Different methods and settings for glucose monitoring for gestational diabetes during pregnancy

Puvaneswary Raman; Emily Shepherd; Therese Dowswell; Philippa Middleton; Caroline A Crowther

doi:10.1002/14651858.CD011069.pub2

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Figure 1

Study flow diagram

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Analysis 1.1

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 1 Hypertensive disorders of pregnancy.

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Analysis 1.2

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 2 Caesarean section.

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Analysis 1.3

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 3 Perinatal mortality.

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Analysis 1.4

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 4 Large‐for‐gestational age.

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Analysis 1.5

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 5 Death or serious morbidity composite.

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Analysis 1.6

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 6 Operative vaginal birth (not a prespecified outcome).

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Analysis 1.7

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 7 Induction of labour.

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Analysis 1.8

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 8 Placental abruption.

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Analysis 1.9

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 9 Gestational weight gain (kg).

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Analysis 1.10

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 10 Weight at 36 weeks (kg).

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Analysis 1.11

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 11 Adherence to the intervention.

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Analysis 1.12

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 12 Sense of well‐being and quality of life: DES: Diabetes Empowerment Scale.

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Analysis 1.13

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 13 Use of additional pharmacotherapy.

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Analysis 1.14

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 14 Maternal hypoglycaemia.

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Analysis 1.15

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 15 Maternal hypoglycaemia: self‐monitored blood glucose episodes hypoglycaemic (< 3.9 mmol/L) (%).

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Analysis 1.16

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 16 Glycaemic control: HbA1c (%).

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Analysis 1.17

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 17 Glycaemic control: HbA1c < 5.8%.

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Analysis 1.18

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 18 Glycaemic control: HbA1c at 36 weeks (mmol/mol).

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Analysis 1.19

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 19 Glycaemic control: self‐monitored blood glucose (mmol/L).

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Analysis 1.20

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 20 Glycaemic control: fasting and 2‐hour post‐prandial blood glucose (mg/dL).

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Analysis 1.21

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 21 Stillbirth.

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Analysis 1.22

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 22 Neonatal death.

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Analysis 1.23

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 23 Gestational age at birth (weeks).

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Analysis 1.24

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 24 Preterm birth < 37 weeks.

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Analysis 1.25

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 25 Macrosomia.

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Analysis 1.26

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 26 Small‐for‐gestational age.

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Analysis 1.27

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 27 Birthweight (g).

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Analysis 1.28

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 28 Head circumference (cm).

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Analysis 1.29

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 29 Length (cm).

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Analysis 1.30

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 30 Shoulder dystocia.

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Analysis 1.31

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 31 Respiratory distress syndrome.

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Analysis 1.32

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 32 Neonatal hypoglycaemia.

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Analysis 1.33

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 33 Hyperbilirubinaemia or jaundice.

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Analysis 1.34

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 34 Hypocalcaemia.

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Analysis 1.35

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 35 Polycythaemia.

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Analysis 1.36

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 36 Number of hospital or health professional visits: face‐to‐face visits.

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Analysis 1.37

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 37 Number of hospital or health professional visits: unscheduled face‐to‐face visits.

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Analysis 1.38

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 38 Neonatal intensive care unit admission.

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Analysis 1.39

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 39 'Neonatal morbidity' (neonatal complications: e.g. hypoglycaemia, hyperbilirubinaemia, respiratory distress syndrome, shoulder dystocia, malformations) (not a prespecified outcome).

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Analysis 1.40

Comparison 1 Telemedicine versus standard care for glucose monitoring, Outcome 40 'Maternal morbidity' (maternal complications: gestational hypertension, pre‐eclampsia, eclampsia, hypoglycaemic episodes) (not a prespecified outcome).

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Analysis 2.1

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 1 Hypertensive disorders of pregnancy: pre‐eclampsia.

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Analysis 2.2

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 2 Caesarean section.

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Analysis 2.3

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 3 Perinatal mortality.

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Analysis 2.4

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 4 Large‐for‐gestational age.

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Analysis 2.5

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 5 Placental abruption.

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Analysis 2.6

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 6 Postpartum haemorrhage.

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Analysis 2.7

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 7 Gestational weight gain (kg/week).

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Analysis 2.8

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 8 Gestational weight gain (lb).

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Analysis 2.9

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 9 Adherence to the intervention: < 70% adherence to home blood glucose measurements or diabetes outpatient clinic appointments.

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Analysis 2.10

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 10 Adherence to the intervention: Dietary Compliance Questionnaire.

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Analysis 2.11

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 11 Sense of well‐being and quality of life: Diabetes Empowerment Scale delta scores.

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Analysis 2.12

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 12 Sense of well‐being and quality of life: emotional adjustment: Appraisal of Diabetes Scale delta scores.

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Analysis 2.13

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 13 Use of additional pharmacotherapy: insulin.

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Analysis 2.14

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 14 Glycaemic control: pre‐prandial blood glucose (mmol/L).

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Analysis 2.15

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 15 Glycaemic control: 1‐hour post‐prandial blood glucose (mmol/L).

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Analysis 2.16

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 16 Stillbirth.

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Analysis 2.17

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 17 Neonatal death.

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Analysis 2.18

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 18 Gestational age at birth (weeks).

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Analysis 2.19

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 19 Macrosomia.

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Analysis 2.20

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 20 Small‐for‐gestational age.

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Analysis 2.21

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 21 Birthweight (kg).

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Analysis 2.22

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 22 Birthweight (percentile).

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Analysis 2.23

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 23 Shoulder dystocia.

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Analysis 2.24

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 24 Neonatal hypoglycaemia.

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Analysis 2.25

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 25 Hyperbilirubinaemia or jaundice.

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Analysis 2.26

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 26 Number of antenatal visits or admissions: prenatal visits with the diabetes team.

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Analysis 2.27

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 27 Neonatal intensive care unit admission.

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Analysis 2.28

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 28 'Birth trauma' (not a prespecified outcome).

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Analysis 2.29

Comparison 2 Self‐monitoring versus periodic glucose monitoring, Outcome 29 'Respiratory complications' (not a prespecified outcome).

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Analysis 3.1

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 1 Caesarean section.

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Analysis 3.2

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 2 Perinatal mortality.

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Analysis 3.3

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 3 Large‐for‐gestational age.

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Analysis 3.4

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 4 Gestational weight gain (kg).

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Analysis 3.5

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 5 Use of additional pharmacotherapy.

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Analysis 3.6

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 6 Glycaemic control: HbA1c at 32 to 36 weeks (%).

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Analysis 3.7

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 7 Stillbirth.

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Analysis 3.8

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 8 Neonatal death.

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Analysis 3.9

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 9 Gestational age at birth (weeks).

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Analysis 3.10

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 10 Preterm birth < 37 weeks.

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Analysis 3.11

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 11 Macrosomia.

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Analysis 3.12

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 12 Small‐for‐gestational age.

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Analysis 3.13

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 13 Birthweight (g).

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Analysis 3.14

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 14 Neonatal hypoglycaemia.

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Analysis 3.15

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 15 Hyperbilirubinaemia or jaundice.

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Analysis 3.16

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 16 Neonatal intensive care unit admission.

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Analysis 3.17

Comparison 3 Continuous glucose monitoring system versus self‐monitoring of glucose, Outcome 17 Length of postnatal stay (baby): length of stay in neonatal intensive care unit (days).

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Analysis 4.1

Comparison 4 Modem versus telephone transmission for glucose monitoring, Outcome 1 Views of the intervention.

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Analysis 5.1

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 1 Hypertensive disorders of pregnancy: pre‐eclampsia.

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Analysis 5.2

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 2 Caesarean section.

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Analysis 5.3

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 3 Large‐for‐gestational age.

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Analysis 5.4

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 4 Perineal trauma.

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Analysis 5.5

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 5 Gestational weight gain (kg).

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Analysis 5.6

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 6 Adherence to the intervention: compliance with schedule (%).

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Analysis 5.7

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 7 Use of additional pharmacotherapy.

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Analysis 5.8

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 8 Glycaemic control: change in HbA1c (%).

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Analysis 5.9

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 9 Glycaemic control: hospitalisation for glycaemic control.

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Analysis 5.10

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 10 Glycaemic control: success in glycaemic control (%).

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Analysis 5.11

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 11 Stillbirth.

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Analysis 5.12

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 12 Gestational age at birth (weeks).

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Analysis 5.13

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 13 Apgar score < 7 at 5 minutes.

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Analysis 5.14

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 14 Macrosomia.

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Analysis 5.15

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 15 Small‐for‐gestational age.

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Analysis 5.16

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 16 Birthweight (g).

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Analysis 5.17

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 17 Shoulder dystocia.

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Analysis 5.18

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 18 Nerve palsies.

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$Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 19 Bone fractures.$

Analysis 5.19

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 19 Bone fractures.

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Analysis 5.20

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 20 Neonatal hypoglycaemia.

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Analysis 5.21

Comparison 5 Postprandial versus preprandial glucose monitoring, Outcome 21 Hyperbilirubinaemia or jaundice.

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Summary of findings for the main comparison. Telemedicine versus standard care for glucose monitoring for gestational diabetes during pregnancy (effect on mother)

Telemedicine versus standard care for glucose monitoring for gestational diabetes during pregnancy (effect on mother)
Patient or population: women with gestational diabetes mellitus Setting: 2 RCTs in USA; 1 RCT each in Italy, Ireland and Spain set in clinics or hospitals Intervention: telemedicine Comparison: standard care
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with standard care	Risk with telemedicine
Hypertensive disorders of pregnancy including pre‐eclampsia, gestational hypertension and eclampsia	Study population		RR 1.49 (0.69 to 3.20)	275 (4 RCTs)	⊕⊝⊝⊝ VERY LOW^1,2
	58 per 1000	87 per 1000 (40 to 187)
Caesarean section	Study population		RR 1.05 (0.72 to 1.53)	478 (5 RCTs)	⊕⊝⊝⊝ VERY LOW^3,4,5
	444 per 1000	467 per 1000 (320 to 680)
Development of type 2 diabetes	Study population		not estimable	(0 RCTs)	‐	None of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Induction of labour	Study population		RR 1.06 (0.63 to 1.77)	47 (1 RCT)	⊕⊝⊝⊝ VERY LOW ^2,6
	538 per 1000	571 per 1000 (339 to 953)
Perineal trauma	Study population		Not estimable	(0 RCTs)	‐	None of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Postnatal depression	Study population		Not estimable	(0 RCTs)	‐	None of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Postnatal weight retention or return to pre‐pregnancy weight	Study population		Not estimable	(0 RCTs)	‐	None of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹Study limitations (downgraded 1 level): 4 RCTs with potentially serious or very serious design limitations ²Imprecision (downgraded 2 levels): wide confidence interval crossing the line of no effect, few events and small sample size(s) ³Study limitations (downgraded 2 levels): 5 RCTs with potentially serious or very serious design limitations (> 40% of weight from 2 RCTs with serious or very serious design limitations) ⁴Imprecision (downgraded 1 level): wide confidence interval crossing the line of no effect ⁵Inconsistency (downgraded 1 level): statistical heterogeneity (I² = 62%) ⁶Study limitations (downgraded 1 level): 1 RCT with potentially serious design limitations

Summary of findings for the main comparison. Telemedicine versus standard care for glucose monitoring for gestational diabetes during pregnancy (effect on mother)

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Summary of findings 2. Telemedicine versus standard care for glucose monitoring in gestational diabetes during pregnancy (effect on child)

Telemedicine versus standard care for glucose monitoring in gestational diabetes during pregnancy (effect on child)
Patient or population: women with gestational diabetes mellitus Setting: 2 RCTs in USA; 1 RCT each in Italy, Ireland, and Spain set in clinics or hospitals Intervention: telemedicine Comparison: standard care
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with standard care	Risk with telemedicine
Perinatal mortality (including stillbirth or neonatal death)	Study population		‐	131 (2 RCTs)	⊕⊝⊝⊝ VERY LOW^1,2	There were no perinatal deaths in 2 RCTs
	See comment	See comment
Large‐for‐gestational age	Study population		RR 1.41 (0.76 to 2.64)	228 (3 RCTs)	⊕⊝⊝⊝ VERY LOW^3,4
	126 per 1000	178 per 1000 (96 to 333)
Death or serious morbidity composite	Study population		RR 1.06 (0.68 to 1.66)	57 (1 RCT)	⊕⊝⊝⊝ VERY LOW^4,5
	560 per 1000	594 per 1000 (381 to 930)
Neurosensory disability	Study population		Not estimable	(0 RCTS)	‐	None of the included RCTs reported this outcome
	0 per 100	0 per 1000 (0 to 0)
Hypoglycaemia	Study population		RR 1.14 (0.48 to 2.72)	198 (3 RCTs)	⊕⊝⊝⊝ VERY LOW^4,6
	82 per 100	94 per 1000 (40 to 224)
Adiposity (e.g. BMI, skinfold thickness, fat mass)	Study population		Not estimable	(0 RCTs)	‐	None of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Type 2 diabetes	Study population		Not estimable	(0 RCTs)	‐	None of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). BMI: body mass index;CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹Study limitations (downgraded 1 level): 2 RCTs with potentially serious design limitations ²Imprecision (downgraded 2 levels): no events and small sample size(s) ³Study limitations (downgraded 2 levels): 2 RCTs with potentially serious design limitations, and 1 RCT with serious or very serious design limitations (> 25% of weight) ⁴Imprecision (downgraded 2 levels): wide confidence interval crossing the line of no effect, (few events), small sample size(s) ⁵Study limitations (downgraded 1 level): 1 RCT with potentially serious design limitations ⁶Study limitations (downgraded 1 level): 2 RCTs with potentially serious design limitations, and 1 RCT with serious or very serious design limitations (< 7% of weight)

Summary of findings 2. Telemedicine versus standard care for glucose monitoring in gestational diabetes during pregnancy (effect on child)

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Summary of findings 3. Self‐monitoring versus periodic glucose monitoring for gestational diabetes during pregnancy (effect on mother)

Self‐monitoring versus periodic glucose monitoring for gestational diabetes during pregnancy (effect on mother)
Patient or population: women with gestational diabetes mellitus Setting: 1 RCT in Canda, 1 RCT in USA set in clinics or hospitals Intervention: self‐monitoring of glucose Comparison: periodic glucose monitoring
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with periodic glucose monitoring	Risk with self‐monitoring of glucose
Hypertensive disorders of pregnancy: pre‐eclampsia	Study population		RR 0.17 (0.01 to 3.49)	58 (1 RCT)	⊕⊝⊝⊝ VERY LOW^1,2
	74 per 1000	13 per 1000 (1 to 259)
Caesarean section	Study population		RR 1.18 (0.61 to 2.27)	400 (2 RCTs)	⊕⊕⊝⊝ LOW^3,4,5
	228 per 1000	270 per 1000 (139 to 519)
Development of type 2 diabetes	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Induction of labour	Study population		Not estimable	(0 RCTs)	‐	Neither of the RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Perineal trauma	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Postnatal depression	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Postnatal weight retention or return to pre‐pregnancy weight	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹Study limitations (downgraded 1 level): 1 RCT with potentially serious design limitations ²Imprecision (downgraded 2 levels): wide confidence interval crossing the line of no effect, few events and small sample size ³Study limitations (downgraded 1 level): 2 RCTs with potentially serious design limitations ⁴Imprecision (downgraded 1 level): wide confidence interval crossing the line of no effect ⁵Inconsistency: did not downgraded for statistical heterogeneity (I² = 49%)

Summary of findings 3. Self‐monitoring versus periodic glucose monitoring for gestational diabetes during pregnancy (effect on mother)

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Summary of findings 4. Self‐monitoring versus periodic for glucose monitoring for gestation diabetes during pregnancy (effect on child)

Self‐monitoring versus periodic for glucose monitoring for gestation diabetes during pregnancy (effect on child)
Patient or population: women with gestational diabetes mellitus Setting: 1 RCT in Canda, 1 RCT in USA set in clinics or hospitals Intervention: self‐monitoring of glucose Comparison: periodic glucose monitoring
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with periodic glucose monitoring	Risk with self‐monitoring of glucose
Perinatal mortality (stillbirth or neonatal death)	Study population		RR 1.54 (0.21 to 11.24)	400 (2 RCTs)	⊕⊝⊝⊝ VERY LOW^1,2
	5 per 1000	8 per 1000 (1 to 57)
Large‐for‐gestational age	Study population		RR 0.82 (0.50 to 1.37)	400 (2 RCTs)	⊕⊕⊝⊝ LOW^1,3
	142 per 1000	117 per 1000 (71 to 195)
Death or serious morbidity composite	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Neurosensory disability	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Hypoglycaemia	Study population		RR 0.64 (0.39 to 1.06)	391 (2 RCTs)	⊕⊕⊝⊝ LOW^1,3
	173 per 1000	111 per 1000 (67 to 183)
Adiposity (e.g. BMI, skinfold thickness, fat mass)	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Type 2 diabetes	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). BMI: body mass index;CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹Study limitations (downgraded 1 level): 2 RCTs with potentially serious design limitations ²Imprecision (downgraded 2 levels): wide confidence interval crossing the line of no effect and few events ³Imprecision (downgraded 1 level): wide confidence interval crossing the line of no effect

Summary of findings 4. Self‐monitoring versus periodic for glucose monitoring for gestation diabetes during pregnancy (effect on child)

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Summary of findings 5. Continuous glucose monitoring system versus self‐monitoring of glucose for gestational diabetes during pregnancy (effect on mother)

Continuous glucose monitoring system versus self‐monitoring of glucose for gestational diabetes during pregnancy (effect on mother)
Patient or population: women with gestational diabetes mellitus Setting: 1 RCT in Finland, 1 RCT in China set in clinics or hospitals Intervention: continuous glucose monitoring system Comparison: self‐monitoring of glucose
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with self‐monitoring of glucose	Risk with continuous glucose monitoring system
Hypertensive disorders of pregnancy	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Caesarean section	Study population		RR 0.91 (0.68 to 1.20)	179 (2 RCTs)	⊕⊕⊝⊝ VERY LOW^1,2
	500 per 1000	455 per 1000 (340 to 600)
Development of type 2 diabetes	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Induction of labour	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Perineal trauma	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Postnatal depression	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Postnatal weight retention or return to pre‐pregnancy weight	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹Study limitations (downgraded 1 level): 2 RCTs with potentially serious design limitations ²Inconsistency (downgraded 1 level): wide confidence interval crossing the line of no effect and small sample sizes

Summary of findings 5. Continuous glucose monitoring system versus self‐monitoring of glucose for gestational diabetes during pregnancy (effect on mother)

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Summary of findings 6. Continuous glucose monitoring system versus self‐monitoring of glucose for gestational diabetes during pregnancy (effect on child)

Continuous glucose monitoring system versus self‐monitoring of glucose for gestational diabetes during pregnancy (effect on child)
Patient or population: women with gestational diabetes mellitus Setting: 1 RCT in Finland, 1 RCT in China set in clinics or hospitals Intervention: continuous glucose monitoring system Comparison: self‐monitoring of glucose
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect (95% CI)	№ of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk with self‐monitoring of glucose	Risk with continuous glucose monitoring system
Perinatal mortality (stillbirth or neonatal death)	Study population		‐	179 (2 RCTs)	⊕⊕⊝⊝ VERY LOW^1,2	There were no perinatal deaths in the 2 RCTs
	See comment	See comment
Large‐for‐gestational age	Study population		RR 0.67 (0.43 to 1.05)	106 (1 RCT)	⊕⊝⊝⊝ VERY LOW^3,4
	527 per 1000	353 per 1000 (227 to 554)
Death or serious morbidity composite	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Neurosensory disability	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Hypoglycaemia	Study population		RR 0.79 (0.35 to 1.78)	179 (2 RCTs)	⊕⊝⊝⊝ VERY LOW^1,5
	130 per 1000	103 per 1000 (46 to 232)
Adiposity (e.g. BMI, skinfold thickness, fat mass)	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
Type 2 diabetes	Study population		Not estimable	(0 RCTs)	‐	Neither of the included RCTs reported this outcome
	0 per 1000	0 per 1000 (0 to 0)
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). BMI: body mass index; CI: confidence interval; RCT: randomised controlled trial; RR: risk ratio
GRADE Working Group grades of evidence High quality: we are very confident that the true effect lies close to that of the estimate of the effect Moderate quality: we are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low quality: our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low quality: we have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹Study limitations (downgraded 1 level): 2 RCTs with potentially serious design limitations ²Inconsistency (downgraded 2 levels): no events and small sample sizes ³Study limitations (downgraded 1 level): 1 RCT with potentially serious design limitations ⁴Inconsistency (downgraded 2 levels): wide confidence interval crossing the line of no effect and small sample size ⁵Inconsistency (downgraded 2 levels): wide confidence interval crossing the line of no effect, few events and small sample sizes

Summary of findings 6. Continuous glucose monitoring system versus self‐monitoring of glucose for gestational diabetes during pregnancy (effect on child)

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Comparison 1. Telemedicine versus standard care for glucose monitoring

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Hypertensive disorders of pregnancy Show forest plot	4	275	Risk Ratio (M‐H, Fixed, 95% CI)	1.49 [0.69, 3.20]

1.1 Pre‐eclampsia, pregnancy‐induced hypertension	3	178	Risk Ratio (M‐H, Fixed, 95% CI)	1.29 [0.58, 2.89]
1.2 Pregnancy‐induced hypertension	1	97	Risk Ratio (M‐H, Fixed, 95% CI)	4.9 [0.24, 99.48]
2 Caesarean section Show forest plot	5	478	Risk Ratio (M‐H, Random, 95% CI)	1.05 [0.72, 1.53]

3 Perinatal mortality Show forest plot	2	131	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

4 Large‐for‐gestational age Show forest plot	3	228	Risk Ratio (M‐H, Fixed, 95% CI)	1.41 [0.76, 2.64]

5 Death or serious morbidity composite Show forest plot	1	57	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.68, 1.66]

6 Operative vaginal birth (not a prespecified outcome) Show forest plot	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	0.50 [0.11, 2.30]

7 Induction of labour Show forest plot	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.63, 1.77]

8 Placental abruption Show forest plot	2	154	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.12, 6.42]

9 Gestational weight gain (kg) Show forest plot	2	300	Mean Difference (IV, Fixed, 95% CI)	‐0.47 [‐1.50, 0.55]

10 Weight at 36 weeks (kg) Show forest plot	1	44	Mean Difference (IV, Fixed, 95% CI)	5.5 [‐5.69, 16.69]

11 Adherence to the intervention Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

11.1 Appointments attended (%)	1	47	Mean Difference (IV, Fixed, 95% CI)	5.20 [‐2.27, 12.67]
11.2 Average daily self‐monitoring of blood glucose frequency: meter memory	1	44	Mean Difference (IV, Fixed, 95% CI)	0.5 [‐0.42, 1.42]
11.3 Average daily self‐monitoring of blood glucose frequency: diary	1	45	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.66, 0.86]
11.4 Frequency of monitoring (number of data points)	1	57	Mean Difference (IV, Fixed, 95% CI)	21.10 [‐9.33, 51.53]
11.5 Frequency of monitoring (number of data sets)	1	74	Mean Difference (IV, Fixed, 95% CI)	1.20 [‐12.32, 14.72]
12 Sense of well‐being and quality of life: DES: Diabetes Empowerment Scale Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

12.1 Total	1	57	Mean Difference (IV, Fixed, 95% CI)	0.40 [0.14, 0.66]
12.2 Subscale 1: managing the psychosocial aspects of diabetes	1	57	Mean Difference (IV, Fixed, 95% CI)	0.5 [0.21, 0.79]
12.3 Subscale 2: assessing dissatisfaction and readiness to change	1	57	Mean Difference (IV, Fixed, 95% CI)	0.40 [0.14, 0.66]
12.4 Subscale 3: setting and achieving diabetes goals	1	57	Mean Difference (IV, Fixed, 95% CI)	0.30 [‐0.04, 0.64]
13 Use of additional pharmacotherapy Show forest plot	5		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

13.1 Insulin	5	484	Risk Ratio (M‐H, Fixed, 95% CI)	1.52 [1.18, 1.96]
13.2 Oral agents	3	184	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.50, 1.42]
13.3 Insulin and oral agents	1	47	Risk Ratio (M‐H, Fixed, 95% CI)	1.24 [0.19, 8.06]
14 Maternal hypoglycaemia Show forest plot	1	203	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

15 Maternal hypoglycaemia: self‐monitored blood glucose episodes hypoglycaemic (< 3.9 mmol/L) (%) Show forest plot	1	44	Mean Difference (IV, Fixed, 95% CI)	‐0.10 [‐1.64, 1.44]

16 Glycaemic control: HbA1c (%) Show forest plot	3	357	Mean Difference (IV, Fixed, 95% CI)	‐0.15 [‐0.26, ‐0.04]

17 Glycaemic control: HbA1c < 5.8% Show forest plot	1	97	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.96, 1.04]

18 Glycaemic control: HbA1c at 36 weeks (mmol/mol) Show forest plot	1	30	Mean Difference (IV, Fixed, 95% CI)	0.20 [‐2.03, 2.43]

19 Glycaemic control: self‐monitored blood glucose (mmol/L) Show forest plot	1	44	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.30, 0.30]

20 Glycaemic control: fasting and 2‐hour post‐prandial blood glucose (mg/dL) Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

20.1 Fasting blood glucose (mg/dL)	2	131	Mean Difference (IV, Random, 95% CI)	‐0.50 [‐5.38, 4.38]
20.2 2‐hour post‐prandial blood glucose (mg/dL)	2	131	Mean Difference (IV, Random, 95% CI)	‐0.21 [‐5.09, 4.67]
21 Stillbirth Show forest plot	3	178	Risk Ratio (M‐H, Fixed, 95% CI)	0.41 [0.02, 9.55]

22 Neonatal death Show forest plot	2	131	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

23 Gestational age at birth (weeks) Show forest plot	5	478	Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.18, 0.37]

24 Preterm birth < 37 weeks Show forest plot	4	275	Risk Ratio (M‐H, Fixed, 95% CI)	0.66 [0.31, 1.39]

25 Macrosomia Show forest plot	2	249	Risk Ratio (M‐H, Random, 95% CI)	1.43 [0.27, 7.52]

26 Small‐for‐gestational age Show forest plot	1	97	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

27 Birthweight (g) Show forest plot	5	477	Mean Difference (IV, Fixed, 95% CI)	63.13 [‐32.32, 158.59]

28 Head circumference (cm) Show forest plot	1	45	Mean Difference (IV, Fixed, 95% CI)	0.70 [0.02, 1.38]

29 Length (cm) Show forest plot	1	42	Mean Difference (IV, Fixed, 95% CI)	0.20 [‐1.34, 1.74]

30 Shoulder dystocia Show forest plot	2	142	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 7.83]

31 Respiratory distress syndrome Show forest plot	3	176	Risk Ratio (M‐H, Fixed, 95% CI)	0.63 [0.26, 1.49]

32 Neonatal hypoglycaemia Show forest plot	3	198	Risk Ratio (M‐H, Fixed, 95% CI)	1.14 [0.48, 2.72]

33 Hyperbilirubinaemia or jaundice Show forest plot	3	176	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.59, 2.01]

34 Hypocalcaemia Show forest plot	1	97	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

35 Polycythaemia Show forest plot	1	97	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

36 Number of hospital or health professional visits: face‐to‐face visits Show forest plot	1	97	Mean Difference (IV, Fixed, 95% CI)	‐0.36 [‐0.92, 0.20]

37 Number of hospital or health professional visits: unscheduled face‐to‐face visits Show forest plot	1	97	Mean Difference (IV, Fixed, 95% CI)	‐0.62 [‐1.05, ‐0.19]

38 Neonatal intensive care unit admission Show forest plot	3	176	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.62, 1.79]

39 'Neonatal morbidity' (neonatal complications: e.g. hypoglycaemia, hyperbilirubinaemia, respiratory distress syndrome, shoulder dystocia, malformations) (not a prespecified outcome) Show forest plot	1	203	Risk Ratio (M‐H, Fixed, 95% CI)	1.52 [0.53, 4.38]

40 'Maternal morbidity' (maternal complications: gestational hypertension, pre‐eclampsia, eclampsia, hypoglycaemic episodes) (not a prespecified outcome) Show forest plot	1	203	Risk Ratio (M‐H, Fixed, 95% CI)	0.49 [0.13, 1.79]

Comparison 1. Telemedicine versus standard care for glucose monitoring

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Comparison 2. Self‐monitoring versus periodic glucose monitoring

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Hypertensive disorders of pregnancy: pre‐eclampsia Show forest plot	1	58	Risk Ratio (M‐H, Fixed, 95% CI)	0.18 [0.01, 3.49]

2 Caesarean section Show forest plot	2	400	Risk Ratio (M‐H, Random, 95% CI)	1.18 [0.61, 2.27]

3 Perinatal mortality Show forest plot	2	400	Risk Ratio (M‐H, Fixed, 95% CI)	1.54 [0.21, 11.24]

4 Large‐for‐gestational age Show forest plot	2	400	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.50, 1.37]

5 Placental abruption Show forest plot	1	58	Risk Ratio (M‐H, Fixed, 95% CI)	2.63 [0.11, 61.88]

6 Postpartum haemorrhage Show forest plot	1	58	Risk Ratio (M‐H, Fixed, 95% CI)	2.63 [0.11, 61.88]

7 Gestational weight gain (kg/week) Show forest plot	1	342	Mean Difference (IV, Fixed, 95% CI)	‐0.1 [‐0.15, ‐0.05]

7.1 1‐hour post‐breakfast glucose < 7.8 mmol/L	1	227	Mean Difference (IV, Fixed, 95% CI)	‐0.10 [‐0.17, ‐0.03]
7.2 1‐hour post‐breakfast glucose ≥ 7.8 mmol/L	1	115	Mean Difference (IV, Fixed, 95% CI)	‐0.10 [‐0.17, ‐0.03]
8 Gestational weight gain (lb) Show forest plot	1	58	Mean Difference (IV, Fixed, 95% CI)	‐5.5 [‐13.57, 2.57]

9 Adherence to the intervention: < 70% adherence to home blood glucose measurements or diabetes outpatient clinic appointments Show forest plot	1	342	Risk Ratio (M‐H, Fixed, 95% CI)	0.74 [0.32, 1.71]

10 Adherence to the intervention: Dietary Compliance Questionnaire Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

10.1 Total compliance score	1	58	Mean Difference (IV, Fixed, 95% CI)	1.5 [‐0.47, 3.47]
10.2 Mean compliance score	1	58	Mean Difference (IV, Fixed, 95% CI)	0.0 [‐0.40, 0.40]
11 Sense of well‐being and quality of life: Diabetes Empowerment Scale delta scores Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

11.1 Overall	1	47	Mean Difference (IV, Fixed, 95% CI)	3.70 [‐2.08, 9.48]
11.2 Setting goals	1	47	Mean Difference (IV, Fixed, 95% CI)	0.65 [‐1.10, 2.40]
11.3 Solving problems	1	47	Mean Difference (IV, Fixed, 95% CI)	1.35 [‐0.37, 3.07]
11.4 Motivating oneself	1	47	Mean Difference (IV, Fixed, 95% CI)	0.63 [‐0.89, 2.15]
11.5 Obtaining support	1	47	Mean Difference (IV, Fixed, 95% CI)	0.94 [‐0.09, 1.97]
11.6 Making decisions	1	47	Mean Difference (IV, Fixed, 95% CI)	0.01 [‐1.39, 1.41]
12 Sense of well‐being and quality of life: emotional adjustment: Appraisal of Diabetes Scale delta scores Show forest plot	1	47	Mean Difference (IV, Fixed, 95% CI)	1.20 [‐0.88, 3.28]

13 Use of additional pharmacotherapy: insulin Show forest plot	2	400	Risk Ratio (M‐H, Fixed, 95% CI)	1.31 [0.69, 2.48]

14 Glycaemic control: pre‐prandial blood glucose (mmol/L) Show forest plot	2	360	Mean Difference (IV, Random, 95% CI)	0.06 [‐0.08, 0.19]

14.1 Breakfast glucose < 7.8 mmol/L	1	192	Mean Difference (IV, Random, 95% CI)	0.10 [‐0.03, 0.23]
14.2 Breakfast glucose ≥ 7.8 mmol/L	1	110	Mean Difference (IV, Random, 95% CI)	0.10 [‐0.07, 0.27]
14.3 All women	1	58	Mean Difference (IV, Random, 95% CI)	‐0.21 [‐0.54, 0.12]
15 Glycaemic control: 1‐hour post‐prandial blood glucose (mmol/L) Show forest plot	2	395	Mean Difference (IV, Random, 95% CI)	‐0.09 [‐0.60, 0.42]

15.1 1‐hour post‐breakfast glucose > 7.8 mmol/L	1	222	Mean Difference (IV, Random, 95% CI)	0.0 [‐0.19, 0.19]
15.2 1‐hour post‐breakfast glucose ≥ 7.8 mmol/L	1	115	Mean Difference (IV, Random, 95% CI)	‐0.60 [‐0.90, ‐0.30]
15.3 All women	1	58	Mean Difference (IV, Random, 95% CI)	0.47 [‐0.12, 1.06]
16 Stillbirth Show forest plot	2	400	Risk Ratio (M‐H, Fixed, 95% CI)	1.54 [0.21, 11.24]

17 Neonatal death Show forest plot	1	58	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

18 Gestational age at birth (weeks) Show forest plot	2	400	Mean Difference (IV, Fixed, 95% CI)	‐0.03 [‐0.32, 0.27]

18.1 1‐hour post‐breakfast glucose < 7.8 mmol/L	1	227	Mean Difference (IV, Fixed, 95% CI)	‐0.20 [‐0.59, 0.19]
18.2 1‐hour post‐breakfast glucose ≥ 7.8 mmol/L	1	115	Mean Difference (IV, Fixed, 95% CI)	0.20 [‐0.31, 0.71]
18.3 All neonates	1	58	Mean Difference (IV, Fixed, 95% CI)	0.30 [‐0.78, 1.38]
19 Macrosomia Show forest plot	1	342	Risk Ratio (M‐H, Fixed, 95% CI)	0.94 [0.53, 1.67]

20 Small‐for‐gestational age Show forest plot	1	342	Risk Ratio (M‐H, Fixed, 95% CI)	1.19 [0.53, 2.67]

21 Birthweight (kg) Show forest plot	2	400	Mean Difference (IV, Fixed, 95% CI)	‐40.22 [‐148.37, 67.93]

21.1 1‐hour post‐breakfast glucose < 7.8 mmol/L	1	227	Mean Difference (IV, Fixed, 95% CI)	‐10.0 [‐145.47, 125.47]
21.2 1‐hour post‐breakfast glucose ≥ 7.8 mmol/L	1	115	Mean Difference (IV, Fixed, 95% CI)	‐70.0 [‐283.34, 143.34]
21.3 All neonates	1	58	Mean Difference (IV, Fixed, 95% CI)	‐150.0 [‐482.61, 182.61]
22 Birthweight (percentile) Show forest plot	1	342	Mean Difference (IV, Fixed, 95% CI)	‐0.67 [‐6.75, 5.42]

22.1 1‐hour post‐breakfast glucose < 7.8 mmol/L	1	227	Mean Difference (IV, Fixed, 95% CI)	1.5 [‐5.71, 8.71]
22.2 1‐hour post‐breakfast glucose ≥ 7.8 mmol/L	1	115	Mean Difference (IV, Fixed, 95% CI)	‐6.00 [‐17.32, 5.32]
23 Shoulder dystocia Show forest plot	1	342	Risk Ratio (M‐H, Fixed, 95% CI)	0.25 [0.03, 2.19]

24 Neonatal hypoglycaemia Show forest plot	2	391	Risk Ratio (M‐H, Fixed, 95% CI)	0.64 [0.39, 1.06]

25 Hyperbilirubinaemia or jaundice Show forest plot	2	370	Risk Ratio (M‐H, Fixed, 95% CI)	0.63 [0.39, 1.04]

26 Number of antenatal visits or admissions: prenatal visits with the diabetes team Show forest plot	1	58	Mean Difference (IV, Fixed, 95% CI)	0.20 [‐1.09, 1.49]

27 Neonatal intensive care unit admission Show forest plot	1	58	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.13, 5.77]

28 'Birth trauma' (not a prespecified outcome) Show forest plot	1	58	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.06, 13.27]

29 'Respiratory complications' (not a prespecified outcome) Show forest plot	1	58	Risk Ratio (M‐H, Fixed, 95% CI)	0.87 [0.06, 13.27]

Comparison 2. Self‐monitoring versus periodic glucose monitoring

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Comparison 3. Continuous glucose monitoring system versus self‐monitoring of glucose

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Caesarean section Show forest plot	2	179	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.68, 1.20]

2 Perinatal mortality Show forest plot	2	179	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

3 Large‐for‐gestational age Show forest plot	1	106	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.43, 1.05]

4 Gestational weight gain (kg) Show forest plot	2	179	Mean Difference (IV, Fixed, 95% CI)	‐1.26 [‐2.28, ‐0.24]

5 Use of additional pharmacotherapy Show forest plot	2	179	Risk Ratio (M‐H, Fixed, 95% CI)	2.86 [1.47, 5.56]

6 Glycaemic control: HbA1c at 32 to 36 weeks (%) Show forest plot	1	106	Mean Difference (IV, Fixed, 95% CI)	‐0.10 [‐0.24, 0.04]

7 Stillbirth Show forest plot	2	179	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

8 Neonatal death Show forest plot	2	179	Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

9 Gestational age at birth (weeks) Show forest plot	2	179	Mean Difference (IV, Fixed, 95% CI)	‐0.17 [‐0.52, 0.19]

10 Preterm birth < 37 weeks Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

11 Macrosomia Show forest plot	2	179	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.35, 2.05]

12 Small‐for‐gestational age Show forest plot	1	106	Risk Ratio (M‐H, Fixed, 95% CI)	1.08 [0.16, 7.37]

13 Birthweight (g) Show forest plot	2	179	Mean Difference (IV, Fixed, 95% CI)	‐110.17 [‐264.73, 44.39]

14 Neonatal hypoglycaemia Show forest plot	2	179	Risk Ratio (M‐H, Fixed, 95% CI)	0.79 [0.35, 1.78]

15 Hyperbilirubinaemia or jaundice Show forest plot	1	73	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.28, 3.80]

16 Neonatal intensive care unit admission Show forest plot	1	73	Risk Ratio (M‐H, Fixed, 95% CI)	0.65 [0.29, 1.50]

17 Length of postnatal stay (baby): length of stay in neonatal intensive care unit (days) Show forest plot	1	18	Mean Difference (IV, Fixed, 95% CI)	‐0.83 [‐2.35, 0.69]

Comparison 3. Continuous glucose monitoring system versus self‐monitoring of glucose

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Comparison 4. Modem versus telephone transmission for glucose monitoring

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Views of the intervention Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

1.1 Overall, I am satisfied with how easy it is to use Accu‐Chek Complete, Acculink	1	38	Risk Ratio (M‐H, Fixed, 95% CI)	1.11 [0.90, 1.38]
1.2 I feel comfortable using the Accu‐Chek Complete, Acculink	1	38	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.66, 1.41]
1.3 Whenever I made a mistake using the Accu‐Chek Complete, Acculink, I could recover easily and quickly	1	38	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.67, 1.25]
1.4 It was easy to learn to use the Accu‐Chek Complete, Acculink	1	38	Risk Ratio (M‐H, Fixed, 95% CI)	1.05 [0.82, 1.34]
1.5 The written material provided for the Accu‐Chek Complete was easy to understand	1	38	Risk Ratio (M‐H, Fixed, 95% CI)	1.18 [0.92, 1.51]

Comparison 4. Modem versus telephone transmission for glucose monitoring

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Comparison 5. Postprandial versus preprandial glucose monitoring

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Hypertensive disorders of pregnancy: pre‐eclampsia Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.15, 6.68]

2 Caesarean section Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.62 [0.29, 1.29]

3 Large‐for‐gestational age Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.29 [0.11, 0.78]

4 Perineal trauma Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.38 [0.11, 1.29]

5 Gestational weight gain (kg) Show forest plot	1	66	Mean Difference (IV, Fixed, 95% CI)	‐0.20 [‐2.81, 2.41]

6 Adherence to the intervention: compliance with schedule (%) Show forest plot	1	66	Mean Difference (IV, Fixed, 95% CI)	‐3.0 [‐3.99, ‐2.01]

7 Use of additional pharmacotherapy Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

7.1 Insulin dose (during the last 4 weeks of pregnancy, including regular and intermediate acting) (units/day)	1	66	Mean Difference (IV, Fixed, 95% CI)	23.60 [11.17, 36.03]
7.2 Insulin dose (during the last 4 weeks of pregnancy, including regular and intermediate acting) (units/kg)	1	66	Mean Difference (IV, Fixed, 95% CI)	0.20 [0.12, 0.28]
8 Glycaemic control: change in HbA1c (%) Show forest plot	1	66	Mean Difference (IV, Fixed, 95% CI)	‐2.4 [‐3.33, ‐1.47]

9 Glycaemic control: hospitalisation for glycaemic control Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	1.33 [0.32, 5.50]

10 Glycaemic control: success in glycaemic control (%) Show forest plot	1	66	Mean Difference (IV, Fixed, 95% CI)	2.0 [‐0.26, 4.26]

11 Stillbirth Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 7.90]

12 Gestational age at birth (weeks) Show forest plot	1	66	Mean Difference (IV, Fixed, 95% CI)	0.30 [‐1.08, 1.68]

13 Apgar score < 7 at 5 minutes Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.04, 3.04]

14 Macrosomia Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.25 [0.08, 0.81]

15 Small‐for‐gestational age Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.13, 71.07]

16 Birthweight (g) Show forest plot	1	66	Mean Difference (IV, Fixed, 95% CI)	‐379.0 [‐650.79, ‐107.21]

17 Shoulder dystocia Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.17 [0.02, 1.31]

18 Nerve palsies Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.5 [0.05, 5.25]

19 Bone fractures Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.07, 15.33]

20 Neonatal hypoglycaemia Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.14 [0.02, 1.10]

21 Hyperbilirubinaemia or jaundice Show forest plot	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.75 [0.18, 3.09]

Comparison 5. Postprandial versus preprandial glucose monitoring

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