More than three decades since the original published description of
gestational diabetes mellitus (GDM), no consensus exists regarding its implications or management. Targeting
fetal macrosomia as the greatest morbidity, treatment strategies for this pregnancy-induced disease of
insulin resistance have largely been modeled from
therapies proven successful in pregnant women with
type 2 diabetes mellitus. Surrounded by a rapidly expanding array of treatment options for
insulin-resistant diabetes, potentially legitimate concerns about teratogenicity and fetal metabolic effects have limited clinical trials of
insulin analogs and oral
antihyperglycemic agents during pregnancy. So far, only
insulin lispro and
glyburide (
glibenclamide) have been tested prospectively in randomized trials of women with GDM. In limited studies, both of these agents have compared favorably with standard
insulin regimens, and neither appear to cause any fetal or neonatal harm. Although acknowledged by the American Diabetes Association (ADA) and the American College of Obstetricians and Gynecologists (ACOG), these seminal studies have not yet prompted a recommendation from either organization on how to utilize
insulin analogs or oral
antihyperglycemic agents in the treatment of GDM. Although they lack an evidence base for many therapeutic strategies for GDM, the current ADA and ACOG guidelines still provide a reasonable set of treatment recommendations.