INTENSIFIED VERSUS CONVENTIONAL MANAGEMENT OF GESTATIONAL DIABETES

OBJECTIVE: We tested the hypothesis that intensified management of ges tational diabetes mellitus on the basis of stringent glycemic control, verified glucose data, and adherence to an established criterion for insulin initiation results in near normoglycemia control and reduction of adverse outcomes. STUDY DESIGN: A prospective, population-based st udy compared the effect on perinatal outcome of conventional (n = 1316 ) and intensified (n = 1145) management. Group assignment was based on availability of memory-based reflectance meters at entry to the progr am. A contemporaneous randomized control group (nondiabetic, n = 4922) was selected. RESULTS: The diabetic groups were comparable in demogra phic characteristics and in factors associated with higher risk for ad verse pregnancy outcome, such as previous macrosomia, previous gestati onal diabetes mellitus, and family history of diabetes. The control gr oup was younger, less obese, and had a lower rate of previous macrosom ia. The intensified management group had rates of macrosomia, cesarean section, metabolic complications, shoulder dystocia, stillbirth, neon atal intensive care unit days, and respiratory complications lower tha n those in the conventional management group and comparable to those o f the nondiabetic controls. Other maternal complication rates, such as for preeclampsia, chronic hypertension, and infection, were similar f or the three groups. Mean blood glucose levels were a good predictor o f perinatal outcome. Gestational age at delivery, previous history of macrosomia, and overall mean blood glucose levels were the only signif icant predictors of birth weight percentile in both diabetic groups (l ogistic regression). CONCLUSION: The intensified management approach i s significantly associated with enhanced perinatal outcome. This manag ement strategy clarifies the relationship between glycemic control and neonatal outcome.