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Gestational Diabetes: Induction Versus Expectant Management of Labour (GINEXMAL)

This study has been completed.
Information provided by (Responsible Party):
Ronfani Luca, IRCCS Burlo Garofolo Identifier:
First received: January 26, 2010
Last updated: April 29, 2015
Last verified: April 2015
The purpose of this study is to determine whether, in Gestational Diabetes Mellitus (GDM) pregnancies, induction of labour at 38-39 weeks of pregnancy is superior to expectant management in terms of maternal and neonatal outcomes.

Condition Intervention
Gestational Diabetes
Gestational Diabetes Mellitus
Diabetes Mellitus, Gestational
Pregnancy-Induced Diabetes
Diabetes, Pregnancy Induced

Study Type: Interventional
Study Design: Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Open Label
Official Title: GINEXMAL RCT: Induction of Labour Versus Expectant Management in Gestational Diabetes Pregnancies

Further study details as provided by IRCCS Burlo Garofolo:

Primary Outcome Measures:
  • C-section rate [ Time Frame: 1 minute after delivery ]

Secondary Outcome Measures:
  • Operative Vaginal Delivery [ Time Frame: 1 minute after delivery ]
  • Perineal Tears or Episiotomy [ Time Frame: 1 minute after delivery ]
  • Postpartum haemorrhage [ Time Frame: within 24 hours from delivery ]
  • Maternal Blood Transfusion [ Time Frame: until maternal discharge ]
  • Maternal Intensive Care Unit Admission [ Time Frame: until maternal discharge ]
  • Neonatal Weight [ Time Frame: 10 minutes after delivery ]
  • Neonatal Apgar score at 1', 5', 10' minutes [ Time Frame: 1, 5, 10 minutes after delivery ]
  • Shoulder Dystocia [ Time Frame: during delivery ]
  • Manoeuvres for Shoulder Dystocia [ Time Frame: during delivery ]
  • Neonatal Intensive Care Unit Admission [ Time Frame: until neonatal discharge ]
  • Arterial cord Ph inferior to 7.2 [ Time Frame: within 5 minutes from delivery ]
  • Neonatal Hyperbilirubinemia [ Time Frame: until neonatal discharge ]
  • Clinical and Biochemical Neonatal Hypoglycemia [ Time Frame: until neonatal discharge ]
  • Neonatal Polycythemia [ Time Frame: until neonatal discharge ]
  • Neonatal Birth Trauma [ Time Frame: 10 minute from delivery or until neonatal discharge ]
  • Neonatal Respiratory Distress/Transient Tachypnea [ Time Frame: until neonatal discharge ]
  • Neonatal Need for Respiratory Support [ Time Frame: until neonatal discharge ]
  • Maternal death [ Time Frame: until neonatal discharge ]
  • Perinatal Death [ Time Frame: until neonatal discharge ]
  • Spontaneous/Instrumental third stage of labour [ Time Frame: within 1 hours from delivery ]
  • Indication for Cesarean Section [ Time Frame: 1 minutes after delivery ]

Enrollment: 425
Study Start Date: March 2010
Study Completion Date: March 2014
Primary Completion Date: March 2014 (Final data collection date for primary outcome measure)
Arms Assigned Interventions
Experimental: INDUCTION of LABOUR

At enrollment patients assigned to the induction group will be admitted to the obstetric ward and will undergo induction of labour as described in the intervention section.

Once patient's Bishop score exceeds 7 or regular contractions are diagnosed, patients will be transferred to the delivery ward for artificial rupture of membranes (ARM) or Oxytocin augmentation as indicated.

Induction of labour will be performed by using dinoprostone 2 mg vaginally or dinoprostone 0.5 mg intracervically at 6-8h interval (up to 5 doses) or dinoprostone 10 mg vaginal device. Patients, in which cervical ripening does not occur (Bishop score < 7) after 5 attempts with PGE2, will be offered either oxytocin or Foley catheter induction or C-section, according to local protocols.

Patients enrolled in the conservative management arm will be followed up twice weekly for foetal wellbeing by Non-stress test and Biophysical profile. Patients will be followed up to 41+0 weeks.

Patients, who will not deliver by this gestational age, will be admitted for labour induction (see the above protocol). Induction of labour will be offered when non-reassuring foetal status is suspected. All patients in the conservative arm will undergo foetal weight ultrasound estimation prior to induction. Patients with estimated foetal weight over 4000 gr will be offered a C-section.

Detailed Description:

Gestational Diabetes Mellitus (GDM) is one of the most common complications of pregnancy and its incidence is estimated as around 7%. Babies born from women with GDM are significantly more exposed to perinatal risk. Furthermore in GDM pregnancies an increased C-section rate has been observed, mostly unjustified.

Strong evidence, based on prospective studies and randomized controlled trials, in favour or against the effectiveness and safeness of induction in women with GDM, are missing. The aim of the present study is to identify the best management for these women at term and provide evidence that could change the current clinical practice.

To reach this objective, 1760 eligible women will be recruited at 9 Teaching Hospitals (5 in Italy, 4 all over the world). Sample size has been estimated to demonstrate a difference between the two arms ≥ 6% (31% of C-section in the expectant group and 25% in the induction group; relative difference between the 2 groups equal to 20% in favor of induction; Kjos et al, 1993), considering an α error equal to 5% and 80% power.

Patients will be randomized to induction of labour (N=880) or expectant management (N=880). Data on maternal and neonatal outcomes will be collected at delivery and until maternal and neonatal discharge.


Ages Eligible for Study:   18 Years and older   (Adult, Senior)
Sexes Eligible for Study:   Female
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Maternal age > 18;
  • Singleton pregnancy in vertex presentation;
  • Gestational age between 38-39 weeks verified by LMP and first trimester ultrasound when available;
  • Women diagnosed with GDM in the current pregnancy [Diagnosis will be based upon abnormal 50 Gr. GCT (>140) followed by >2 abnormal indices in the OGTT (according to C&C criteria). Women with GCT>200 mg/dl will undergo 100 gr OGTT as well];
  • No other contraindications for vaginal delivery.

Exclusion Criteria:

  • Pre-gestational diabetes;
  • Prior C-section;
  • Suspected estimated fetal weight> 4000 gr. at enrollment;
  • Any known contraindications for vaginal delivery;
  • Uncertain gestational age;
  • Non-reassuring fetal status necessitating immediate obstetrical intervention (prompt delivery/prompt C-section);
  • Maternal disease complicating pregnancy and necessitating delivery (e.g Severe PET);
  • Bishop score >7 at enrollment;
  • Major fetal malformation.
  Contacts and Locations
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Please refer to this study by its identifier: NCT01058772

Helen Schneider's Hospital for Women - Rabin Medical Center
Petah-Tiqva, Israel, 49100
I Ostetricia Spedali Civili
Brescia, Italy, 25100
Department of Gynecology Perinatology and Human Reproduction
Florence, Italy, 50141
Unità Operativa di Ostetricia e Ginecologia - Ospedale Buzzi
Milan, Italy, 20154
Institute for Maternal and Child Health - IRCCS Burlo Garofolo
Trieste, Italy, 34100
Dipartimento di Discipline Ginecologiche ed Ostetriche - Università di Torino
Turin, Italy, 10126
Division Woman and Baby - UMC Utrecht/ Wilhelmina Children's Hospital
Utrecht, Netherlands, 3508 AB
Department of ob/gyn, Division of perinatology - University Medical Centre
Ljubljana, Slovenia, SI-1000
Sri Lanka
Department of Obstetrics and Gynecology - University of Colombo
Colombo, Sri Lanka, Colombo 08
Sponsors and Collaborators
IRCCS Burlo Garofolo
Study Director: Salvatore Alberico, MD Institute for Maternal and Child Health - IRCCS Burlo Garofolo
Study Director: Moshe Hod, MD Helen Schneider's Hospital for Women - Rabin Medical Center
  More Information

Responsible Party: Ronfani Luca, Dr, IRCCS Burlo Garofolo Identifier: NCT01058772     History of Changes
Other Study ID Numbers: RC 22/09
Study First Received: January 26, 2010
Last Updated: April 29, 2015

Keywords provided by IRCCS Burlo Garofolo:
Induced Labour
Expectant Management
C-section rate
Maternal Outcomes
Neonatal Outcomes

Additional relevant MeSH terms:
Diabetes Mellitus
Diabetes, Gestational
Glucose Metabolism Disorders
Metabolic Diseases
Endocrine System Diseases
Pregnancy Complications processed this record on April 24, 2017