INSULIN-REQUIRING DIABETES IN PREGNANCY - A RANDOMIZED TRIAL OF ACTIVE INDUCTION OF LABOR AND EXPECTANT MANAGEMENT

OBJECTIVE: Our purpose was to assess whether a program of expectant ma nagement of uncomplicated pregnancies in mothers with insulin-requirin g gestational or pregestational class B reduces the incidence of cesar ean birth. STUDY DESIGN: Two hundred women with uncomplicated, insulin -requiring diabetes at 38 weeks' gestation who were compliant with car e and whose infants were judged appropriate for gestational age were r andomly assigned to (1) active induction of labor within 5 days or (2) expectant management. The expectant management group was monitored wi th weekly physical examination and twice-weekly nonstress tests and am niotic fluid volume estimation until delivery. RESULTS: Expectant mana gement increased the gestational age at delivery by 1 week. Approximat ely half (49%) of the mothers in the expectant management group requir ed induction of labor for obstetric indications. The cesarean delivery rate was not significantly different in the expectant management grou p (31%) from the active induction group (25%). The mean birth weight ( 3672 +/- 407 gm) and percentage large for gestational age, as defined by birth weight greater-than-or-equal-to 90th percentile, of infants i n the expectantly managed group (23%) was greater than those in the ac tive induction group (3466 +/- 372 gm, p < 0.0001, 10% large for gesta tional age). This difference persisted after controlling for gestation al age and maternal age and body weight (p < 0.01). CONCLUSION: In wom en with uncomplicated insulin-requiring gestational or class B pregest ational diabetes, expectant management of pregnancy after 38 weeks' ge station did not reduce the incidence of cesarean delivery. Moreover, t here was an increased prevalence of large-for-gestational-age infants (23% vs 10%) and shoulder dystocia (3% vs 0%). Because of these risks, delivery should be contemplated at 38 weeks and, if not pursued, care ful monitoring of fetal growth must be performed.