Active Compared With Expectant Delivery Management in Women With Gestational Diabetes A Systematic Review Catherine Takacs Witkop, MD, MPH, Donna Neale, MD, Lisa M. Wilson, ScM, Eric B. Bass, MD, MPH, and Wanda K. Nicholson, MD, MPH, MBA OBJECTIVE: We conducted a systematic review to esti- mate benefits and harms of the choice of timing of induction or elective cesarean delivery based on esti- mated fetal weight or gestational age in women with gestational diabetes mellitus (GDM). DATA SOURCES: 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 OF STUDY SELECTION: Two investigators in- dependently 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. TABULATION, INTEGRATION, AND RESULTS: Five studies met our inclusion criteria: one randomized con- trolled 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 dif- ferences 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 indica- tions, but there was insufficient evidence to assess other clinical outcomes. CONCLUSION: Active rather than expectant manage- ment 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. (Obstet Gynecol 2009;113:206–17) G estational diabetes mellitus (GDM) is one of the most common medical complications of preg- nancy, affecting an estimated 7% of annual births in the United States. 1–3 Practice patterns related to deliv- ery management of patients with GDM, therefore, have the potential to affect maternal and neonatal outcomes in millions of patients. Obstetric providers use a variety of parameters in clinical decision making for delivery management. Estimated fetal weight, gestational age, and maternal glucose control are measures of particular importance in pregnancies See related article on page 193. 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, Balti- more, Maryland. This article is based on research conducted by the Johns Hopkins Evidence-based Practice Center under contract number 290-02-0018 with the Agency for Healthcare Research and Quality, Rockville, Maryland. Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or of the U.S. Department of Health and Human Services. Corresponding author: Catherine Takacs Witkop, U.S. Air Force Academy, 10 AMDS/SGPF, 2355 Faculty Drive, Rm 2N286, USAFA, CO 80840; e-mail: katika@aya.yale.edu. Financial Disclosure The authors did not report any potential conflicts of interest. © 2008 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/08 206 VOL. 113, NO. 1, JANUARY 2009 OBSTETRICS & GYNECOLOGY