Toward the beginning of your third trimester, you will almost certainly be screened for gestational diabetes. According to various U.S., U.K., and Australian healthcare patient information publications, the reason for this screening and for the management that follows a positive test is to reduce or prevent a long list of serious adverse consequences.¹⁷ These include, depending on which one you read, overly large babies and their potential consequences: birth injuries (broken bones or nerve injuries), brain injury as a result of shoulder dystocia (the head is born, but the shoulders hang up behind the pubic bone), and maternal birth trauma, as well as stress on your heart and kidneys, preterm birth, stillbirth, low blood sugar in the baby, postpartum hemorrhage, and developing maternal or child diabetes later in life. For those who test positive, the rest of pregnancy will involve finger pricks to test blood sugar levels several times a day, a special diet, possibly oral medication or insulin injections, extra doctor visits, and labor induction, possibly before 39 weeks, the threshold at which the baby is no longer at elevated risk for breathing difficulties and possible negative effects on breastfeeding ability and childhood development.^{2, 5, 13, 36}

Is all of this worth it?

In this post, we’ll explore whether gestational diabetes management performs as advertised or whether, on the contrary, it does more harm than good. Here are the questions we’ll address:

• Does blood sugar, a.k.a., blood glucose, screening distinguish a population at increased risk for adverse outcomes?
• Do gestational diabetes diagnosis and management improve outcomes?
• Do gestational diabetes diagnosis and management introduce harms?

As always, I’ll end with “Your Takeaway,” practical suggestions on what you can do with the information you’ve learned.

But first, a little background:

Pregnancy’s Effect on Glucose Metabolism

Insulin is the hormone responsible for enabling glucose to be moved from the bloodstream into cells where it fuels cellular metabolism. In pregnancy, certain placental hormones inhibit that ability, making maternal cells insulin resistant. This increases the amount of circulating glucose, which makes it available for fetal growth and development. Insulin resistance increases as pregnancy advances, and as a result, blood glucose levels after eating rise linearly throughout pregnancy. By the third trimester, blood glucose levels after eating run higher than when not pregnant, despite secreting normal and above normal amounts of insulin. In some women and birthing people, their pancreas is unable to compensate for the increased demand and glucose levels rise above those common in pregnancy. Those who are high BMI are especially prone to this because fat cells are already insulin resistant and are contributing to higher levels of circulating glucose.⁹ In the last couple of decades of the 1900s, a consortium of experts decided that blood glucose levels during pregnancy that were elevated—but still short of those diagnostic of the other types of diabetes—constituted a new disease, which they called gestational, meaning, occurring during pregnancy, diabetes.

Does Blood Glucose Screening Distinguish a Population at Increased Risk for Adverse Outcomes?

To answer whether gestational diabetes increases risk for severe adverse outcomes, the first thing that muddies the waters is that gestational diabetes differs from other types of diabetes in ways that reduce the risks associated with the other types. For one thing, glucose metabolism is normal until the third trimester, which means gestational diabetics aren’t at risk for adverse outcomes such as miscarriage or congenital anomalies that may occur as a result of serious glucose metabolism disturbances early in pregnancy. For another, they are also not at risk for hypertension or kidney complications resulting from damage to blood vessels or kidneys arising from longstanding diabetes. For a third, diagnostic thresholds for gestational diabetes are set lower than those for the other types,¹¹ which means most gestational diabetics have only mildly elevated glucose levels after eating. That means they aren’t at increased risk of stillbirth, a potential consequence of major fluctuations between very high and very low blood glucose levels in poorly controlled diabetes. (Given these differences from true diabetes, you may be wondering why the experts chose to use the same term. This was done deliberately. Back when they were deciding whether mildly elevated blood glucose in pregnancy was a new disease, they rejected calling it “glucose intolerance of pregnancy” in favor of calling it “diabetes” to ensure that it would be taken seriously and that insurance companies would pay for the increased surveillance and treatment.¹ The practice of upleveling who is considered to have a disease and shrinking the pool of people considered to be healthy in our medical system has been going on for a long time, and is accelerating, the most recent example of this being the idea of pre-dementia.)

The one concern gestational diabetes shares with the other types is the possibility of growing bigger babies and the potential consequences of that. These would be increased cesarean delivery, maternal birth trauma, birth injury to the baby during a difficult vaginal delivery, and the potential consequences of shoulder dystocia, these being brain injury or injury to a complex of nerves serving the shoulder and arm. Even here, though, it’s not so easy to disentangle whether risk for adverse outcomes is attached to mildly elevated blood glucose or other factors because lumped together under the gestational diabetes label are several disparate groups:

• Those who are high BMI, who are more likely to have bigger babies and to have hypertension independent of whether they also have elevated blood glucose,
• Those who have previously undiagnosed prepregnant diabetes, who will be at greater risk of pregnancy complications than those who have mildly elevated blood glucose appearing for the first time during pregnancy, and
• Those who have PCOS or lupus,^{12, 31} health complications that increase probability of elevated blood glucose and that also could affect pregnancy outcomes independent of elevated blood glucose.

To what extent, then, might adverse outcomes be due to these other factors and not mildly elevated glucose values?

The second thing clouding the issue is that the relationship between blood glucose levels and birthweight is linear.¹⁵ That means that where you decide to set thresholds separating normal from abnormal are arbitrary. But the point of a diagnostic test is to identify a population whose members would benefit from closer surveillance and treatment while excluding those who would not. Because the diagnostic threshold for gestational diabetes is arbitrary, various bodies issuing diagnostic guidelines have chosen different ones, which gives us a natural experiment for evaluating whether diagnostic thresholds below those of true diabetes do, in fact, discriminate between those who would benefit from those who would not. Studies report that using more liberal criteria increases the percentage of those diagnosed as having gestational diabetes but doesn’t improve outcomes compared with more restrictive criteria.^{16, 31} In other words, test criteria don’t discriminate between those who would benefit from intensified surveillance and treatment from those who wouldn’t.

The finding that a proportion of those undergoing gestational diabetes management didn’t benefit from it raises the next question: Does anyone with mildly elevated glucose levels derive benefit?

Do Gestational Diabetes Diagnosis and Management Improve Outcomes?

So far, we’ve established that some of those diagnosed as gestational diabetics don’t stand to benefit from monitoring and treatment because dropping diagnostic thresholds to include them didn’t improve outcomes, that others would have had bigger babies or other complications such as hypertension regardless of their identification and management as gestational diabetics, and that still others might benefit, not because they have levels diagnostic of gestational diabetes, but because they had prepregnant diabetes that was first detected in pregnancy. That being said, let’s now see whether diagnosis, monitoring, and treatment benefits this mixed bag as a group.

According to the research, here’s what they don’t do:

An evidence synthesis conducted by the U.S. Agency for Healthcare Research and Quality reported that screening for gestational diabetes didn’t reduce the incidence of hypertension, cesarean delivery, large-for-gestational-age babies (birthweight in the upper 10 percent for babies of that gestational age), macrosomic babies (birthweight 8 lb 13 oz or 4,000 gm or more), or babies with hypoglycemia (low blood glucose) after birth.³¹ (FYI: newborn hypoglycemia occurs because if maternal glucose levels have been high—which, I should add, they shouldn’t be in treated gestational diabetics—the newborn has high circulating levels of insulin in response and has now been cut off from the glucose supply.) Looking at treatment versus no treatment, the same report found that treatment didn’t reduce the incidence of hypertension, maternal birth trauma, stillbirth or newborn death, newborn hypoglycemia, maternal development of type 2 diabetes, or childhood high BMI.

A systematic review (a study pooling data from studies on a particular topic) compared the effect of various treatment strategies on the incidence of adverse outcomes in gestational diabetic pregnancies.²² Studies of individual strategies were small, which means benefit can’t be ruled out; still, the reviewers failed to find reductions with any of the strategies in reducing incidence of hypertension, cesarean delivery, later development of type 2 diabetes, maternal birth trauma, stillbirth or newborn death, newborn hypoglycemia, or childhood high BMI. In particular, the review found that while inducing labor, a common policy with gestational diabetes, tended to reduce large-for-gestational-age babies, this benefit didn’t result in fewer cesareans or incidences of maternal trauma.

Is there anything they do?

According to the evidence synthesis, treatment reduced the incidence of macrosomic and large-for-gestational-age babies, and while it didn’t reduce cesareans overall, it reduced the number of first cesareans.³¹ The evidence synthesis also reported a reduction in birth injuries and shoulder dystocia, but I find that conclusion problematic because the reviewers only found a reduction in this outcome when they left out the studies where there were no occurrences in either group. When they included those studies, the difference disappeared. (One of the studies, the reviewers note, attributed the lack of birth injuries to having a cesarean rate over 60 percent in both treated and untreated groups!) Finally, studies were contradictory on whether treatment reduced admissions to a newborn intensive care unit. Pooling data among five studies comprising 1,600 participants in all, reviewers found a decrease in admissions with gestational diabetes treatment whereas a single study with 1,000 participants reported an increase.

The systematic review reported only one beneficial strategy backed by “moderate to high quality” evidence.²² This was “lifestyle changes,” which the reviewers defined as a combination of “two or more interventions such as: healthy eating, exercise, education, mindfulness eating (focusing the mind on eating), yoga, relaxation, etc.,” and which the review found reduced large-for-gestational-age babies. For all other treatment strategy comparisons, conclusions as to their value weren’t possible either because of insufficient or poor quality evidence.

Now we’ve seen that gestational diabetes diagnosis and management do little to avert the list of adverse outcomes for which it is prescribed. This isn’t surprising, seeing as elevated blood glucose is primarily a marker for high BMI or health conditions that are their root causes, but lack of benefit makes the question of potential harm all the more important, which takes us to the next question.

Do Gestational Diabetes Diagnosis and Management Introduce Harms?

The answer to the question of whether gestational diabetes diagnosis and management introduce harms is “yes.”

The most serious harm is that being labeled a gestational diabetic increases the probability of cesarean. A large Australian study found that among women and birthing people having babies who weren’t macrosomic, the cesarean rate overall was 35 percent among gestational diabetics versus 27 percent in those with normal glucose tolerance.¹⁶ Similarly, the evidence synthesis included a study finding that in pregnancies with normal glucose tolerance, cesarean rates were higher with macrosomic babies (45% vs. 24%), but the presence or absence of macrosomia made no difference with gestational diabetes (33% in both cases).³¹ In other words, the belief that the baby is likely to be big—which doctors would have with a diagnosis of gestational diabetes—influences decision making around cesareans regardless of whether the baby is big or not.

The gestational diabetic label also increases the probability of labor induction. The Australian study found that 50 percent of gestational diabetics were induced versus 26 percent of those with normal glucose tolerance.¹⁶ Even more concerning, 47 percent of gestational diabetics versus 19 percent with normal glucose tolerance had an early-term planned delivery, meaning they were either induced or had a planned cesarean after reaching 37 weeks but before 39 weeks. While labor that starts on its own in this time period poses no problems, inductions and planned cesareans before 39 weeks increase the risk of breathing difficulties^{2, 36} and may have negative effects on breastfeeding ability and childhood development.^{5, 13}

Finally, there are other harms not mentioned in the research. One is that the body releases glucose in response to stress,³⁵ and gestational diabetes management is nothing if not stressful—not to mention the ongoing anxiety of being labeled “high risk.” Another is possibly being excluded from receiving care from a midwife, thereby depriving gestational diabetics of their best chance of birthing a bigger baby vaginally. Case in point: the cesarean rate with gestational diabetes was 9 percent with care by midwives at a freestanding birth center, rising to 11 percent when including those transferred to obstetric management or roughly half the rate reported in studies of gestational diabetes management by obstetricians at the time.²⁷ A third is that cesarean delivery or just routine management of the baby may prevent skin-to-skin contact with the mother after the birth and early breastfeeding. This would increase the baby’s stress, causing the baby to burn through its glucose stores and increasing risk of hypoglycemia while also depriving the baby of access to the breast, its cure.³²

So, to sum up, in previous sections, we’ve seen that having mildly elevated blood glucose levels alone doesn’t identify a population at increased risk of severe adverse outcomes and that treatment doesn’t avert them, and in this section, we’ve seen that gestational diabetes diagnosis and management not only does little good, it causes some of the harms it is intended to prevent.

This brings us to the question of where that leaves you.

Your Takeaway

In this section, I hope to help you navigate the obstetric care system in a way that enables you to obtain its benefits while avoiding its harms. To do that, I’ll start by laying out the pros and cons of your options and follow that with a list of data-based, no-risk strategies for avoiding a false-positive glucose test, birthing a bigger baby, and preventing newborn hypoglycemia.

First and foremost, though, don’t let the “diabetes” label scare you. You have the equivalent of catching a cold, not pneumonia. If your only problem is mildly elevated blood glucose, the only thing you are at increased risk for is having a bigger baby, and even that isn’t all that likely. In the Australian study, 83 percent of babies of gestational diabetic pregnancies were not macrosomic.¹⁶ Keeping things in perspective is important for two reasons: 1) you don’t want to make fear-based decisions, and 2) stress and anxiety increase your glucose levels.

Making Informed Decisions

• Should you agree to gestational diabetes screening?

Pro: The screening process will tell you if you have a condition that requires extra attention and care. In addition, if your care providers believe gestational diabetes poses serious risks, declining screening may set up an adversarial relationship.

Con: Once you get on the train, it will be very difficult to get off.

Suggestion: Before agreeing to be screened, find out more about how your care providers manage gestational diabetes.

• Should you agree to routine fetal surveillance tests (nonstress test, stress test, biophysical profile, amniotic fluid volume measurement) or ultrasound scans to estimate birthweight?

Pro:  None. 

Con:  Babies are not at any greater risk of being in trouble than when your glucose levels are normal, and fetal surveillance tests have high false-positive rates, meaning the test falsely indicates a problem. Once you have a positive test, though, you are almost certainly looking at immediate induction and a higher probability of having a cesarean.^{4, 14, 18, 21, 26} Ultrasound scans are as likely to be wrong as to be right when they predict high birth weight,³ but the obstetrician’s belief that the baby is big increases the chances of cesarean regardless of the baby’s actual weight.^{6, 8, 20, 23, 24, 28-30, 33, 34, 37-39}

• Should you agree to induction for suspected big baby?

Pro: None.

Con: If this is your first baby, induction for suspected macrosomia increases your probability of cesarean.²⁵

• Should you agree to routine induction prior to 39 weeks?

Pro: None.

Con: As I noted above, early term induction increases the risk of breathing difficulties^{2, 36} and may have negative effects on breastfeeding ability and childhood development.^{5, 13}

• Should you agree to your baby having routine testing for hypoglycemia?

Pro: Babies of gestational diabetics sometimes develop hypoglycemia, which needs to be treated if found. (See below for how to prevent newborn hypoglycemia.)

Con: Testing involves one or more painful heel sticks to draw blood. Babies not displaying symptoms such as tremor are unlikely to have a problem requiring treatment.

Suggestion: Decline testing unless the baby is big, small, or been born after a difficult labor—all situations increasing the probability of hypoglycemia. If you agree to testing, suckling at the breast at the time of the heel stick counteracts pain and prevents distress.

Strategies to Minimize a False-Positive Test

• Take the test at the earliest point it is offered. The test is usually offered between 24 and 28 weeks. As I wrote, glucose levels rise linearly during pregnancy. By taking the test as early as you can, you may avert a diagnosis of gestational diabetes that might have been made had you taken the test later.
• Postpone the test if you are ill or have an infection. Illness or infection can elevate glucose levels.
• Engage in visualization and relaxation techniques before and during the testing process to reduce anxiety. Anxiety increases blood glucose.

Strategies for Managing Blood Glucose Levels

We saw earlier that “lifestyle changes,” which encompass all of these strategies, was the only strategy a systematic review reported was backed by solid evidence of benefit,²² in this case, reducing large-for-gestational-age babies.

• Eat a healthy diet that reduces stress on the pancreas. The diets prescribed for gestational diabetics do this. In fact, research shows that the Mediterranean diet, a popular example of this type of diet, can also prevent gestational diabetes.
• Engage in moderate, regular exercise. Your muscles burn glucose.
• Engage in strategies that help you cope with stress. Meditation, mindfulness practices, yoga, spiritual practices, etc. can help you reduce stress levels, and reducing stress levels can reduce blood glucose levels.

Strategies for Birthing a Bigger Baby

Some suggestions may not be doable if you’re reading this late in pregnancy. I’ve put the three that need the longest lead time at the top of the list. However, even if these aren’t options for you, the others should still prove helpful.

• If they don’t already, switch to care providers who take the physiologic approach. They will be more likely to have policies and practices that promote your ability to birth a bigger baby, e.g., encouraging mobility in labor and pushing and birth positions other than on your back, evaluating your progress on an individual basis and not according to rule, etc. To determine where your care providers stand, ask them about their care policies and practices when they think the baby may be bigger than average.
• Hire a doula. A doula will have ideas to help you progress in labor and can also keep up your and your partner’s spirits if you experience self-doubt or negativity from medical staff.

• Take a set of childbirth classes intended to prepare you to labor without an epidural. You can still decide if you want one in labor, but epidurals inhibit mobility and slow labor, and you’ll learn strategies to help you manage without one.

• If this is your first baby, decline an induction for suspected big baby. It increases your probability of cesarean.²⁵
• Decline a routine IV and request that nurses listen to the fetal heart rate periodically (intermittent auscultation) in lieu of routine continuous fetal monitoring. IVs and continuous fetal monitoring inhibit mobility, and mobility works in your favor.¹⁹ Routine continuous fetal monitoring doesn’t improve outcomes, and a systematic review concluded that the evidence does not support routine IVs.¹⁰
• Expect a longer than average labor. Impatience is your enemy, especially with a bigger baby.
• If IV oxytocin is needed to strengthen contractions, give it time to work. See next bullet.
• Decline a cesarean or instrumental vaginal delivery based solely on exceeding a preset time limit. That decision should be based on an evaluation of how well you and your baby are tolerating labor, what’s been tried to improve labor or pushing progress, and what progress you’ve made.
• Push in a position other than on your back or semi-reclining. Side-lying, hands-and-knees, and other non-supine positions allow your pelvis to expand to accommodate the baby, and upright positions put gravity in your favor.
• Plan to deliver on all fours or be prepared to shift to all fours if the shoulders hang up. This can help avert a shoulder dystocia or release the baby’s shoulders should one occur.⁷ In many cases, you can shift to all fours even with an epidural with assistance and spotters.

Strategies for Avoiding Newborn Hypoglycemia

• Keep your baby skin-to-skin after birth and even if you’re not planning on breastfeeding, put the baby to breast as soon as the baby shows interest. Skin-to-skin contact stabilizes and keeps the baby calm, and colostrum, the pre-milk substance in the breast for the first few days after birth, provides, as midwife Rachel Reed puts it, “a nutrient dense package of glucose” such that even a few drops significantly increases glucose levels.³² Cuddling the baby skin-to-skin is possible after delivery even with a cesarean as is getting started breastfeeding once you’re moved to recovery.

References

1. Summary and recommendations of the Second International Workshop-Conference on Gestational Diabetes. Diabetes 1985 34(Suppl 2):123-6.
2. ACOG. Committee opinion No. 561: Nonmedically indicated early-term deliveries. Obstet Gynecol 2013;121(4):911-5.
3. ACOG. Macrosomia: ACOG Practice Bulletin, Number 216. Obstet Gynecol 2020;135(1):e18-e35.
4. Bellussi F, Po G, Livi A, et al. Fetal Movement Counting and Perinatal Mortality: A Systematic Review and Meta-analysis. Obstet Gynecol 2020;135(2):453-62.
5. Bentley JP, Roberts CL, Bowen JR, et al. Planned Birth Before 39 Weeks and Child Development: A Population-Based Study. Pediatrics 2016;138(6).
6. Blackwell SC, Refuerzo J, Chadha R, et al. Overestimation of fetal weight by ultrasound: does it influence the likelihood of cesarean delivery for labor arrest? Am J Obstet Gynecol 2009;200(3):340 e1-3.
7. Bruner JP, Drummond SB, Meenan AL, et al. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med 1998;43(5):439-43.
8. Cheng ER, Declercq ER, Belanoff C, et al. Labor and Delivery Experiences of Mothers with Suspected Large Babies. Matern Child Health J 2015;19(12):2578-86.
9. Insulin Resistance. 2021. (Accessed Aug 8, 2024, at https://my.clevelandclinic.org/health/diseases/22206-insulin-resistance.)
10. Dawood F, Dowswell T, Quenby S. Intravenous fluids for reducing the duration of labour in low risk nulliparous women. Cochrane Database Syst Rev 2013;6:CD007715.
11. Diabetes Tests & Diagnosis. 2022. (Accessed Aug 5, 2024, at https://www.niddk.nih.gov/health-information/diabetes/overview/tests-diagnosis.)
12. Gernaat SAM, Simard JF, Wikstrom AK, et al. Gestational Diabetes Mellitus Risk in Pregnant Women With Systemic Lupus Erythematosus. J Rheumatol 2022;49(5):465-9.
13. Gill JV, Boyle EM. Outcomes of infants born near term. Arch Dis Child 2017;102(2):194-8.
14. Grivell RM, Alfirevic Z, Gyte GM, et al. Antenatal cardiotocography for fetal assessment. Cochrane Database Syst Rev 2015(9):CD007863.
15. Hapo Study Cooperative Research Group, Metzger BE, Lowe LP, et al. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med 2008;358(19):1991-2002.
16. Hegerty C, Ostini R. Benefits and harms associated with an increase in gestational diabetes diagnosis in Queensland, Australia: a retrospective cohort comparison of diagnosis rates, outcomes, interventions and medication use for two periods, 2011-2013 and 2016-2018, using a large perinatal database. BMJ Open 2023;13(5):e069849.
17. Hegerty CK. The new gestational diabetes: Treatment, evidence and consent. Aust N Z J Obstet Gynaecol 2020;60(3):482-5.
18. Lalor JG, Fawole B, Alfirevic Z, et al. Biophysical profile for fetal assessment in high risk pregnancies. Cochrane Database Syst Rev 2008(1):CD000038.
19. Lawrence A, Lewis L, Hofmeyr GJ, et al. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev 2013;10:CD003934.
20. Levine AB, Lockwood CJ, Brown B, et al. Sonographic diagnosis of the large for gestational age fetus at term: does it make a difference? Obstet Gynecol 1992;79(1):55-8.
21. Manzanares S, Carrillo MP, Gonzalez-Peran E, et al. Isolated oligohydramnios in term pregnancy as an indication for induction of labor. J Matern Fetal Neonatal Med 2007;20(3):221-4.
22. Martis R, Crowther CA, Shepherd E, et al. Treatments for women with gestational diabetes mellitus: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2018;8(8):CD012327.
23. Matthews KC, Williamson J, Gupta S, et al. The effect of a sonographic estimated fetal weight on the risk of cesarean delivery in macrosomic and small for gestational-age infants(). J Matern Fetal Neonatal Med 2017;30(10):1172-6.
24. Melamed N, Yogev Y, Meizner I, et al. Sonographic prediction of fetal macrosomia: the consequences of false diagnosis. J Ultrasound Med 2010;29(2):225-30.
25. Moldeus K, Cheng YW, Wikstrom AK, et al. Induction of labor versus expectant management of large-for-gestational-age infants in nulliparous women. PLoS One 2017;12(7):e0180748.
26. Morris RK, Meller CH, Tamblyn J, et al. Association and prediction of amniotic fluid measurements for adverse pregnancy outcome: systematic review and meta-analysis. BJOG 2014;121(6):686-99.
27. O’Brien ME, Gilson G. Detection and management of gestational diabetes in an out-of-hospital birth center. J Nurse Midwifery 1987;32(2):79-84.
28. Papaccio M, Fichera A, Nava A, et al. Obstetric consequences of a false-positive diagnosis of large-for-gestational-age fetus. Int J Gynaecol Obstet 2022;158(3):626-33.
29. Parry S, Severs CP, Sehdev HM, et al. Ultrasonographic prediction of fetal macrosomia. Association with cesarean delivery. J Reprod Med 2000;45(1):17-22.
30. Peleg D, Warsof S, Wolf MF, et al. Counseling for fetal macrosomia: an estimated fetal weight of 4,000 g is excessively low. Am J Perinatol 2015;32(1):71-4.
31. Pillay J, Donovan L, Guitard S, et al. Screening for Gestational Diabetes: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2021;326(6):539-62.
32. Gestational Diabetes: Beyond the Label. 2023. (Accessed Aug 20, 2024, at https://www.rachelreed.website/blog/gestational-diabetes-beyond-the-label.)
33. Sadeh-Mestechkin D, Walfisch A, Shachar R, et al. Suspected macrosomia? Better not tell. Arch Gynecol Obstet 2008;278(3):225-30.
34. Scifres CM, Feghali M, Dumont T, et al. Large-for-Gestational-Age Ultrasound Diagnosis and Risk for Cesarean Delivery in Women With Gestational Diabetes Mellitus. Obstet Gynecol 2015;126(5):978-86.
35. Sharma K, Akre S, Chakole S, et al. Stress-Induced Diabetes: A Review. Cureus 2022;14(9):e29142.
36. Tita ATN, Jablonski KA, Bailit JL, et al. Neonatal outcomes of elective early-term births after demonstrated fetal lung maturity. Am J Obstet Gynecol 2018.
37. Vendittelli F, Riviere O, Breart G, et al. Is prenatal identification of fetal macrosomia useful? Eur J Obstet Gynecol Reprod Biol 2012;161(2):170-6.
38. Vitner D, Bleicher I, Kadour-Peero E, et al. Does prenatal identification of fetal macrosomia change management and outcome? Arch Gynecol Obstet 2019;299(3):635-44.
39. Weiner Z, Ben-Shlomo I, Beck-Fruchter R, et al. Clinical and ultrasonographic weight estimation in large for gestational age fetus. Eur J Obstet Gynecol Reprod Biol 2002;105(1):20-4.