Personalizing therapy in early gestational diabetes.

Purpose of review: Early gestational diabetes mellitus (eGDM) is being increasingly detected on the background of rising obesity rates and widespread early pregnancy screening. However, diagnostic criteria and management strategies remain uncertain. This review summarizes current evidence on diagnostic thresholds, maternal and fetal outcomes, and the impact of early treatment, with an emphasis on balancing benefits and risks.

Recent findings: While observational studies link eGDM to adverse maternal and fetal outcomes, evidence from intervention studies remains limited. The Treatment of Booking Gestational Diabetes Mellitus (TOBOGM) is the only large multicenter randomized controlled trial (RCT) published till date. The early intervention arm in the study received education on dietary counseling and capillary blood glucose monitoring, with pharmacotherapy using insulin or metformin introduced when indicated. The trial reported that treatment before 14 weeks reduced neonatal respiratory distress in higher glycemic bands but increased the risk of small-for-gestational-age state at lower glycemic bands. Notably, one-third of the untreated control group reverted to normoglycemia at 24-28 weeks. Given the uncertainties in diagnostic thresholds used in TOBOGM, a composite risk score-based approach integrating clinical and biochemical parameters may provide an alternative for identifying pregnancies in need of intervention.

Summary: Current diagnostic criteria may not identify eGDM pregnancies that would benefit from intervention. Redefining diagnostic thresholds and integrating them with clinical risk factors could categorize pregnancies in need of intervention. Appropriately designed RCTs are required to generate evidence for accurate identification and optimal treatment of eGDM.