A Randomized Controlled Trial Using Glycemic Plus Fetal Ultrasound Parameters Versus Glycemic Parameters to Determine Insulin Therapy in Gestational Diabetes With Fasting Hyperglycemia

We read with interest the paper from Kjos et al. (1) exploring the usefulness of an approach to the management of gestational diabetes mellitus (GDM) that takes into account not only maternal glycemic parameters but also ultrasound information of fetal growth. The rationale behind this approach is that due to (unmeasurable) differences in nutrient placental transport, only a minority of infants are at risk of perinatal morbidity, and that by focusing only on maternal hyperglycemia, a large subset of women will require insulin therapy, leading to the potential to increase the risk of small-for-gestational-age (SGA) infants (2). An article from our group (3) is also quoted as an example of increased risk of SGA infants in mothers with intensively treated GDM, when in fact the birth weight distribution was perfectly symmetrical (7.32% SGA, 85.0% adequate for gestational age, 7.68% large for gestational age) and comparable to that of the control population (data not shown in the article). However, in these infants of mothers with GDM, we did observe an increased morbidity in the SGA subgroup versus those who were adequate and large for gestational age, which is the usual pattern in newborns (4–6). Our interpretation of both observations (normal birth weight distribution and increased morbidity in the SGA subgroup in women with GDM receiving intensive metabolic therapy) is that the treatment “restored” birth weight and morbidity levels to those that could be expected without the concurrence of GDM. It is also remarkable that large-for-gestational-age infants did not have a particularly increased risk of morbidity.