New strategies for the treatment of gestational diabetes.
The approach to gestational diabetes mellitus has altered markedly in the last decade; it is guided by universal screening and an impetus to establish 24-h euglycemia in these women, through serial measurements of blood glucose by home monitoring and glycated hemoglobin. The best screening and diagnostic procedures for documentation of gestational diabetes remain the subject of considerable debate. Improved outcome has been associated with improved levels of glycemia. While continuous monitoring of blood glucose is not practical, four blood glucose checks per day (fasting and 1 h after the start of each meal) had proven feasible and allowed the development of treatment strategies designed to maintain fasting blood glucose less than 80 mg/dl and post-prandial glucose less than 140 mg/dl. Diet prescriptions that help achieve these goals include a caloric intake sufficient to avoid the ketonuric threshold (30 kcal/kg in women 80-120% ideal body weight) and less than or equal to 40% carbohydrate. Seventy-five percent of women with gestational diabetes respond to diet therapy alone. Cardiovascular conditioning exercise for 20 min three times per week has been shown to be useful in lowering both fasting and post-prandial glucose levels. If diet and exercise do not achieve the requisite glucose levels, insulin therapy based on body weight and gestational age is instituted.