Active compared with expectant delivery management in women with gestational diabetes: a systematic review.
OBJECTIVE
We conducted a systematic review to estimate benefits and harms of the choice of timing of induction or elective cesarean delivery based on estimated fetal weight or gestational age in women with gestational diabetes mellitus (GDM).


METHODS
An electronic literature search was performed using MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature, and The Cochrane Central Register of Controlled Trials from inception to January 2007.


METHODS
Two investigators independently reviewed titles and abstracts, assessed article quality, and abstracted data. Maternal outcomes included cesarean delivery and operative vaginal delivery. Neonatal outcomes included birth weight, macrosomia, large for gestational age, shoulder dystocia, birth trauma, neonatal intensive care admissions, and perinatal mortality.


RESULTS
Five studies met our inclusion criteria: one randomized controlled trial (RCT) and four observational studies. The RCT (n=200) compared the effect of labor induction at term with expectant management. The proportion of newborns with birth weight greater than the 90th percentile was significantly greater in the expectant-management group (23% compared with 10% with active induction, P=.02); there were no significant differences in rates of cesarean delivery, shoulder dystocia, neonatal hypoglycemia, or perinatal deaths. The four observational studies suggest a potential reduction in macrosomia and shoulder dystocia with labor induction and cesarean delivery for estimated fetal weight indications, but there was insufficient evidence to assess other clinical outcomes.


CONCLUSIONS
Active rather than expectant management of labor at term for women with GDM may reduce rates of macrosomia and related complications. Further RCTs and observational studies with a broader range of outcomes are needed for sufficient evidence to inform clinical practice.
Witkop
Catherine Takacs
CT
From the Johns Hopkins Bloomberg School of Public Health, Departments of General Preventive Medicine and Population, Family and Reproductive Health; the Johns Hopkins School of Medicine, Departments of Obstetrics and Gynecology and Medicine; and the Johns Hopkins Evidence-based Practice Center, Baltimore, Maryland.
Neale
Donna
D
Wilson
Lisa M
LM
Bass
Eric B
EB
Nicholson
Wanda K
WK
D001724:Birth Weight; D002585:Cesarean Section; D016640:Diabetes, Gestational; D005260:Female; D020567:Fetal Weight; D005865:Gestational Age; D006801:Humans; D007226:Infant Mortality; D007231:Infant, Newborn; D007746:Labor Presentation; D007751:Labor, Induced; D011247:Pregnancy