Alexandra Katz, Aidan Shulkin, Samantha Jacobson, Chella Price, Michael A Tsoukas, Isabella Albanese, Agnieszka Majdan, Jill Pancer, Ariane Godbout, Kaberi Dasgupta, Anne-Sophie Brazeau, Tricia Peters
ACS exposure in GDM is associated with a predictable but variable, transient deterioration in maternal glycaemia. GDM-specific evidence suggests that structured pregnancy-adapted monitoring and insulin-adjustment pathways may help attenuate post-ACS hyperglycaemia. However, the evidence remains heterogeneous and largely observational. Prospective studies are needed to validate GDM-specific algorithms, clarify thresholds for insulin initiation or escalation and define indications for subcutaneous versus IVI.
BACKGROUND: Antenatal corticosteroids (ACS) promote foetal lung maturation in pregnancies at risk of preterm birth; however, in gestational diabetes mellitus (GDM), they can exacerbate maternal glycemia and contribute to adverse neonatal outcomes. Clinical guidelines offer limited direction on optimal treatment adjustment.
OBJECTIVES: To synthesize the evidence on glycaemic responses and management strategies following ACS exposure in individuals with GDM.
METHODS: A systematic review of Embase, MEDLINE and CENTRAL in October 2025 in accordance with PRISMA guidelines. Studies reporting on glycaemic outcomes and/or management strategies following ACS exposure in individuals with GDM were included.
RESULTS: Twenty studies were included. Maternal glycemia rose predictably after ACS, with hyperglycaemia typically emerging within 9-16 h, peaking over the subsequent 24-72 h and often persisting up to 5 days. Among individuals managed with medical nutrition therapy or oral hypoglycaemic agents at baseline, insulin initiation ranged from 13% to 91%. Among those already using insulin, 67%-88% required dose escalation, with mean increases typically ranging from 47% to 91%. Pregnancy-adapted intravenous insulin (IVI) pathways reported higher time-in-range and fewer hyperglycaemic/hypoglycaemic events than adult IVI protocols. However, emerging evidence suggests that structured, pregnancy-specific subcutaneous insulin protocols may achieve comparable or improved glycaemic control.
CONCLUSIONS: ACS exposure in GDM is associated with a predictable but variable, transient deterioration in maternal glycaemia. GDM-specific evidence suggests that structured pregnancy-adapted monitoring and insulin-adjustment pathways may help attenuate post-ACS hyperglycaemia. However, the evidence remains heterogeneous and largely observational. Prospective studies are needed to validate GDM-specific algorithms, clarify thresholds for insulin initiation or escalation and define indications for subcutaneous versus IVI.