points out that women with either a BMI between 25
of this descriptive review was to synthesize and com- and 35 kg/m2 or ethnicity as their only risk factor
pare recommendations from influential guidelines on should be considered as “moderate risk,” whereas those
the diagnosis and management of GDM. with both these factors or one of the others mentioned
previosuly should be considered as “high risk.” The NICE
guideline also mentions that the detection of glycosuria
EVIDENCE ACQUISITION
at any time during antenatal care should raise suspicion
The most recently published guidelines on GDM were of GDM.
retrieved, and a descriptive review was conducted. In par- Moreover, a recent umbrella review of meta-analyses
ticular, 7 guidelines were identified from the National on risk factors for GDM concluded that BMI greater

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 TABLE 1
Summary of Recommendations on Screening and Diagnosis of GDM
NICE FIGO ADIPS SOGC ACOG ADA ES
Country United Kingdom International Australia Canada United States United States International
Issued February 2015 October 2015 May 2013 December 2019 February 2018 January 2020 November 2013
Title Diabetes in The International ADIPS Consensus Guideline No. 393- Gestational Diabetes 14. Management Diabetes and
Pregnancy: Federation of Guidelines for the Diabetes in Mellitus of Diabetes in Pregnancy: An
Management Gynecology and Testing and Pregnancy Practice Bulletin Pregnancy: Endocrine Society
From Obstetrics (FIGO) Diagnosis of No. 190 Standards of Clinical Practice
Preconception to Initiative on Gestational Gestational Diabetes Medical Care Guideline
the Postnatal Diabetes Mellitus: A Mellitus in Australia in Diabetes—
Period Pragmatic Guide for 2020
Diagnosis,
Management, and Care
Pages 55 39 8 13 16 10 23
References 0 292 16 86 109 113 234
Risk factors for Ethnicity, previous Ethnicity, older maternal Moderate: Maternal age >35 y, Ethnicity, older maternal Not discussed Not discussed
GDM GDM, FH of age, high parity, Ethnicity, BMI BMI >30 kg/m2, age, obesity (BMI
diabetes, BMI increased BMI, FH 25–35 kg/m2 ethnicity, FH of DM, >25 kg/m2), previous
>30 kg/m2, diabetes, excessive High: previous GDM, previous GDM, GDM, physical inactivity,
previous weight gain in previous previous FH of diabetes, previous
macrosomic pregnancy, low height, hyperglycemia, age macrosomic macrosomic baby,
neonate (≥4.5 kg). PCOS, previous poor ≥40 y, FH of neonate, PCOS, hypertension, HbA1c
Glycosuria pregnancy outcome, diabetes, BMI acanthosis ≥5.7%, PCOS,
(2 + 1 time or previous macrosomic >35 kg/m2, previous nigricans, high-density lipoprotein
1 + 2 times or baby, previous GDM, macrosomia, PCOS, corticosteroids' <35 mg/dL, triglyceride
more) preeclampsia, multifetal medication, use. >250 mg/dL, acanthosis
pregnancy corticosteroids' use. nigricans, history of CVD
Screening for At 24–28 weeks for At 24–28 wk for all At 24–28 wk for all At 24–28 wk for all At 24–28 wk for all women. Not discussed Before 13 wk or as

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GDM women with risk women. women. women. If obese with additional soon as possible
factors. If high risk, test earlier. If high risk, test If high risk, test risk factor, test earlier. for all pregnant
If previous GDM, If negative, repeat earlier. earlier. If negative, repeat testing women.
Diagnosis and Management of GDM • CME Review Article

test earlier. testing at 24–28 wk If negative, repeat If negative, repeat at 24–28 wk At 24–28 wk if
If negative, repeat testing at 24–28 wk testing at 24–28 wk previous results are
testing at negative
24–28 wk
(Continued on next page)
369
 370
TABLE 1. (Continued)

NICE FIGO ADIPS SOGC ACOG ADA ES

Early screening Only for women with 75 g 2 h OGTT for 1 Moderate risk factor: Not discussed Overweight women with Not discussed FPG (92–125 mg/dL for
previous GDM: high-risk women (FPG random or additional risk factors. GDM, ≥126 mg/dL
self-monitoring of or HbA1c to all women in FPG +/− OGTT. FPG, 75 g 2 h OGTT, for overt diabetes),
blood glucose or high-resource countries 1 High- or 2 HbA1c or 2-step process random PG
75-g 2-h OGTT and in medium- to moderate-risk starting with 50 g OGTT (≥200 mg/dL for
low-resource ones with factors: 75-g 2-h overt diabetes) or
high-risk populations) OGTT HbA1c (≥6.5% for
overt diabetes).
A second abnormal
test on another day
is required for overt
diabetes' diagnosis
Screening for 2-h pregnancy 2-h pregnancy OGTT 2-h pregnancy OGTT 50-g glucose 1-h 50-g glucose 1-h Not discussed 2-h pregnancy OGTT
GDM at OGTT with 75-g with 75-g oral with 75-g oral screening test. screening test. with 75-g oral
24–28 wk oral glucose glucose glucose If glucose If glucose glucose
<7.8 mmol/L, no >130–140 mg/dL,
further testing. If perform a 100-g 3-h
glucose = 7.8–11 OGTT†. Two or more
mmol/L, perform a thresholds are required
75 g 2 h OGTT*. If for the diagnosis
glucose ≥11.1
mmol/L, GDM
diagnosed.
Alternatively,
2-h 75 g OGTT
Criteria for GDM FPG ≥5.6 mmol/L FPG ≥5.1–6.9 mmol/L FPG ≥5.1 mmol/L FPG ≥5.1 mmol/L FPG ≥5.1 mmol/L Not discussed FPG ≥5.1 mmol/L
diagnosis with 2-h glucose 1-h glucose 1-h glucose 1-h glucose 1-h glucose 1-h glucose
Obstetrical and Gynecological Survey

2-h OGTT (at ≥7.8 mmol/L ≥10 mmol/L ≥10 mmol/L ≥10 mmol/L ≥10 mmol/L ≥10 mmol/L
least 1 value 2-h glucose 2-h glucose 2-h glucose 2-h glucose 2-h glucose
should be met) ≥8.5–11 mmol/L ≥8.5 mmol/L ≥8.5 mmol/L ≥8.5 mmol/L ≥8.5 mmol/L

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*FPG ≥5.3 mmol/L, 1-hour glucose ≥10.6 mmol/L, and 2-hour glucose ≥9 mmol/L for the diagnosis of GDM.
†
Two different sets of cutoff values are proposed. FPG >5.3 mmol/L, 1-hour PG >10 mmol/L, 2-hour PG >8.6 mmol/L, and 3-hour PG >7.8 mmol/L OR FPG >5.8mmo/L, 1-hour PG >10.6
mmol/L, 2-hour PG >9.2 mmol/L, and 3-hour PG >8 mmol/L.
FH, family history; PCOS, polycystic ovary syndrome; CVD, cardiovascular disease.
 TABLE 2
Summary of Recommendations on the Management of GDM During Pregnancy, Labor, and the Postpartum Period
NICE FIGO ADIPS SOGC ACOG ADA ES
Self-monitoring Recommended. Fasting and Recommended. Not discussed Recommended. Recommended. Recommended. Recommended.
1-h postprandial glucose Fasting and 1- or 2-h Fasting and 1- or Fasting and 1- or Fasting and Pre- and 1- or 2-h
to all GDM women. postprandial glucose 2-h postprandial 2-h postprandial postprandial postprandial. Bedtime
Preprandial and bedtime (2–3/d) to all GDM glucose to all glucose to all GDM glucose. and during the night
when using multiple daily women GDM women women. (4/d) Preprandial only when indicated
insulin injections when using insulin
pumps or
basal-bolus therapy
Glucose targets FPG <5.3 mmol/L FPG <95 mg/L Not discussed FPG <5.3 mmol/L FPG <95 mg/L FPG <95 mg/L FPG <95 mg/L
1-h postprandial (5.3 mmol/L) 1-h postprandial 1-h postprandial (5.3 mmol/L) (5.3 mmol/L)
<7.8 mmol/L 1-h postprandial <7.8 mmol/L <140 mg/dL 1-h postprandial 1-h postprandial
2-h postprandial <140 mg/dL 2-h postprandial 2-h postprandial <140 mg/dL <140 mg/dL
<6.4 mmol/L (7.8 mmol/L) <6.7 mmol/L <120 mg/dL (7.8 mmol/L) (7.8 mmol/L)
Glucose >4 mmol/L 2-h postprandial 2-h postprandial 2-h postprandial
<120 mg/dL <120 mg/dL <120 mg/dL
(6.7 mmol/L) (6.7 mmol/L) (6.7 mmol/L)
HbA1C targets Not recommended. Measure Only to verify the Not discussed Not discussed Not discussed <6% (achieved without ≤6.5–7% for pregnant
HbA1c only at the time of self-monitored hypoglycemia) women with
GDM diagnosis to identify glucose reports <7% (to prevent preexisting diabetes
preexisting DM hypoglycemia)
CGM Only when severe No clear benefits Not discussed Not discussed Not discussed Only in addition to Only when
hypoglycemia and self-monitoring self-monitoring
unstable glucose levels. Or cannot assess the
to get informed about glycemic control
glucose variability
Antenatal fetal Ultrasound at 28, 32, and Ultrasound every Not discussed Ultrasound at From 32 wk: fetal Not discussed Not discussed
surveillance 36 wk (AF and fetal growth) 2–4 wk from 28, 32, and 36 wk testing and AF
38 and 39 wk: assessment diagnosis to term (AF and fetal (mainly for women
of fetal well-being (fetal growth) growth) with poorly
Assessment of fetal Weekly from controlled GDM
well-being is 36 wk: and A2GDM)

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recommended assessment of
fetal well-being
Diagnosis and Management of GDM • CME Review Article

Initial Lifestyle interventions when Lifestyle interventions Not discussed Lifestyle Lifestyle interventions Lifestyle interventions Lifestyle interventions as
management FPG <7 mmol/L at as first-line treatment interventions as as first-line as first-line treatment first-line treatment
of GDM diagnosis Medical therapy first-line treatment Insulin when glucose Medical therapy when
Insulin when FPG when glucose treatment Medical therapy targets are not glucose targets are
≥7 mmol/L or targets are not Medical therapy when glucose achieved not achieved
6–6.9 mmol/L + achieved when glucose targets are not
complications targets are not achieved
achieved after
1–2 wk
(Continued on next page)
371
 372
TABLE 2. (Continued)

NICE FIGO ADIPS SOGC ACOG ADA ES

Nutritional Diet with low glycemic index A minimum of 175 g Not discussed Not discussed Carbohydrate (ideally A minimum of 175 g of Carbohydrate intake
interventions of carbohydrate complex) intake: carbohydrate (ideally 35%–45% of total
(35%–45% of total 33%–40% of complex), 71 g of calories. 3 meals and
calories); 3 meals calories, protein protein and 28 g of 2–4 snacks
and 2–3 snacks, 20% and fat 40% fiber. Low saturated
food with low of calories. Low fat intake
glycemic index and glycemic index
high fiber content food; 3 meals and
2–3 snacks
Insulin Rapid-acting analogs over Combination of long or Not discussed Not discussed Combination of long Not discussed Rapid-acting analogs
treatment soluble human insulin intermediate with or intermediate over soluble human
Insulin pumps if no control rapid-acting insulin with rapid-acting insulin
achieved with multiple insulin Insulin pumps if no
daily injections Focused treatment control achieved with
if only isolated at multiple daily
specific time of the injections
day abnormal
values.
OAD agents Metformin if glucose targets Metformin, insulin, or Not discussed Insulin or oral Insulin (first-line Insulin (first-line Insulin (first-line medical
are not achieved with diet glyburide. Consider hypoglycemic medical treatment) medical treatment). treatment). Glyburide
and exercise insulin as first-line agents Metformin if insulin Metformin and as an alternative,
Insulin if metformin fails to treatment only if high is not accepted glyburide (not except when high risk
achieve glucose targets or risk of failure of oral tolerated or recommended as of failure of oral
is contraindicated/ medication afforded. Glyburide first-line) medication.
unaccepted (not recommended Metformin not as first-
Glyburide as an alternative as first-line) line
to metformin or insulin
Obstetrical and Gynecological Survey

Timing of <40+6 wk for uncomplicated Induction at 38–39 wk if Not discussed Induction between A1GDM 39–40+6 wk Not discussed Not discussed
delivery GDM EFW = 3800–4000 g 38 and 40 wk A2GDM 39–39+6 wk
Induction of labor or or LGA or poor depending on the Earlier delivery if

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elective cesarean delivery glycemic control, glycemic control complications exist
if no spontaneous birth previous stillbirth, and the comorbid GDM not controlled
until this time or earlier if vascular disease factors. (39 wk for even in hospital:
complications exist If not, continue to insulin-treated 34–36+6 wk
40–41 wk GDM and 40 wk Cesarean delivery
If EFW >4000 g offer for diet-controlled considered if EFW
cesarean delivery GDM) ≥4500 g
Blood glucose Recommended. Monitoring Recommended. Not discussed Not discussed Not discussed Not discussed Recommended.
control of capillary PG every hour. Glucose target is Glucose target is
during labor Glucose target is 4–7 mmol/L 4–7 mmol/L
4–7 mmol/L
 Diagnosis and Management of GDM • CME Review Article 373

than 30 kg/m2 and hypothyroidism were the 2 risk fac-

24–72 h after delivery;

test, any glycemic test

6–12 wk postpartum

history of GDM and

tors with the most convincing evidence of association

negative postnatal
self-monitoring for

75-g 2-h OGTT at

to all women with

therapy. FPG or

To all women with

To all women with

history of GDM
with GDM. Prepregnancy BMI (as a continuous variable),
75-g 2-h OGTT at 4–12 Discontinue any

Recommended
overweight (BMI 25–30 kg/m2), snoring, sleep-disordered

periodically
breathing, polycystic ovary syndrome, and family history
fasting

GDM of diabetes demostrated to be highly suggestive evidence

for GDM.21

glycemic test at least

wk postpartum to all

history of GDM, any

hyperglycemia and
prevent congenital
diagnostic criteria)
women with GDM

history of GDM in
SCREENING FOR GDM
To all women with

Women with history To all women with

(nonpregnancy

malformations
Recommended

order to treat
All the reviewed guidelines, except from the one by the
every 3 y

NICE, the ADA (makes no relevant recommendation),

and the ES, recommend screening for all pregnant women
at 24 to 28 weeks of gestation, in order to detect and early
manage GDM. Moreover, the NICE recommends targeted
of GDM should be
wk postpartum to

any glycemic test

75-g OGTT at 4–12

want to conceive
screening only for women with risk factors for GDM
frequently if they
To all women with
history of GDM,

screened more
all women with

(24–28 weeks). A multicenter randomized trial reported

Not discussed

every 1–3 y

on the beneficial role of the appropriate treating of GDM

for the reduction of some fetal and maternal complica-
again
GDM

tions.22 Additionally, evidence from a systematic review

on the benefits and harms of screening for GDM before
between 6 wk and

and after 24 gestational weeks found a substantial benefit

6 mo postpartum

of screening after 24 weeks, but not earlier in preg-

Recommended
Discontinue any therapy and 75-g 2-h OGTT at 6–12 75-g 2-h OGTT at 75-g 2-h OGTT

Not discussed

OGTT annually if Not discussed

nancy.23 On the contrary, the ES recommends a univer-

sal first-trimester (ideally before 13 gestational weeks)
testing for diabetes using fasting/random plasma glucose
(PG) levels or HbA1c in terms of preventing potential fe-
tal complications of GDM in pregnancy, aknowledging
all women with

(nonpregnancy
postpartum to

with history of

contemplate
Not discussed

that this strategy increases the false-positive results. This

every 1–2 y
To all women

GDM, FPG

pregnancy
diagnostic
6–12 wk

recommendation is based on a meta-analysis, which

another
criteria)
GDM

found that there is a statistically significant association

they

between positive screening tests and pregnancies at high

risk of adverse perinatal outcomes (macrosomia and ges-
wk postpartum to all

tational hypertension).24 As reported by the ES, testing

hyperglycemia and
prevent congenital
diagnostic criteria)
women with GDM

history of GDM in
Preconception To all women with history of To all women with

should be repeated at 24 to 28 gestational weeks with a

(nonpregnancy

malformations
To all women with history of Recommended
Recommended

order to treat

75-g 2-hour oral glucose tolerance test (OGTT), if overt

or GDM is not diagnosed by the initial test.
Earlier screening (before universal screening at 24–
28 weeks) is recommended by some of the other socie-
ties only for women who present with risk factors for
Measure FPG at 6–13 wk

developing GDM; if the results are normal, the screen-

If >13 wk, FPG or HbA1c

plan another pregnancy

diabetes (HbA1c) if they
GDM, offer testing for

ing should be repeated at 24 to 28 weeks.25 According

postnatal test, HbA1c
GDM and negative
(no routine OGTT)

to the NICE, women with a previous history of GDM

test for persistent
hyperglycemia

are considered as high risk and should be screened ear-

Breastfeeding Recommended
postpartum

lier because the recurrence rate of GDM in a subsequent

every year

pregnancy is reported to be as high as 45%.26 Moreover, the

FIGO recommends early screening in high-resource coun-
AF, amniotic fluid.

tries and low- to medium-resource ones with high-risk

populations. The ADIPS and the ACOG, on the other
screening for

screening for
diabetes and
prediabetes

hand, consider early screening for women with addi-

screening
Postpartum

diabetes

tional risk factors. Hence, according to all guidelines,

type 2
Lifelong

pregnant women with risk factors for GDM should be

considered as candidates for an early screening.

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374 Obstetrical and Gynecological Survey

However, a controversy exists among the guidelines starting with a 50-g glucose challenge screening test
regarding the appropriate screening method, when early with measurement of PG level 1 hour postload. If the
testing is indicated, that is, in high-risk patients. The PG level is between 7.8 and 11 mmol/L, a 75-g 2-hour
NICE, FIGO, and the ADIPS recommend the perfor- OGTT should be performed with the following thresh-
mance of a 75-g 2-hour OGTT. The ACOG, based on olds: FPG of 5.3 mmol/L or greater, 1-hour PG of
an observational retrospective cohort study from 2016, 10.6 mmol/L or greater, or 2-hour PG of 9 mmol/L or
mentions that HbA1c may also be of value because its greater, for the diagnosis of GDM. If the PG 1 hour after
first-trimester levels are predictive of GDM, but has low the 50 g load is less than 7.8 mmol/L, there is no need
accuracy (for a cutoff level of 5.25%, the sensitivity and for further testing, whereas if it exceeds the value of
the specificity were 74% and 51%, respectively).27 The 11.1 mmol/L, GDM is diagnosed without requiring an
NICE also suggests self-monitoring of blood glucose OGTT. The ACOG also recommends a 2-step approach,
levels for women with previous GDM as an alternative with a 50-g glucose challenge test being the initial step,
to OGTT. The FIGO points out that when early screening followed by a 100-g 3-hour OGTT if PG is greater than
is indicated, it is prudent to measure fasting plasma glu- 130 or 140 mg/dL 1 hour later. As for the latter test, 2 or
cose (FPG) or HbA1c in all pregnant women during their more abnormal values are required in order to diagnose
first antenatal appointment. Of note, the SOGC and the GDM, and the ACOG proposes the use of 2 different
ADA do not make any relevant recommendation. The sets of diagnostic criteria, either from the National Dia-
different recommendations on the appropriate method betes Data Group (105, 190, 165, and 145 mg/dL, re-
of early screening probably reflect the different financial spectively) or from Carpenter and Coustan (95, 180,
status of each related country. 155, and 140 mg/dL, respectively) based mainly on the
different prevalence of GDM in some communitites
and the available resources.30,31
DIAGNOSIS OF GDM
This variation among the reviewed guidelines is proba-
The FIGO, ADIPS, and the ES endorse the World bly related to different studies. In particular, according to
Health Organization (2013) and International Associ- data from a recent meta-analysis of more than 2500 partic-
ation of the Diabetes and Pregnancy Study Groups ipants, the 1-step approach resulted in a lower risk of
(2010) criteria for the diagnosis of GDM at 24 to LGA neonates (relative risk [RR], 0.46; 95% confidence
28 weeks' gestation, which are based on the Hyper- interval [CI], 0.25–0.83), admission to neonatal intensive
glycemia and Adverse Pregnancy Outcomes study of care unit (RR, 0.49; 95% CI, 0.29–0.84), neonatal hypo-
2008.25,28,29 The Hyperglycemia and Adverse Pregnancy glycemia (RR, 0.52; 95% CI, 0.28–0.95), and lower mean
Outcomes study included more than 20,000 pregnant birth weight (mean difference [MD], −112.91 grams;
women who underwent 2-hour OGTT at 24 to 32 gesta- 95% CI, −190.48 to −35.33).32 However, evidence from
tional weeks and found that abnormal OGTT increases a large retrospective cohort study of more than 23,000
the risk of large-for-gestational-age (LGA) neonates, ce- women has shown that the 1-step approach was associ-
sarean delivery, and neonatal hypoglycemia.28 Hence, ated with a higher rate of cesarean deliveries and more
according to the aforementioned guidelines, the adequate neonatal intensive care unit admissions compared with
screening method is the performance of a single-step 75-g the 2-step approach.33 Table 3 summarizes the accuracy
2-hour OGTT. If the FPG is equal to or more than of each diagnostic method.23
5.1 mmol/L (92 mg/dL), the 1-hour postload glucose
is equal to or more than 10 mmol/L (180 mg/dL), or MANAGEMENT OF GDM
the 2-hour postload glucose is equal to or more than
Antenatal Care
8.5 mmol/L (153/dL), then a definitive diagnosis of
GDM is established. Moreover, the NICE guideline
Self-monitoring of PG Levels
states that the diagnosis of GDM is established if the
FPG is equal to or more than 5.6 mmol/L or a 2-hour Self-monitoring of capillary glucose is recommended
PG of 7.8 mmol/L or greater. Of note, an FPG of by 6 of 7 reviewed guidelines (the ADIPS makes no
7 mmol/L (126 mg/dL) or greater or a 2-hour value of recommendation) because it has been proven that it helps
11.1 mmol/L (200 mg/dL) or greater is compatible with achieving a tight glycemic control and lowers the risk of
overt diabetes rather than GDM.18 fetal and maternal complications.34 Following the diagno-
On the other hand, the SOGC and the ACOG do not sis of GDM, women should measure daily the morning
recommend the single-step approach as the optimal FPG and the 1- or 2-hour postprandial PG levels ap-
screening method; however, they consider it as a reason- proximately 3 times a day. A prospective study includ-
able option. The SOGC recommends a 2-step approach ing 112 women failed to find significant differences

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 Diagnosis and Management of GDM • CME Review Article 375

TABLE 3 On the other hand, the ADA recommends the mea-

Estimated Accuracy for Different Diagnostic Tests for GDM surement of HbA1c during pregnancy at least once in
Sensitivity Specificity each trimester and mentions that HbA1c should be less
Carpenter and Coustan (cutoff 140 mg/dL) 85% 86% than 6% in order to reduce fetal complications. This rec-
Carpenter and Coustan (cutoff 130 mg/dL) 99% 77% ommendation is based on evidence from a single-center
FPG (cutoff 92 mg/dL) 76% 92% prospective study that enrolled 1989 pregnant women
HbA1c (cutoff 7.2%) 64% 64% and found that higher midpregnancy HbA1c levels were
HbA1c (cutoff 5.5%) 82% 21%
significantly associated with increased risks of gesta-
tional hypertension or preeclampsia, preterm delivery,
between the 1- and 2-hour postprandial glucose mea- admission to the neonatal intensive care unit, low birth
surements on the neonatal and obstetrical outcomes.35 weight, and macrosomia (OR ranges, 1.20–9.98, 1.31–5.16,
In addition, daily monitoring is preferred over weekly 0.88–3.15, 0.89–4.10, and 2.22–27.86, respectively).42
testing because it is associated with reduced rates of Moreover, the ADA states that, if this target (6%) can-
macrosomia (21.9% vs 29.5%; P = 0.013) and LGA ne- not be achieved without hypoglycemic events, a thresh-
onates (23.1% vs 34.4%; P ≤ 0.001), as reported by a old of 7% is acceptable. However, HbA1c should be an
retrospective cohort study.36 The ES also recommends additional tool, not a substitute of self-monitoring, for
the preprandial PG monitoring, whereas the NICE and the the achievement of glycemic control.
ADA mention that preprandial and bedtime measuments
should be restricted only in special cases of insulin therapy Continuous Glucose Monitoring
as they have been proven to be inferior to postprandial ones According to the NICE guideline, continuous glucose
in controlling the fetal development.37 monitoring (CGM) should be considered only for insulin-
In general, there is consensus on the recommended treated patients who experience severe hypoglycemic
glucose targets, which should be less than 5.3 mmol/L events or have variable PG levels or when information
(95 mg/L) for the FPG and less than 7.8 mmol/L about the glucose variability is needed. Additionaly, the
(140 mg/dL) and 6.7 mmol/L (120 mg/dL) for the 1- ES suggests the use of CGM if better glycemic control
and the 2-hour postprandial PG, respectively. The is required, because of its proven ability to accurately
ES sets a FPG cutoff point of 5 mmol/L (90 mg/dL), detect postprandial hyperglycemia and nocturnal hypo-
if it can be achieved without hypoglycemia, based on glycemic events that may not be recognized by intermit-
a recent meta-analysis, which proved that this value is tent blood glucose monitoring.43 The ADA points out
associated with lower risk of macrosomia (odds ratio that self-monitoring combined with CGM is more likely
[OR], 0.53; 95% CI, 0.31–0.90; P = 0.02).38 However, to achieve HbA1c targets. On the contrary, the FIGO states
the SOGC mentions that these targets can be more “re- that there is no clear improvement in glycemic control and
laxed” in cases of low fetal abdominal circumference, pregnancy outcome with the use of CGM. Hence, the re-
since several randomized trials have shown that the out- viewed guidelines agree that CGM should be used for
comes are similar to those with strict criteria, in order to specific cases where a stricter monitoring of glycemic
avoid the occurrence of small-for-gestational-age fe- control is needed.
tuses due to GDM overtreatment.39,40 In addition, the
NICE guideline highlights the importance of maintain- Fetal Surveillance
ing blood glucose levels greater than 4 mmol/L during
medical treatment of GDM. There is an overall consensus among the NICE, FIGO,
SOGC, and the ACOG guidelines regarding the appropri-
ate ultrasound surveillance of pregnancies complicated
HbA1c Targets
with GDM. In particular, an ultrasound evaluation of the
The NICE and the FIGO recommend the measure- amniotic fluid volume and fetal growth every 4 weeks
ment of HbA1c levels only to identify preexisting diabe- at minimum, starting from the time of diagnosis (usually
tes at the time of diagnosis or to confirm the reliability at 28 weeks) until term, is strongly recommended. More-
of self-monitored reports because they are not associ- over, clinicians should assess the fetal well-being (fetal
ated with any adverse pregnancy outcomes, except con- kick count, nonstress test, or biophysical profile) weekly
genital malformations. In particular, a prospective study from 36 weeks (SOGC) or at 38 and 39 weeks (NICE)
highlighted that the clinical role of HbA1c is limited be- because stillbirth and perinatal mortality are significantly
cause of its poor predictability.41 Moreover, the ES rec- increased in pregnancies complicated by GDM.44 In ad-
ommends the use of HbA1c for pregnant women with dition, the beneficial role of biophysical profile as the
preexisting diabetes. principal technique of antepartum fetal surveillance has

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376 Obstetrical and Gynecological Survey

been studied in 238 well-controlled diabetic pregnan- and the ES recommend the use of insulin when glycemic
cies.45 In the presence of comorbid factors, a more in- targets are not achieved with diet and exercise, the NICE
tensive ultrasound evaluation of the fetus is justified and the FIGO suggest the addition of metformin when
according to the SOGC and the ACOG. lifestyle changes alone fail to maintain euglycemia. Re-
garding the alternatives to insulin medication, the ES
Lifestyle Management of GDM supports glyburide, whereas the ACOG and the ADA
recommend the use of metformin. The latter has been
All the reviewed medical societies (except from the
proved to freely cross the placental barrier, and the fetus
ADIPS) state that the combination of nutritional inter-
can be exposed in high concentrations.54 In the largest
ventions and physical activity constitutes the cornerstone
randomized controlled trial, metformin was associated
in the management of GDM. The goal is to meet mater-
with a lower rate of neonatal hypoglycemia (3.3% vs
nal and fetal nutritional needs, achieve and maintain op-
8.1%; P < 0.008), but a higher rate of preterm delivery
timal glycemic control, and avoid ketosis.46 If glucose
(12.1% vs 7.6%; P = 0.04) than insulin.55 Of note, no
targets are not achieved with lifestyle interventions after
differences in congenital anomalies or serious perinatal
1 to 2 weeks, medical therapy is recommended, either
outcomes were identified in the 2 groups.
with insulin or oral antidiabetic (OAD) drugs.16 Re-
Regarding insulin, the NICE states that it should be
garding physical activity, regular aerobic exercise for
offered immediately, with or without metformin, when
30 minutes 5 times a week or 150 minutes per week
FPG is greater than 7 mmol/L at diagnosis or fetal com-
should be suggested47; 2 studies showed that this activity
plications exist. The FIGO and the ES state that insulin
significantly reduces the FPG and postprandial PG levels
should be considered as a first-line treatment modality
and, subsequently, the daily insulin needs.48,49 However,
when OAD agents are likely to fail. Risk factors for
the optimal type, timing, and duration of physical activ-
OAD agents' failure include the diagnosis of GDM be-
ity are not well established yet. A recent meta-analysis
fore 20 gestational weeks, the need of medical therapy
(2015) showed that exercise interventions in pregnancy
after 30 weeks, weight gain during pregnancy more than
can also provide a slight protective effect against the de-
12 kg, and FPG greater than 110 mg/dL or 1-hour post-
velopment of GDM (RR, 0.72; 95% CI, 0.09–0.42;
prandial glucose greater than 140 mg/dL.56,57 The FIGO
P = 0.005).50 Of note, the NICE guideline points out that
and the ACOG state that the ideal insulin regimen con-
lifestyle interventions are not sufficient as first-line treat-
sists of a combination of long- or intermediate-acting
ment when the FPG exceeds 7 mmol/L at diagnosis or if
(detemir and glargine) with rapid-acting (aspart and
fetal complications exist; in such cases, immediate treat-
lispro) insulin; the recommended dose is 0.7 to 1 U/kg
ment of insulin is required.
per day and usually requires adjustment during preg-
Nutrition counseling and diet modification should be
nancy. The ACOG suggests a more focused treatment
ideally individualized by a dietitian; the FIGO, ACOG,
when abnormal values are observed only at a specific
ADA and the ES recommend a diet composed of 35%
time of the day. The NICE and the ES recommend
to 45% complex carbohydrates, 20% protein, and 40%
rapid-acting analogs over soluble human insulin and
low saturated fat, although the actual dietary compo-
the use of insulin pumps when GDM cannot be con-
sition that improves pregnancy outcomes remains to
trolled with multiple daily injections. Evidence from a
be determined.51 A pilot study in 2015 showed that
prospective observational study that included 107 preg-
a higher-complex-carbohydrate/lower-fat diet lowers
nant women found that lispro (a rapid-acting analog)
maternal insulin resistance and infant adiposity.52 Car-
provides better glycemic control (HbA1c 5.9 vs 6.7;
bohydrate intake should be distributed in 3 meals and
P = 0.009) and lower total insulin requirements during
2 to 4 snacks per day.1 Pregnant women should also
pregnancy compared with regular insulin, without in-
be advised to consume food with low glycemic index
creasing the risk of congenital malformations.58
and high fiber content because this achieves a better
The NICE and the FIGO recommend the use of met-
glycemic target; according to a meta-analysis, glycated
formin for the initial medical treatment of GDM, as 2
proteins were reduced 7.4% more in women following
meta-analyses of 2015 proved that it performs slightly
the low-glycemic compared with the high-glycemic in-
better than insulin and reduces several adverse maternal
dex diet.53
and neonatal outcomes.59,60 They also point out that
metformin should be added when glycemic targets are
Medical Management of GDM
not met in 1 to 2 weeks of diet and exercise, whereas in-
There is a controversy among the reviewed guide- sulin should be considered in case of failure or contraindi-
lines on the first- and the second-line pharmacological cation to metformin. Furthermore, 3 recent meta-analyses
treatment of GDM. Hence, whereas the ACOG, ADA, proved that metformin yields equivalent outcomes to

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

 Diagnosis and Management of GDM • CME Review Article 377

insulin regarding the reduction of maternal and peri- in the absence of other fetal or maternal conditions,
natal complications.61–63 However, the ACOG, ADA, expectant management in diabetic pregnancies is a
and the ES state that this OAD agent should be consid- safe practice.71 Moreover, the SOGC sets an upper limit
ered as a reasonable choice only for women who cannot of 40 weeks of gestation for these pregnancies. For
accept, afford, or safely administer insulin therapy, in insulin-treated GDM, delivery should be considered
view of its lack of superiority and the fact that it is trans- between 39 (SOGC) and 39+6 (ACOG) weeks. This
ferred through the placenta and there is no long-term recommendation is based on evidence from a retrospec-
safety data for the exposed offspring.55,64,65 A 2019 sys- tive cohort study, which found that in women with
tematic review and meta-analysis showed that metformin- GDM, at 39 weeks the risk of expectant management
exposed infants have lower average birth weight (MD, exceeds that of delivery regarding fetal and neonatal
−107.7 g; 95% CI, −182.3 to −32.7; P = 0.005), but mortality rates (RR, 1.8; 95% CI, 1.2–2.6).72 Moreover,
higher BMI during middle childhood (MD, 0.78 kg/m2; a randomized trial including 200 GDM cases showed
95% CI, 0.23–1.33; P = 0.005), compared with children that expectant management after 38 weeks increased
whose mothers were treated with insulin66; this growth the rate of shoulder dystocia and LGA neonates, with-
pattern has been associated with adverse long-term out reducing the cesarean delivery rate.73 Additionally,
cardiometabolic outcomes.66 Additionally, according to a decision analysis found that delivery of women with
ADA, the use of metformin is contraindicated in the GMD at 38 or 39 weeks of gestation would reduce
presence of hypertension, preeclampsia, and high-risk the perinatal mortality without affecting the cesarean
of fetal growth restriction because of its potential associ- delivery rates.74 In the presence of fetal or maternal
ation with those pregnancy complications.67 complications, induction of labor or elective cesarean
Regarding glyburide, the NICE states that it should be delivery (if indicated) should be offered earlier.
considered for cases that glucose targets are not achieved Because of the increased risk of neonatal hypoglyce-
with metformin, or the latter is intolerable, or women de- mia in case of maternal hyperglycemia during labor,75
cline insulin therapy. Moreover, the ACOG and the ADA the NICE, FIGO, and the ES recommend monitoring
do not recommend this drug as first-line treatment, stating of blood glucose levels, which should be maintained
that it is inferior to both insulin and metformin in main- between 4 and 7 mmol/L, whereas the other guidelines
taining glycemic control and improving perinatal out- make no relevant recommendation.
comes. According to a network meta-analysis (2015), Regarding the mode of delivery, elective cesarean
glyburide, when compared with insulin, is associated with section should be considered when the estimated fetal
increased risk of neonatal hypoglycemia (OR, 2.64; 95% weight (EFW) is greater than 4000 g (at 38–39 weeks,
CI, 1.59–4.38), high neonatal birth weight (weight MD, according to FIGO) or 4500 g (timing of delivery is re-
130.68 g; 95% CI, 55.98–205.38), and macrosomia lated to the type of treatment [ACOG]). This recom-
(OR, 3.09; 95% CI, 1.59–6.04).68 To date, long-term mendation is based on a retrospective cohort study of
health data for the exposed to glyburide offspring are 36,241 singleton pregnancies stratified by the diagnosis
not available. In contrast, the ES suggests the administra- of GDM, which showed that neonates with birth weight
tion of glyburide as an alternative to insulin, based on an of 4000 g or greater had higher probabilities of shoulder
earlier meta-analysis (2010) that proved the safety and dystocia (10.5% vs 1.6%; P < 0.001), Erb's palsy (2.6%
effectiveness of this hypoglycemic agent.69 Hence, the vs 0.2%; P < 0.001), respiratory distress syndrome
different recommendations on glyburide may be related (4.0% vs 1.5%; P = 0.03), and hypoglycemia (5.3%
to the different publication dates of the relevant data. vs 2.6%; P = 0.04), when compared with those of birth
weight less than 4000 g.76 Thus, the policy of elective
cesarean delivery, apart from being more cost-effective,
INTRAPARTUM CARE
may also reduce these adverse perinatal outcomes.77
Four of the reviewed guidelines (NICE, FIGO, SOGC, Of note, GDM is not a contraindication to vaginal birth
and ACOG) state that the timing of delivery for GDM after cesarean delivery.78 A large retrospective study
pregnancies should be based on the glycemic control (2019) showed that the performance of ultrasound at
and the presence of complications or comorbid factors. 35+0–36+6 weeks in predicting LGA neonates was mod-
According to the NICE, FIGO, and ACOG, uncompli- est (65% and 46% for neonates with birth weight >97th
cated and well-controlled cases of GDM should be and >90th percentiles, respectively, at a screen-positive
managed expectantly until 40+6 weeks of gestation, rate of 10%). Therefore, the authors concluded that rou-
and induction of labor should be offered if spontaneous tine fetal biometry at about 36 weeks is a screening
delivery does not occur until that point.70 In support of rather than a diagnostic test for fetal macrosomia and
this approach, a randomized controlled trial found that proposed a 2-stage strategy for maximizing the prenatal

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

378 Obstetrical and Gynecological Survey

prediction of an LGA neonate: an EFW >70th percen- the NICE, FIGO, SOGC, ADA, and the ES (the other
tile at 36 weeks should be used to identify pregnancies guidelines make no relevant recommendation). Particu-
in need of another scan at 38 weeks, at which those with larly, a 2012 cohort study of 522 participants with GDM
an EFW >85th percentile should be considered for iat- showed that a higher intensity of lactation may improve
rogenic delivery during the 38th week.79 maternal insulin resistance and glucose intolerance at 6
Notably, in cases of anticipated preterm delivery, the to 9 weeks postpartum, thus lowering the risk of diabetes
presence of GDM should not be regarded as a contraindi- later in life.83 Moreover, a study that enrolled 15,253 in-
cation to the administration of corticosteroids, but appro- fants identified an inverse association of breastfeeding
priate adjustments of insulin dosage are usually required with childhood obesity (OR, 0.66; 95% CI, 0.53–0.82).84
(NICE, SOGC).80 In addition, betamimetic agents should
not be used for tocolysis in diabetic women (NICE). Lifelong Screening for Diabetes
All the reviewed guidelines (apart from the SOGC that
makes no recommendation) recommend that women
POSTNATAL CARE
with history of GDM and normal postnatal screening
Postpartum Screening test results should undertake lifelong screening for
the development of prediabetes or type 2 diabetes.
After giving birth, women should discontinue any
However, there is no established consensus on the ap-
treatment for GDM because glucose intolerance fre-
propriate screening method and interval. Hence, the
quently resolves immediately.3 The NICE and the
NICE suggests the annual evaluation of HbA1c, and the
ES recommend blood glucose testing at 24 to 72 hours
ADIPS supports the measurement of FPG every 1 to
after delivery to exclude persistent hyperglycemia.
2 years after delivery, whereas the ACOG and the ADA
Even if glucose returns to normal, the history of GDM
state that glycemic control should be conducted every 1
increases the risk of developing type 2 diabetes later in
to 3 years using any of the available tests. This variation
life more than 7 times (RR, 7.43; 95% CI, 4.79–11.51),
probably reflects national policies, which are related to
as shown by a meta-analysis (2009).8 Thus, all the re-
cost-effective analyses.
viewed guidelines encourage the reevaluation of the
glycemic status postpartum. Preconception Screening for Future Pregnancies
Moreover, it has been proven that 1 of 3 affected
women will have persistent diabetes or impaired glu- There is an overall agreement that women who expe-
cose tolerance during the postnatal period, according rienced GDM in a previous pregnancy and plan another
to a retrospective cohort study of 344 women with pregnancy should undergo glycemic control evaluation
GDM.81 Hence, the NICE recommends the measure- frequently, either with HbA1c measurement (NICE) or
ment of FPG levels 6 to 13 weeks after delivery or the OGTT (ADIPS). This strategy will alow early detection
evaluation of HbA1c if the woman presents later. All and treatment of hyperglycemia before fertilization and
the other guidelines support the performance of a thus reduce the risk of congenital malformations and
75-g 2-hour OGTT using the nonpregnancy diagnos- spontaneous abortions.82
tic criteria as the most sensitive screening method.82
The appropriate time for this test varies between the CONCLUSIONS
guidelines: at 6 to 12 weeks (FIGO, ADIPS, ES), 4 This comparative review of 7 guidelines identified an
to 12 weeks (ACOG, ADA), or 6 weeks to 6 months overall consensus regarding the importance of screening
postpartum (SOGC). If the FPG is greater than 7 mmol/L and effectively managing GDM. Four of 7 guidelines
or HbA1c exceeds 6.5%, clinicians should offer their (the FIGO, ADIPS, SOGC, and the ACOG) recommend
patients a diagnostic test to confirm type 2 diabetes. universal screening at 24 to 28 weeks for GDM and test-
Women with FPG of less than 6 mmol/L or HbA1c of ing those with additional risk factors earlier. Notably,
less than 5.7% should be considered as low risk and ad- the NICE recommends targeted screening at this period
vised to repeat testing.31 (24–28 weeks) only to women with risk factors. The ES
Thus, there is a consensus on postpartum screening in proposes a different strategy of offering first-trimester
cases of GDM up to 12 weeks after delivery. screening to all pregnant women and retesting at 24 to
28 weeks if the initial results are negative, and the FIGO
Breastfeeding
recommends the latter approach only for high-resource
Breastfeeding contributes to long-term metabolic bene- countries or medium- and low-resource countries with
fits for both the mother and the offspring and should be high-risk populations. In addition, all the medical societies
strongly advised to all women with GDM, according to point out that self-monitoring of capillary glucose levels

Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.

 Diagnosis and Management of GDM • CME Review Article 379

and a combined adoption of regular physical activity and 8. Bellamy L, Casas JP, Hingorani AD, et al. Type 2 diabetes mellitus
after gestational diabetes: a systematic review and meta-analysis.
adequate diet should be the first-line measures for achiev- Lancet. 2009;373:1773–1779.
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recommended fasting and postprandial blood glucose tar- tween gestational diabetes mellitus and long-term maternal car-
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