Treatments for gestational diabetes

 

Abstract

Background

Gestational diabetes (GDM) affects 3% to 6% of all pregnancies. Women are often intensively managed with increased obstetric monitoring, dietary regulation, and insulin. However, there has been no sound evidence base to support intensive treatment. The key issue for clinicians and consumers is whether treatment of GDM improves perinatal outcome.

Objectives

To compare the effect of alternative treatment policies for GDM on both maternal and infant outcomes.

Search methods

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (January 2009) and bibliographies of relevant papers. We updated this search on 1 July 2011 and added the results to the awaiting classification section of the review.

Selection criteria

Randomised controlled trials comparing alternative management strategies for women with GDM and impaired glucose tolerance in pregnancy.

Data collection and analysis

Two authors and a member of the Cochrane Pregnancy and Childbirth Group's editorial team extracted and checked data independently. Disagreements were resolved through discussion with the third author.

Main results

Eight randomised controlled trials (1418 women) were included.

Caesarean section rate was not significantly different when comparing any specific treatment with routine antenatal care (ANC) including data from five trials with 1255 participants (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.80 to 1.12). However, when comparing oral hypoglycaemics with insulin as treatment for GDM, there was a significant reduction (RR 0.46, 95% CI 0.27 to 0.77, two trials, 90 participants).

There was a reduction in the risk of pre-eclampsia with intensive treatment (including dietary advice and insulin) compared to routine ANC (RR 0.65, 95% CI 0.48 to 0.88, one trial, 1000 participants). More women had their labours induced when given specific treatment compared to routine ANC (RR 1.33, 95% CI 1.13 to 1.57, two trials, 1068 participants). The composite outcome of perinatal morbidity (death, shoulder dystocia, bone fracture and nerve palsy) was significantly reduced for those receiving intensive treatment for mild GDM compared to routine ANC (RR 0.32, 95% CI 0.14 to 0.73, one trial, 1030 infants).

There was a reduction in the proportion of infants weighing more than 4000 grams (RR 0.46, 95% CI 0.34 to 0.63, one trial, 1030 infants) and the proportion of infants weighing greater than the 90th birth centile (RR 0.55, 95% CI 0.30 to 0.99, three trials, 223 infants) of mothers receiving specific treatment for GDM compared to routine ANC. However, there was no statistically significant difference in this proportion between infants of mothers receiving oral drugs compared to insulin as treatment for GDM.

Authors' conclusions

Specific treatment including dietary advice and insulin for mild GDM reduces the risk of maternal and perinatal morbidity. However, it is associated with higher risk of labour induction. More research is needed to assess the impact of different types of intensive treatment, including oral drugs and insulin, on individual short- and long-term infant outcomes.

[Note: the 29 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.]

 

Plain language summary

Treatments for gestational diabetes

The best way of identifying and treating women with abnormal blood glucose tests in pregnancy is not known. Raised blood glucose levels during pregnancy is known as gestational diabetes. This abnormality may be associated with bigger babies, more difficult births and could be associated with higher rates of operative delivery such as caesarean section. The review of eight studies (1418 women) suggests that offering specific treatment for gestational diabetes may be associated with better baby and mother outcomes, but has not found robust evidence on the best choice of treatment which provides the better outcomes for these women and their babies, even if identified correctly. More research is needed to assess long-term mother and baby outcomes.

 

摘要

背景

妊娠糖尿病的治療方法

在所有懷孕的人口當中，其中的3% 到6% 會出現妊娠糖尿病(GDM)。這些婦女們通常會受到較嚴密管制包括產科監控、飲食規範，以及胰島素等方面。然而，並沒有強力的證據基礎可以支持執行這些密集的治療。對於臨床醫師與消費者來說，對於妊娠糖尿病的治療是否可以改善周產期胎兒的狀況，才是關鍵的問題。

目標

要比較各種妊娠糖尿病的治療策略之間對於母體與嬰兒雙方的狀況所產生的功效。

搜尋策略

我們搜尋了the Cochrane Pregnancy and Childbirth Group's Trials Register(2009年1月)以及相關文章的參考書目。

選擇標準

針對在懷孕期間患有妊娠糖尿病以及葡萄糖耐受異常的婦女，以隨機對照試驗在各種治療策略之間進行比較。

資料收集與分析

有2位作者以及1位the Cochrane Pregnancy and Childbirth Group之編輯群中的成員，獨立地擷取並檢查了資料。意見分歧的狀況出現時，則透過跟第3位作者之間的討論解決。

主要結論

其中共收集了8組隨機對照試驗(1418名婦女)。當我們將任何1種特定的治療方式與只進行例行性的產前檢查(ANC)進行比較的時候，剖腹產的比例並沒有明顯的不同，資料來源含取自於5組試驗與1255名參與者的資料(risk ratio (RR) 0.94, 95% confidence interval (CI) 0.80 to 1.12)。然而，當我們將口服之降血糖藥物與用胰島素做為妊娠糖尿病治療方法進行比較的時候，就有明顯的下降(RR 0.46, 95% CI 0.27 to 0.77, two trials, 90 participants)。跟只進行例行性的產前檢查比較起來，經過了密集的治療(包括飲食方面的建議與胰島素使)之後，得到子癲前症(preeclampsia)的風險就降低了(RR 0.65, 95% CI 0.48 to 0.88, one trial, 1000 participants)。跟例行性的產前檢查比較起來，當接受了特定之治療的婦女們，有更多的婦女會選擇引產的方式(RR 1.33, 95% CI 1.13 to 1.57, two tri als, 1068 participants)。跟例行性的產前檢查比較起來，那些輕度妊娠糖尿病並接受密集治療的婦女，在混合周產兒罹病率(包括死亡、肩部難產、骨折，以及神經麻痺)明顯地減少(RR 0.32, 95% CI 0.14 to 0.73, one trial, 1030 infants)。跟例行性的產前檢查比較起來，那些因妊娠糖尿病已接受特定之治療的母親，出生體重超過4000公克的嬰兒比例降低了(RR 0.46, 95% CI 0.34 to 0.63, one trial, 1030 infants)，以及體重超過百分之90的嬰兒之比例也降低了(RR 0.55, 95% CI 0.30 to 0.99, three trials, 223 infants)。然而，對於妊娠糖尿病的母親以口服藥物或胰島素來當作治療方法比較起來，在她們嬰兒之間的這種比例上，並沒有統計學上的顯著差異。

作者結論

對於輕度的妊娠糖尿病來說，包括飲食方面的建議與胰島素在內的特定治療方式，可以降低母體與周產兒罹病率。然而，這樣的作法卻帶來了較高的引產機率。在個別之短期與長期的嬰兒狀況，則還需要有更多的研究，以評估不同之密集治療類型的影響，包括了口服的藥物與胰島素。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

對於那些在懷孕當中血中葡萄糖測試結果異常的婦女來說，如何辨認及治療她們的最佳方法，還是未知的。在懷孕期間，血中葡萄糖值升高已經被廣知為妊娠糖尿病。這樣的異常現象可能會造成嬰兒的體型較大、生產變得比較困難，而且也可能會造成手術生產像是剖腹產之比例提高。本篇包含了8份研究(1418名婦女)的回顧認為，對妊娠糖尿病孕婦而給予特定的治療，可以讓嬰兒與母親的預防、改善，但是在治療方法的最佳選擇方面，則還沒有發現強烈的證據 在母體與胎兒之長期預防，評估則尚需要更多的研究。