Make a Donation
     Connect with UsFacebookTwitterYouTube
    Google Custom Search

    Questions? Ask Henci!


    Find out what other moms-to-be are asking. Join in the discussion with Henci Goer, whose expertise is determining what the research tells us best promotes safe, healthy birth. If you would like to contact Henci outside of the Ask Henci forum, send an email to Goersitemail@aol.com.

    You must establish a username and password to participate in the Ask Henci forum, click here to submit your request.


    Sep 25
    2012

    Gestational Diabetes Treatments....

    Amy Geraets

    I am 20 weeks into my 7th pregnancy and finding myself incredibly discouraged with my care providers approach to gestational diabetes. In my first 5 pregnancies, I passed the one-hour glucose test, but failed it by one-point in my sixth pregnancy. So, being the compliant patient I was at the time, I took the 3-hour test and failed miserably (course, I also just sat in the waiting room from one draw to the next not knowing it would be smart to be active instead). There is diabetes on both sides of my family, I was 38 at the time and I have a history of larger babies (8 pounds 6 ounces, 8 pounds 15 ounces and 9 pounds 1 ounce were my three largest). So, I continued to be a compliant patient and I followed all of their directions regarding diet, exercise and eventually, insulin. My son was born weighing 8 pounds 4 ounces. His initial blood sugar level was 40 and they climbed up from there. He was considered jaundiced and they sent us home with a biliblanket.

    Because of the gestational diabetes in his pregnancy, I was told I had to take the one-hour glucose test at 14 weeks. Unfortunately, it never occured to me to refuse it. I drank the glucola, went to my pre-natal appointment and returned to the lab one-hour later for my draw. It took the tech three pokes and 30 minutes to get blood out of me (finally succeeded in my hand). I failed the test by several points, but refused to take the 3-hour so they turned me over to the Diabetes and Pregnancy Care team whom I have been working with for the past 5 weeks (it took a week before I had test results and an appointment). Before meeting with them, I started keeping a food log and testing my glucose levels 4 times a day. For the past 3 weeks, they have been pressuring me to start insulin because my fasting levels are above 90. My fasting levels range from 85 to 111 with the majority of them falling between 90 and 100. So far, they are not concerned with my post-prandial numbers.

    I am incredibly hesitant to start on insulin at this point. I have been told the point of insulin is to reduce the risk of having a big baby and because I have a history of big babies to begin with, there is more reason for me to start on the insulin. I am not concerned about baby's size so much as baby's blood sugar levels at birth. I have been told the only side effect to insulin is the potential -- albeit quite rare -- for me to get hypoglycemic. I'm struggling with the guidelines they have established for fasting numbers (60-90) as they seem low and rigid. I'm quite concerned -- based on previous experience as well as those of friends and acquaintences -- about the amount of intervention that will be "recommended" as I progress through the pregnancy.

    Can you direct me to anything in particular regarding insulin therapy in pregnancy that would support not starting it at this point? would you agree with my care providers that it is in mine and baby's best interests to begin?

    Thank you so very much for your time and reply!

    Amy Geraets 

    Henci Goer

    Unfortunately, my focus has always been on what the research has to say on what best promotes healthy birth in women who are not experiencing pregnancy complications, and while I think that running mildly higher than normal blood sugar levels after eating--what has come to be called "gestational diabetes," but should more properly be called "carbohydrate intolerance of pregnancy"--falls in that category, your situation does not. The fact that your blood sugar is still high after an overnight fast and that this was the case as early in pregnancy as 14 wks indicates a more serious problem.

    If I understand your concern correctly, you feel that using insulin during the last pregnancy turned out to be problematic for the baby. He was smaller than your other children have tended to be, which suggests that he may not have been getting all the fuel he needed for growth, and his blood sugar was low at birth, which tends to support that theory. I think the way to go here is to work with your care team in making shared decisions. I would raise these concerns and point out that, in fact, it looks like you may well have been hypoglycemic and that it is important for you and your team to come up with a nutrition, exercise, and insulin regimen that keeps your blood sugar in the higher end of normal range. If there isn't a doctor who specializes in diabetes on the Diabetes and Pregnancy Care team, I would insist on a referral. I say this because my brother is an endocrinologist, and Type 1 diabetes runs in my family, so I am very aware that insulin regimens can be tricky, especially so in pregnancy when metabolism is more volatile, and needs change as pregnancy progresses. I have heard him rant more than once about the problems that can arise from having nonspecialists such as internists or obs manage diabetes. As for other interventions, you have the right to make informed decisions, which of necessity must encompass informed refusal as well as informed consent. "Informed Decision-Making" on the Childbirth Connection website can help you with this. 

    I hope this helps.

    ~ Henci  

    Amy Geraets

    Henci, 

    Thank you so very much for your reply. I appreciate the time you take to help those of us looking for answers via this forum. After I posted my question, I was able to spend some time reading many of the other threads on gestational diabetes on this forum which I found incredibly helpful. I had a standard 20-week ultrasound last week that showed baby is normal (based on what they can tell at this point). The doctor told me they now manage their GDM patients with weekly ultrasounds and twice weekly NST's beginning at 32-weeks. She also said they do not allow their insulin-dependent mothers to go beyond 39-weeks due to the risk of the placenta degrading as well as stillbirth. In that particular practice, there is not an endocrinologist that monitors moms with GDM. I appreciate your comments re: your brother and his rants. I do have an endocrinologist to monitor my thyroid and he has told me he is not at all concerned with my glucose levels at this point. However, when I shared that information with my care providers, I was told endocrinologists don't work enough with GDM and they don't want him following me. 

    You mentioned that my concern seemed to be derived from the effects of insulin on my newborn in my last pregnancy and I suppose that is the gist of it. I would prefer to see the focus on how to avoid low blood sugars in baby rather than focusing on baby's potential size. At this point, I really just want a care provider that will listen to me as a patient when I have questions/concerns about their protocols. Tomorrow I see a different doctor and will see if there's a better fit. 

    Henci Goer

    I hope the new doctor is a better fit. I would be more than a little leery of a doctor who told me to ignore a specialist's opinion based on the blanket statement that "endocrinologists don't work enough with GDM." Were I in your shoes, before I followed the diabetic team doctor's advice, I would want to explore with my endocrinologist how much experience he had caring for diabetic patients in general and pregnant diabetics who had no diabetes complications in particular. I would also want to know the reasons why he is unconcerned about your sugar levels and what sugar levels he would find concerning and why. And I would want to see if he shared the opinion of the diabetes team dr that an otherwise healthy insulin-dependent diabetic who had blood sugar under good control was at heightened risk of stillbirth.

    It isn't as if the regimen the diabetes team doctor is recommending is harmless. NSTs have a high false-positive rate (the test says there is a problem but there isn't). This means they can lead not only to an unnecessary induction but, given that the cervix is unlikely to be ready and the dr anxious, to one that is likely to end in cesarean surgery. The same holds true for ultrasounds to estimate the amount of amniotic fluid, and ultrasounds to estimate fetal weight have consistently been shown to increase the odds of cesarean delivery without improving outcomes. Planned induction at 39 wks runs the risk that the cervix is not yet ready, which increases the likelihood of cesarean even in women with only prior vaginal births, although not to the degree that it does in first-time moms. If there is real reason for concern, then the potential benefits of monitoring and planned induction doubtless outweigh the risks, but were I you, I would want to feel confident that was the case before I agreed.

    ~ Henci

    Amy Geraets

    Hello Henci, 

    I am much more comfortable with the new doctor and so grateful I actually followed my instincts and sought out another provider! He was much more respectful of me as an individual patient. He answered my questions -- and even joked with me at one point which was a tremendous blessing to me. He's more relaxed and friendly than the first peri I saw and I desperately needed that. While he does want to see my levels well-controlled, he was not nearly as "gloom and doom" as the first doctor and diabetes care team. He wants to do a growth scan every four weeks beginning at 34 weeks as well as NST's twice weekly beginning at 32 weeks. However, I believe he would be willing to compromise on the frequency of those tests. Finally, he did not say I have to be induced by 39 weeks and, in fact, did not mention inducing or a "mandatory" c-section at all. So very different from my appointment the week before. 

    Thank you so very much for your responses to my questions as well as your work for pregnant mamas and their babies. You are a blessing to us all!

    Amy

    Henci Goer

    This is great news! Thank you for your kind words, and I'm glad to have been of assistance.

    ~ Henci


    All Times America/New_York

    Forum Disclaimer

    Please note that this Forum is intended to help women make informed decisions about their care. The content is not a substitute for medical advice.



    Copyright 2014 Lamaze International. All rights reserved. Privacy Statement | Terms of Use