A 28-year-old woman has gestational diabetes diagnosed at 26 weeks. Her fasting glucose is 7.2 mmol/L on repeat testing. She was initially managed with dietary changes. What is the NEXT appropriate step?

• A Initiate insulin therapy immediately ✓
• B Continue dietary management for 2 more weeks and recheck
• C Start metformin 500 mg twice daily
• D Add glyburide (glibenclamide) 2.5 mg daily

Explanation

Pharmacological treatment for GDM is indicated when dietary control fails to achieve glycemic targets (fasting glucose <5.3 mmol/L and 2-hour post-meal <6.7 mmol/L per NICE; or fasting <5.0–5.3 mmol/L by various guidelines). A fasting glucose of 7.2 mmol/L is well above target and insulin therapy should be initiated promptly. While metformin and glyburide are used in some guidelines as alternatives, insulin remains the first-line pharmacotherapy in most international guidelines (WHO, ACOG) given its safety profile and placental non-passage. Glyburide crosses the placenta and is associated with higher neonatal hypoglycemia.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.