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Pathophysiology or Practice Style?

C. David Naylor, MD, DPhil; Mathew Sermer, MD; Erluo Chen, MB, MPH; Kathy Sykora, MSc; Toronto Trihospital Gestational Diabetes Investigators

JAMA. 1996;275(15):1165-1170.

Abstract
Objective.
—To examine the relationship between birth weight and mode of delivery among women with untreated borderline gestational diabetes mellitus (GDM), treated overt GDM, and normoglycemia.

Design.
—Prospective cohort study

Setting.
—Three Toronto, Ontario, teaching hospitals.

Patients.
—A total of 3778 volunteers aged 24 years or older.

Interventions.
—Subjects underwent a 3-hour, 100-g oral glucose tolerance test at 28 weeks' gestation, regardless of screening test results. Usual care was provided to 143 women who met the National Diabetes Data Group criteria for GDM. Physicians were blinded to glucose test results for all others, including 115 untreated women with borderline GDM by the broader criteria of Carpenter and Coustan.

Main Outcome Measures.
—Crude and adjusted rates of cesarean delivery and neonatal macrosomia (birth weight >4000 g).

Results.
—Compared with normoglycemic controls, the untreated borderline GDM group had increased rates of macrosomia (28.7% vs 13.7%, P<.001) and cesarean delivery (29.6% vs 20.2%, P=.02). Cesarean delivery in this subgroup was associated with macrosomia (45.5% vs 23.5%, P=.03). Usual care of known GDM normalized birth weights, but the cesarean delivery rate was about 33% whether macrosomia was present or absent. A clearly increased risk of cesarean delivery among treated patients compared with normoglycemic controls persisted after adjustment for multiple maternal risk factors (adjusted odds ratio, 2.1; 95% confidence interval, 1.3 to 3.6).

Conclusions.
—Infant macrosomia was a mediating factor in high cesarean delivery rates for women with untreated borderline GDM. While detection and treatment of GDM normalized birth weights, rates of cesarean delivery remained inexplicably high. Recognition of GDM may lead to a lower threshold for surgical delivery that mitigates the potential benefits of treatment.

(JAMA. 1996;275:1165-1170)

Author Affiliations
From the Departments of Medicine (Dr Naylor), Surgery (Dr Naylor), Obstetrics and Gynecology (Dr Sermer), and Clinical Epidemiology and Health Care Research Program, Sunnybrook Unit (Drs Naylor and Chen), University of Toronto (Ontario); and the Institute for Clinical Evaluative Sciences (Toronto) (Dr Naylor and Ms Sykora). A complete list of the Toronto Trihospital Gestational Diabetes Investigators appears at the end of the article.

Footnotes
Reprints: C. David Naylor, MD, DPhil, G-106, Sunnybrook Health Science Centre, 2075 Bayview Ave, North York, Ontario, Canada M4N 3M5.

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