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    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.

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    Mar 21
    2013

    'Gestational Diabetes' diagnosis

    Grace Joukhadar

    Hi Henci,

    I am currently 28 weeks pregnant.  I did the routine glucose tolerance test at 19 weeks and it came as a 9.2 after 2 hours.  My fasting level was 5.3, after 1hour it was 10 and then 9.2 after 2 hours.  The 'healthy' range should be no more than 8.0 after 2hours, so I don't consider this really a huge issue.  However I have been labelled with gestational diabetes and have been sent to see an OB to be closely monitored for baby size...they request I do an ultrasound every two weeks and based on results, they may recommend early induction. 

    I have done a good journal and taken my blood glucose level 4 times a day with a home kit.  My fasting numbers have always been in the healthy range (less than 5.5) and two hours after meals have also been in healthy range (less than 7.0)...(except when I have indulged a couple of times in high sugar/carbs where the highest was 8.3).  None of these figures worry me at all.  I don't feel they are excessively high at all. 

    I have read your articles on gestational diabetes and I really feel they 'gel' with me.  I do not find it necessary to do any extra ultrasounds or see the OB every two weeks, as I am concerned that the belief that I may have a big baby will alter the care I receive (induction etc) and also may affect my positive attitude to my birthing experience. 

    I live in a small town in Western Australia and only have access to one public hospital.  We have no home-birth doulas, which is my preference. 

    What is your opinion on receiving extra ultrasounds and OB check-ups and maintaining a food log/blood glucose levels...? My gut tells me not to worry about it at all...and no longer worry about taking my glucose level every day or keeping a food journal either. My mum had larger babies and so did my husband's mum..I think the possibility of having a larger baby is probably due to my race (Middle Eastern) and also my age (I will be 34 when the time arrives)

    Do you have any advice for me?

    Grace

    Henci Goer

    Blood sugars can rise as pregnancy progresses, so you will probably want to continue eating a diet that puts less stress on your pancreas and monitoring blood sugar as well as getting regular exercise. (Speaking of which, I hope that your OB has referred you to someone trained in advising pregnant women with a tendancy to high blood sugar on diet.) The bigger problem as I see it is that I have skimmed the evidence report underpinning the March 2013 U.S. National Institutes of Health conference on gestational diabetes. Nowhere is there support for frequent ultrasounds or for inducing labor as a means of improving outcomes. In fact, increased induction of labor is listed as one of the harms of being identified as a gestational diabetic. Here are the relevant passages from the report that came out of this conference:

    4. Does treatment modify the health outcomes of mothers who meet various criteria for gestational diabetes mellitus and their offspring?

     

    We also have very solid data that inducing for suspected big baby in general increases likelihood of cesarean without improving outcomes and that when the OB suspects the baby is large (estimated birth weight > 4 kg), the woman is much more likely to have a cesarean then when the baby actually is that big, but the OB didn't suspect it. Here are the studies establishing that induction for suspected big baby is not helpful:

    Irion O, Boulvain M. Induction of labour for suspected fetal macrosomia. Cochrane Database Syst Rev 1998(2):CD000938.

    Sanchez-Ramos L, Bernstein S, Kaunitz AM. Expectant management versus labor induction for suspected fetal macrosomia: a systematic review. Obstet Gynecol 2002;100(5 Pt 1):997-1002.

    Here are studies showing that what your OB thinks he knows about your baby's size can hurt you:

    Levine AB, Lockwood CJ, Brown B, et al. Sonographic diagnosis of the large for gestational age fetus at term: does it make a difference? Obstet Gynecol 1992;79(1):55-8.

    Melamed N, Yogev Y, Meizner I, et al. Sonographic prediction of fetal macrosomia: the consequences of false diagnosis. J Ultrasound Med 2010;29(2):225-30.

    Parry S, Severs CP, Sehdev HM, et al. Ultrasonographic prediction of fetal macrosomia. Association with cesarean delivery. J Reprod Med 2000;45(1):17-22.

    Sadeh-Mestechkin D, Walfisch A, Shachar R, et al. Suspected macrosomia? Better not tell. Arch Gynecol Obstet 2008;278(3):225-30.

    Weeks JW, Pitman T, Spinnato JA, 2nd. Fetal macrosomia: does antenatal prediction affect delivery route and birth outcome? Am J Obstet Gynecol 1995;173(4):1215-9.

    Weiner Z, Ben-Shlomo I, Beck-Fruchter R, et al. Clinical and ultrasonographic weight estimation in large for gestational age fetus. Eur J Obstet Gynecol Reprod Biol 2002;105(1):20-4.

    If you continue to have a healthy pregnancy and blood sugar remains under control, you may wish to refuse monitoring and induction--or any other tests or procedures for that matter--unless your care provider can demonstrate to your satisfaction that the benefits of undergoing them outweigh the potential harms.

    ~ Henci

    . . . One randomized controlled trial has shown higher induction of labor rates in women with GDM compared to normal controls. Women with GDM are more likely to undergo increased maternal and fetal monitoring. Subjective interpretation of ultrasound findings and fetal non-stress tests produces a high rate of false positives and is a factor in unnecessary induction of labor leading to failed inductions and cesarean delivery. Data regarding the effect of changing the diagnostic criteria for GDM on inductions are uncertain.

    Cesarean rates may be higher in women given the diagnosis of GDM, and it is uncertain whether treatment can mitigate this increase. Cesarean delivery is associated with a higher rate of short- and long-term complications.

    6. Given all of the above, what diagnostic approach(es) for gestational diabetes mellitus should be recommended, if any?

    . . . There also is evidence that treatment of women with GDM—diagnosed either by the one-step or two-step approach—may improve some outcomes. Outcomes that have been improved with treatment include the frequencies of macrosomia, large-for-gestational-age birth weight, shoulder dystocia, and hypertensive disease of pregnancy. Despite improvements in these intermediate outcomes, the frequencies of composite neonatal morbidity and cesarean delivery have not been consistently improved with treatment. Long-term outcomes for mothers and their offspring have not been improved in the few studies that have been performed.

    Grace Joukhadar

    Henci, thank you for this.  I read all your links and I feel very comfortable knowing that all the extra screening is unnecesary for me. I have seen my OB since I last wrote and he too thinks I am now 'low risk' based on how well my sugars are now with a more careful diet.  He does still recommend extra scans (which he admitted is simple his job and hospital policy to recommend), but I have politely declined.  He respects my decision which I am very pleased about. 

    I am now 33 weeks and feeling good and very excited.  Thank you for your response and always appreciate the links you make to research. 

    Thank you once again. I recommend your work to every pregnant woman I meet!

    Grace

    Henci Goer

    I am delighted to hear this! Let me know how everything goes.

     

    ~ Henci


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