obstuesday | to jab or not to jab?

This is a clinical scenario (or you can call it predicament) that a fellow O&G enthusiast brought up in her facebook status.

"28 yo G2P1 @ 31w, GDM with BSP 6.3/4.1/4.2/4.3
is it wise to start insulatard based on fasting dxt only?"
(the proper formal long version would be: a 28 years old lady Gravida 2 Para 1 at 31weeks gestation, with gestational diabetes mellitus coming in with blood sugar profile of fasting 6.3mmol/L, prelunch 4.1mmol/L, predinner 4.2mmol/L, prebed 4.3mmol/L, is it wise to start insulatard (insulin) based on fasting blood sugar only?)

Along the comments, there were some suggestions on starting oral hypoglycaemics and referrals to the medical team.

My answer to her was:

Acceptable level of fasting BSP is 5.3-5.7, i hold the threshold of 5.6
at the level of 6.3, authenticity of the BSP must be questioned thoroughly (her diet and how BSP was taken)

As the protocol suggest and the normalcy of all postmeal BSP, diet control with the proper referral to the dietician should be the first move before an abnormal repeat which indicates a stronger indication for the commencement of insulin therapy after counselling of the patient regarding the indications, benefits and risks (mainly iatrogenic hypoglycaemia) of it.

Having said that, jumping the gun to insulin without trial of diet control may be warranted if there are past supporting evidence for poor glycaemic control ie. first pregnancy was shrouded with GDM on high dose insulin, first child which is macrosomic or with abnormalities associated with high gestational glycaemia, or a grossly deranged MGTT results or ultrasonic evidence of fetal abnormalities associated with poor glycaemic control in this pregnancy (of which these details was not given)

Although insulin is the gold standard for good glycaemic control, in selected patients, which have poor social support,resistance to hospitalization for insulin, morbid fear of needles/pain related to it, or just refusal (or poor country with insufficient budget for insulin - this is input from Ainy Nor), OHA can be considered only if the administration properly guided by consultation with a MaternalFetal Consultant.

referral to medical or the endocrine team is reserved only for patients with poorly controlled BSP with high dose of insulin or patients with volatile glycaemic control with bouts of life-threatening hypoglycaemias.

(short) refer dietician, repeat 2weeks, if fasting BSP >5.6, start insulin after counsel patient.

to jab or not to jab?
think thrice before jab.

P.S. Happy Merdeka to all. I'm on call. Haiz.