The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
|
Orgasmic Birth -- the documentary! ABC's 20/20 will be airing a segment about Orgasmic Birth on May
16th for their special Mother's Day show.
Interviews with Christiane Northrup, MD, Ina May Gaskin, MA, CPM, Sarah J Buckley, MD, Marsden Wagner, MD Joyous, sensuous and revolutionary, this pioneering film will compel many to reexamine their perceptions about childbirth. Viewers will understand how the use of normal, undisturbed birthing methods can aid the health and well-being of future generations. |
Management
of Diabetes in Pregnancy by Yvonne Cheng, MD, MPH
Gestational
Diabetes from The
Brewer Pregnancy Diet
Diagnosis of insulin resistance and/or prediabetes in the general population can point to several interventions that may reduce the risk of eventually developing full-blown diabetes and/or cardiovascular disease. That is pretty important.
In pregnancy, the reason for doing an early (before 20 weeks) diabetes screen is to diagnose pre-existing diabetes. Ideally, real diabetes would be picked up before even getting pregnant, because high sugars in the embryonic stage are teratogenic (as much as a 10% rate of major congenital anomalies including heart and kidney stuff). Think about it this way - blood with elevated glucose is hyperosmolar and nutrients can't be transported properly across the cell membranes. This sets off an inflammatory response as well, and the placenta doesn't embed properly, hence the higher association with pre-eclampsia and abruption later on (in uncontrolled pre-gestational diabetics). The earlier the diagnosis is made, the earlier you can try to correct the situation.
The risk factors that would cause me to want to get an early glucose
test in pregnancy are those for diabetes in anyone - obesity as defined
by elevated BMI, history of prior glucose intolerance, PCOS (or hx of PCOS
like symptoms), prior gestational diabetes, prior baby > 5000 gms.
I am not real thrilled with the idea of testing everyone at 28 weeks, but
there are certainly some moms who I want to test early and repeat the test
on (if first test was normal). I have also been very surprised to
find significant glucose intolerance in a couple of extremely thin Asian
women recently. [Ed: I've heard a number of midwives observe that Asians
are much more likely to be diagnosed as gestational diabetics; is this
because we're using studies on non-Asians to establish blood sugar levels
that may or may not be relevant for Asians?]
I like to do a hemoglobin A1C with the initial labs for all my clients
to see what her glucose levels were like before pregnancy.
Gestational
diabetes: the consequences of not treating.
Langer O, Yogev Y, Most O, Xenakis EM.
Am J Obstet Gynecol. 2005 Apr;192(4):989-97.
OBJECTIVE: Untreated gestational diabetes mellitus carries significant risks of perinatal morbidity at all severity levels; treatment will enhance outcome. STUDY DESIGN: A matched control of 555 gravidas, gestational diabetes mellitus diagnosed after 37 weeks, were compared with 1110 subjects treated for gestational diabetes mellitus and 1110 nondiabetic subjects matched from the same delivery year for obesity, parity, ethnicity, and gestational age at delivery. The nondiabetic subjects and those not treated for gestational diabetes mellitus were matched for prenatal visits. RESULTS: A composite adverse outcome was 59% for untreated, 18% for treated, and 11% for nondiabetic subjects. A 2- to 4-fold increase in metabolic complications and macrosomia/large for gestational age was found in the untreated group with no difference between nondiabetic and treated subjects. Comparison of maternal size, parity, and disease severity revealed a 2- to 3-fold higher morbidity rate for the untreated groups, compared with the other groups. CONCLUSION: Untreated gestational diabetes mellitus carries significant risks for perinatal morbidity in all disease severity levels. Timely and effective treatment may substantially improve outcome.
[Ed: The untreated group was women who started care very late in pregnancy. One can assume that these are women who were not getting a lot of health care before pregnancy either. It occurs to me that although these women were diagnosed as having gestational diabetes, nothing was done postpartum to ascertain whether any of these women were actually overtly diabetic, a category excluded from the other study groups. Given that this study was an attempt to use a case-control study to come as close to a RCT as ethically possible, it would have seemed obvious to repeat the OGTT at postpartum intervals to separate out the results from women who were frankly diabetic, and it would have been extremely useful to know whether the slight difference in stillbirths rate was associated with undiagnosed true diabetes. The average age of the untreated GDM group is 27.6, compared to the average age of the treated GDM group, 29.1 years. This hints at an increased incidence of true diabetes in the former group. (This "oversight" is similar to the error made in the Australian study of women who weren't tested for GD; it seems obvious to me that postpartum testing would have provided some really useful additional information - maybe this is information that GD devotees don't want to know?)
The primary morbidity in this study is the baby's weight, which further affects 3 other co-morbidities: macrosomia, LGA and Ponderal Index. If a higher birth weight is a bad thing, then all women should be treated for GDM since the untreated nondiabetic group had an average birth weight that was 45 grams (1.6 ounces) higher than the treated GDM group. Or maybe GDM treatment is really making the babies smaller because it's depriving them of calories they need to grow normally?
I'm always skeptical of the hypoglycemia findings in these studies because hypoglycemia is irrelevant in a newborn who is otherwise normal, i.e. able to maintain body temperature (without the artificial cooling cause by premature bathing). Babies who were starved in utero will weigh less, and they will not have as much brown fat to metabolize to sustain the brain in the hours immediately after birth; thus they must metabolize glucose stores, possibly depleting them more quickly than the babies metabolizing their brown fat.
Interesting side note - most of the women in this study were Hispanic,
and the average gestational age at the time of birth was 39 weeks, fairly
close for all study subject groups.]
Exercise
may prevent pregnancy-related diabetes - 5/16/05 - (Reuters Health)
- Engaging in regular vigorous physical activity before pregnancy reduces
the risk of developing pregnancy-induced diabetes (a.k.a. gestational diabetes),
according to researchers.
Treating diabetes in pregnancy curbs complications - 6/13/05
NEW YORK (Reuters Health) - Treating women who develop diabetes in pregnancy (gestational diabetes) reduces the rate of serious complications without increasing the rate of cesarean delivery, new research shows.
Although the risks related to gestational diabetes are well known, it has been unclear if screening and treatment to lower maternal blood sugar levels can reduce these risks, Dr. Caroline A. Crowther and her associates comment in their report, published in The New England Journal of Medicine.
The Journal released the article early to coincide with the authors' presentation at the American Diabetes Association meeting in San Diego.
To evaluate the effects of treating gestational diabetes, Crowther, with the University of Adelaide in Australia, and her associates studied women with signs of gestational diabetes between 24 and 34 weeks into pregnancy.
By random draw, a total of 490 women were assigned to intensive treatment, including dietary advice, blood sugar monitoring, and insulin therapy, the authors note. Another 510 patients were assigned to routine care.
Serious complications among the infants -- death, shoulder impeding delivery, bone fracture, and nerve palsy -- were significantly more frequent in the routine-care group (4 percent versus 1 percent) after accounting for factors such as maternal age, race or ethnic group, and number of previous pregnancies.
A higher percentage of infants in the intervention group were admitted to the neonatal nursery (71 percent versus 61 percent), and women in the intervention group were more likely to undergo labor induction (39 percent versus 29 percent), both of which the investigators attribute to the treating physicians' knowledge of their gestational diabetes.
The rates of cesarean section were similar in the two groups.
At three months after delivery, women in the intervention group had lower rates of depression and higher scores on quality of life scales.
The report "provides some long-awaited evidence to support the use of screening and treatment for women at risk," Drs. Michael F. Greene and Caren G. Solomon, from Massachusetts General Hospital in Boston, write in an accompanying editorial.
SOURCE: The New England Journal of Medicine, June 16, 2005.
Effect
of Treatment of Gestational Diabetes Mellitus on Pregnancy Outcomes.
[Full-text
article]
Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS.
N Engl J Med. 2005 Jun 12; [Epub ahead of print]
Background We conducted a randomized clinical trial to determine whether treatment of women with gestational diabetes mellitus reduced the risk of perinatal complications. Methods We randomly assigned women between 24 and 34 weeks' gestation who had gestational diabetes to receive dietary advice, blood glucose monitoring, and insulin therapy as needed (the intervention group) or routine care. Primary outcomes included serious perinatal complications (defined as death, shoulder dystocia, bone fracture, and nerve palsy), admission to the neonatal nursery, jaundice requiring phototherapy, induction of labor, cesarean birth, and maternal anxiety, depression, and health status. Results The rate of serious perinatal complications was significantly lower among the infants of the 490 women in the intervention group than among the infants of the 510 women in the routine-care group (1 percent vs. 4 percent; relative risk adjusted for maternal age, race or ethnic group, and parity, 0.33; 95 percent confidence interval, 0.14 to 0.75; P=0.01). However, more infants of women in the intervention group were admitted to the neonatal nursery (71 percent vs. 61 percent; adjusted relative risk, 1.13; 95 percent confidence interval, 1.03 to 1.23; P=0.01). Women in the intervention group had a higher rate of induction of labor than the women in the routine-care group (39 percent vs. 29 percent; adjusted relative risk, 1.36; 95 percent confidence interval, 1.15 to 1.62; P<0.001), although the rates of cesarean delivery were similar (31 percent and 32 percent, respectively; adjusted relative risk, 0.97; 95 percent confidence interval, 0.81 to 1.16; P=0.73). At three months post partum, data on the women's mood and quality of life, available for 573 women, revealed lower rates of depression and higher scores, consistent with improved health status, in the intervention group. Conclusions Treatment of gestational diabetes reduces serious perinatal morbidity and may also improve the woman's health-related quality of life.
What really catches my eye is that in this most recent study, they finally admit that they have not previously had good evidence to support the use of screening and treatment for women at risk. So they come up with this one study and claim that now this is the gold standard of GD studies. I don't know . . . the credibility of the medical community on this issue is very poor . . . are they just flogging a dead horse or is this real science?
I also really have to wonder at their eagerness to make the full text of this article available to the general public. They won't do this for really important articles about GBS or VBAC, but they'll do it for GD? Is this a journal article or advertising for high-intervention obstetrics?
And suddenly obstetrics is concerned about the quality of a woman's birth experience? Why isn't a woman's dissatisfaction with a bad birth experience considered a "serious perinatal outcome" when it comes to episiotomies, unnecessary cesareans and the unavailability of VBAC care?
What happens when you look at the details of this study?
Two stillbirths were unexplained intrauterine deaths at term of appropriately grown infants, and the other, at 35 weeks’ gestation, was associated with preeclampsia and intrauterine growth restriction. One infant had a lethal congenital anomaly, and one infant died after an asphyxial condition during labor without antepartum hemorrhage. There was no significant difference in the rates of shoulder dystocia between the intervention and routine-care groups (1 percent and 3 percent, respectively) (Table 2). No infant in the intervention group had a bone fracture or nerve palsy, whereas in the routine-care group, one infant had both a fractured humerus that was not related to a difficult birth and a radial-nerve palsy, one infant had Erb’s palsy related to shoulder dystocia, and one infant had Erb’s palsy alone (Table 2).Five neonatal deaths in the untreated group sounds terrible, but look at the specific reasons for death.
"Two stillbirths were unexplained intrauterine deaths at term of appropriately grown infants" - in theory, the babies would have been macrosomic if their mothers' glucose levels were unusually high.
". . . and the other, at 35 weeks’ gestation, was associated with preeclampsia and intrauterine growth restriction" - and this is related to gestational diabetes . . . how?
"One infant had a lethal congenital anomaly" - are the authors saying that GD care prevents congenital anomalies?
". . . and one infant died after an asphyxial condition during labor without antepartum hemorrhage" - it would be helpful to know more details about this case . . . was there a concealed placental abruption? Was there a cord accident? Did the mother's blood pressure drop drastically after she got an epidural? Is there any evidence that this death could have been prevented by GD care?
"There was no significant difference in the rates of shoulder dystocia between the intervention and routine-care groups (1 percent and 3 percent, respectively) (Table 2). No infant in the intervention group had a bone fracture or nerve palsy, whereas in the routine-care group, one infant had both a fractured humerus that was not related to a difficult birth and a radial-nerve palsy, one infant had Erb’s palsy related to shoulder dystocia, and one infant had Erb’s palsy alone (Table 2)." - It would be helpful to know if the case of Erb's palsy related to shoulder dystocia resolved spontaneously, as this is the only negative outcome that is plausibly related to GD care.
I notice that no retrospective testing of the bereaved mothers was mentioned. It would have seemed like really good science to do a hemoglobin A1C test on these mothers to get a good sense of their glucose levels in the preceding 3-4 months. Better yet, all women in the study should have had the same prenatal testing done so that we would know whether these bad outcomes were even occurring in women who met treatment criteria for GD.
Each of these deaths is surely tragic, but it is intellectually dishonest for the authors to imply that they would have been prevented by glucose monitoring or insulin injections. It is plausible that the 35-week death from pre-eclampsia complications might have been prevented by better overall nutrition, which is often the best side effect of GD "treatment".
If it didn't seem too outrageous to be even remotely possible, I would suggest that there were actually multiple "non intervention" groups, and the researchers simply chose the one with the worst outcomes to use as the control group.
It is mildly ironic that the hypoglycemia was lower in the "untreated" group. So much for the big concerns about rebound hypoglycemia as a consequence of untreated GD.
It is refreshing that the article considers cesarean birth to be a perinatal complication, rather than simply "an alternative to vaginal birth".
My conclusion: Women really need caring support during their pregnancy,
and if this is provided through diet counseling associated with GD treatment,
that's better than nothing. How about trying care that's really focused
on supporting the quality of the mother's experience of pregnancy/birth/postpartum,
such as is routine in midwifery care? I'll bet that would really
reduce depression and improve health status!
Ultrasound
Measurement of Fetal Growth Facilitates Management of Gestational Diabetes
CME [Medscape registration is free]
Long-held prenatal beliefs challenged - [2/2/04] Screening for gestational diabetes may be another example of how resources could be better spent.
"An entire generation of obstetricians, almost two generations of obstetricians, have bought into the idea that screening for gestational diabetes is important and serves to improve pregnancy outcomes," says Ohio State OB-GYN Mark Landon.
But it's unclear whether treating mild cases, usually with diet, is
beneficial, and some research suggests it could have drawbacks, such as
an unnecessarily higher rate of C-sections. Landon leads an ongoing, government-sponsored
study to determine the effectiveness of treating the condition.
Screening
for gestational diabetes: a summary of the evidence for the U.S. Preventive
Services Task Force. [Medscape has an expanded
abstract, halfway down the page. Medscape registration is free]
Brody SC, Harris R, Lohr K.
Obstet Gynecol. 2003 Feb;101(2):380-92.
These authors wrote another article - Summary
of the Evidence - Screening for Gestational Diabetes
"Screening for GDM is contentious. The reason for this controversy
is largely a lack of high-quality research addressing the central issues."
Medscape offers
an excellent summary
Oct., 2003 - From The UK's National
Institute for Clinical Excellence (NICE)'s CG6
Antenatal care - routine care for the healthy pregnant woman: "The
evidence does not support routine screening for gestational diabetes mellitus
and therefore it should not be offered." (on the bottom of page 4).
Gestational Diabetes Mellitus Diagnosed With a 2-h 75-g Oral Glucose Tolerance Test and Adverse Pregnancy Outcomes [Medscape registration is free]
"GDM based on a 2-h 75-g OGTT defined by either WHO or ADA criteria
predicts adverse pregnancy outcomes." and "Finally, our study, being observational
in nature, cannot estimate gains to be made through diagnosis and treatment
of this condition. "
The Society of Obstetricians and Gynecologists of Canada (SOGC) issued
new guidelines - it is no longer advisable to screen every pregnant patient
for gestational diabetes because the benefits of screening have not been
proven scientifically. [September 17, 2002 Volume 38 Issue 33 Medical
Post.] Here are their 2002
Clinical Guidelines.
The American Diabetes Association released new
recommendations for screening and retesting of diabetes. The ADA now
recommends that women at low risk not be screened. (Here is their
outdated
information sheet.)
Debate over
screening for gestational diabetes by Malcolm Griffiths
BMJ 1998;316:861 ( 14 March ) - Letters
From: C-upi@clari.net (UPI / Stories of modern science...from UPI.,
Bill Clough (UPI))
Organization: Copyright 1997 by United Press International ** via
ClariNet **
Date: Thu, 27 Nov 1997 0:51:14 PST
BOSTON, Nov. 26 (UPI) -- Toronto researchers say too many mothers-to- be are getting unnecessary blood tests for pregnancy related diabetes.
The scientists say they have developed a simple screening technique to determine who is really at risk. They estimate the technique could cut the number of such tests by one third, eliminating hundreds of thousands of tests a year.
The new screening method, an evaluation based on a woman's height, weight, age and race, would also limit false positive readings, which lead to more complicated, time consuming tests, the scientists say.
In a study in the New England Journal of Medicine, investigators from the University of Toronto used the method to screen more than 3,000 pregnant women, who were also given the standard blood test for diabetes. They found that nearly 35 percent did not need the blood tests.
Dr. C. David Naylor says the new method is "dead simple," and "picks up just as many cases as universal screening."
Naylor, a professor of medicine at the University of Toronto, also says the study found that false positives dropped about 5 percent with the new screening method.
Pregnant women are usually screened for gestational diabetes with a simple blood test, which costs around five dollars and takes an hour.
But if a women gets a false positive from the first test, she is then given an oral glucose tolerance test.
Naylor says this involves a two-day high-carbohydrate diet, fasting and giving blood four times during three hours in a blood-letting station. The woman also must drink large, sometimes nauseating, amounts of sugar water.
Naylor says, "This falls under the heading of serious nuisance for women who are already busy enough."
In a NEJM editorial, Dr. Michael F. Greene of Massachusetts General Hospital says that the study supports the American College of Obstetricians and Gynecologists and the American Diabetes Association, which call for selective screening.
But he says, "busy obstetricians are unlikely to wend their way" through a complex diagnostic screen for each pregnant woman.
(Written Mara Bovsun in New York)
Selective
Screening for Gestational Diabetes Mellitus
Naylor CD, Sermer M, Chen E, Farine D
N Engl J Med 1997 Nov 27;337(22):1591-1596
I particularly recommend checking out the editorial. It's quite amusing, really. Well, it would be funny if it weren't so sad. The editorial acknowledges that GD testing is often unreproducible and "treatment" doesn't produce any statistically significant changes in outcome, but it still struggles to emphasize how very important it is to test as many women as possible.
Probably because of the combination of the low incidence of gestational diabetes and the extremely low incidence of perinatal mortality in developed countries, it has not been possible to demonstrate an association between gestational diabetes and perinatal mortality. More problematic has been the inability to demonstrate clearly and consistently that any intervention significantly reduces these risks. Although in some trials aggressive insulin therapy has reduced the incidence of macrosomia and operative delivery, (3) in others it has not. Despite some lingering uncertainties about the utility of making the diagnosis, (4) gestational diabetes mellitus is a real disorder, and obstetricians are obliged to recognize it.Maybe it's just my reading of it.
And I'd appreciate any insight into how the author of that editorial can claim that one of the reasons we don't see statistically significant changes in outcome because of GD "treatment" is that neonatal mortality is so low. Wouldn't a lower mortality rate just highlight any changes in outcome from GD "treatment" because the relative improvement would be greater?
A lot of this just confirms what Henci Goer says in her Emperor's
New Clothes article on GD.
Gestational hypoglycemia confers favorable obstetric outcome - 6/26/05 - Determining the perinatal significance of hypoglycemia during a 100 g glucose tolerance test in pregnant women. . . . Pregnant women who experience hypoglycemia during a glucose tolerance test have a lower rate of gestational diabetes and lower neonatal birth weights than those with higher glucose levels, study results show. . . . "Based on our study, however, the patient can be reassured that such a phenomenon is not unusual, is transitory, and carries a favorable prognosis in terms of obstetric outcome," the team concludes.
Hypoglycemia during
the 100-g oral glucose tolerance test: incidence and perinatal significance.
Weissman A, Solt I, Zloczower M, Jakobi P.
Obstet Gynecol. 2005 Jun;105(6):1424-8.
CONCLUSION: The incidence of reactive hypoglycemia during the 100-g
oral glucose tolerance test in our population is 6.3%. Women who experience
hypoglycemia during the test have a significantly lower incidence of gestational
diabetes and neonatal birth weights.
Gestational
diabetes by Henci Goer - What is gestational diabetes? An updated
version of her classic work!
Article by Henci Goer on the Uselessness of Standard Management of Gestational Diabetes
Testing for and treating "gestational diabetes" does not improve outcomes.
It does not reduce miscarriage and stillbirth rates, and it does not reduce
complications typically associated with macrosomic babies. All it does
is identify women who might be at risk for developing diabetes later in
life. This has no implications for the current pregnancy.
Gestational Diabetes: A Diagnosis Still Looking
for a Disease? by Michel Odent, M.D.
All About
Gestational Diabetes by Kmom
A Mother Summarizes Her Reasons for Declining
Glucose Screen
Treatments for gestational diabetes and impaired glucose tolerance in pregnancy (Cochrane Review)
"Reviewers' conclusions: There are insufficient data for any reliable conclusions about the effects of treatments for impaired glucose tolerance on perinatal outcome.."'
Childbirth
Connections makes the entire chapter available.
In that BMJ discussion, Soares makes it sound as if he believes that
screening has no particular benefits for pregnancy but could be useful
as part of a general health management approach. If this is the case, then
they should be urging screening for everyone, not just for pregnant women.
Oh, and while we are talking about evidence based practice, is there
any good evidence that glucose screening and defining women as "gestational
diabetic" has any impact on outcome?
At a conference I attended last summer, a presentation was made on GDM. Among the issues was the re-calibrating of cutoffs which is apparently in the works and moving through committees at ACOG and will be published soon. But the presenter made the point that GDM testing and identification has changed neonatal and maternal outcomes only in the ability to further identify the sub-set of the GDM population that requires insulin. This is why they want to "tighten" the cutoffs, so that more insulin-requiring GDM can be found.
The notes are at my office, but compelling information was presented about the difference in neonatal and maternal outcomes when more insulin-requiring moms were identified.
So we should be thinking about GDM this way:
Notes from a GDM presentation by Steven Gabbe,
M.D. in 1990
At 17 weeks my glucose test came back 105, and they keep saying, "Well,
let's hope that it stays low in the next test". It would be really difficult
for me to find time for the 3 hour test. Of course if it was the best thing
to do for my baby, I would, but is it? What would the reasoning be for
refusing the second test?
The reasoning for declining the second test would be the same as for declining the first test:
Testing and "treatment" doesn't improve outcomes.
Say that 100 times until you really believe it, because you'll be made
to feel that you don't love your baby if you won't let them do everything
they want to you, even if they have no evidence that this test will help
you or your baby.
When my 1st baby was born, he weighed 9 lbs 10 ozs. When the neo-natologist
came in to talk to me about his treatment, she said that babies of mothers
with GD often aspirate meconium.
Oh, I think this one takes the cake.
Yes, there is an association between higher blood sugar levels and larger babies. There is also an association between starvation and smaller babies.
Yes, there is an association between older/larger babies and meconium, because mature babies start moving their bowels in utero. Small babies also get "meconium aspiration syndrome", but they call it pneumonia if there's no meconium present, so the "association" doesn't show up on paper.
And, yes, there is an association between meconium and meconium aspiration syndrome, as in, if there's no meconium, they won't call pneumonia "meconium aspiration syndrome" - they'll just call it pneumonia. (However, research shows that removing the meconium doesn't reduce "meconium aspiration syndrome". Hmmmmm.)
Now, if they could just show that "association" has anything to do with cause and effect, then they'd have something to talk about.
I have never read anything remotely reliable about a cause-and-effect
relationship between true diabetes and meconium aspiration syndrome (really
pneumonia), and it is really really hard to imagine how high blood sugar
levels in a mom could cause lung defects in the baby. I just did
a quick search through my files and could find absolutely no mention of
meconium having anything to do with "gestational diabetes".
It seems irresponsible to me when people say that high blood sugar during
pregnancy isn't a problem. And why would they argue against it, anyway,
when the treatment is mostly just eating a more healthy diet and getting
lots of exercise.
Yes, pathologically high levels of blood sugar can cause problems for mother and babies. The blood sugar levels used to define gestational diabetes are not pathologically high. The placenta specifically produces hormones to raise a pregnant woman's blood sugar levels. Many birth professionals throughout the world recognize this as a normal and healthy aspect of pregnancy.
Yes, a good diet and getting lots of exercise are good things for anybody, and especially for a pregnant woman. True informed consent guidelines dictate that this is exactly what I tell women. I don't lie to them about complications that might result if they don't follow my advice.
I am not arguing against eating well in pregnancy.
I am arguing about mis-representing research on the subject. I am arguing
against the erosion of self-confidence and the medical system's assertions
that women with "gestational diabetes" couldn't grow a healthy baby without
them. I am arguing against the fallacy that testing for and treating
"gestational diabetes" is going to improve a woman's pregnancy outcome.
What makes you think that treatment for "gestational diabetes" increases your chance of VBAC? If someone has told you this, I suggest you ask for references to the studies; I don't think they exist.
Certainly, eating less is likely to decrease the size of your baby, but how is this going to increase the chance of VBAC? It's easy to think that a baby that weighs less will have a smaller head and thus be easier to birth, but this isn't the case.
What happens to a two-year-old who eats more food than they need? Do they grow taller or have a bigger head? No, they put on extra subcutaneous fat. What happens to a two-year-old who doesn't eat as much food as they need? They will probably be skinny. If they're getting way less food than they need, their growth may be stunted and they may not reach the full adult height that their genes dictated.
Restricting your food intake isn't going to result in a baby with a smaller head unless you're starving yourself. For women who are close to starvation levels, their baby may have a condition called "brain-sparing IUGR - brain-sparing IntraUterine Growth Retardation". This is where a baby isn't getting enough nutrients so sends them primarily to the head, resulting in a normal head size with a grossly reduced body size.
Notice that the word "macrosomia" means "big body", not "big head". It's no more difficult to birth a fat baby than a skinny baby, given the same size head and shoulder girdle. Fat flows and conforms to the shape of the birth canal in a way that bones cannot.
Yes, women who are "treated for gestational diabetes" may grow a baby that weighs 6-8 ounces less than it otherwise would. But the reduction is in the baby's body size and fat reserves, rather than in head size. How is this going to increase your chances for a VBAC?
It doesn't take a great stretch of the imagination to wonder how "treatment for gestational diabetes" actually increases risk of a cesarean. Women diagnosed with GD typically experience a loss of faith in their ability to grow and birth a healthy baby. Every time they measure their blood sugar or chart their food intake or inject insulin to themselves, this is a message to their body and their subconscious that there's something wrong with their body. This disempowers them at a time when feeling their power is exactly what they need in order to give birth. This loss of faith makes them more vulnerable to being pressured into making choices that aren't in their best interests, such as a pitocin induction. They may be treated as high-risk during their labor, which increases the risk of c-section.
So, I'd be curious to hear your chain of reasoning as to how treatment for GD will increase your chance of VBAC. A reference to a study would be well received.
There are many ways to improve your chances of a VBAC: it is well documented that hiring a midwife increases your chances, but you may not be able to take advantage of midwifery care if you've been diagnosed as having GD. I don't have evidence about the increased chances of a VBAC if you plan a homebirth, but I know nobody does cesareans at home.
It is well recognized that squatting opens the pelvis 20-30%. If your
care provider doesn't support squatting during pushing (lending new meaning
to the phrase "supported squat"), I would suggest that putting energy into
changing this would do a lot more for your chances of VBAC than restricting
food intake.
From - Obstetrical Ultrasound Measurements (Creighton University Medical Center):
Head size is determined largely by brain growth which is relatively independent of nutritional (maternal/placental insufficiency) growth retarding processes, and head growth is often relatively "spared" in such growth retardation. When the head growth is retarded, it is often the result of non-nutritional "symmetric growth retardation" associated with genetic, toxic, or infectious damage to the fetus.
DIET FOR THE PREVENTION OF OVERGROWTH OF THE CHILD
We have learned that it is impossible to influence the size of the child through dieting the mother. Short of actual famine there is no effect from reduction or alteration of the food. The great hunger experience in Germany during the War blockade proved this. The babies were as large and as rosy as ever -- even when the mothers were half starved. Still some physicians believe it can be done.
Joseph DeLee AM, MD, 'Obstetrics For Nurses' -- 1937
Cow's Milk Protein Linked to Diabetes
You say glycosuria is a normal finding of pregnancy?! At what
point is the level NOT normal?
Yes, I did say that glycosuria is oftentimes a normal finding of pregnancy.
We see women with 4+ glucose on dipstick urine who have perfectly normal
bloodsugars.
I have had her do random sugars (all wnl) and we did a GTT at 28 weeks
which consisted of a FBS followed by Anne Frye's high sugar breakfast and
then we did 1 and 2 hour post-prandials all again wnl.
I have no idea what Anne Frye's high sugar breakfast is. However, normal
FBS, normal postprandial glucoses, and normal glucoses after high glucose
load pretty much rule out gestational diabetes.
About Preparing
for the Glucose Tolerance Testing
I am still very curious as to why she is running such high glucose on
the dipsticks??? Any ideas??
Increased renal blood flow, increased glomerular filtration, decreased
reabsorption of glucose all result in glycosuria as a normal pregnancy
finding. She is running high glucose on dipstick simply because she is
a pregnant woman. There is nothing wrong with this woman!!! You
have checked her blood glucoses and they are fine....therefore, her glycosuria
is attributed to the normal physiologic renal changes of pregnancy.
Why isn't it clear to everyone that this woman's kidneys are filtering the glucose through rather than attributing it to elevated blood sugar despite the normal tests?
Renal function changes remarkably in pregnancy. Glomerular filtration
rate increases nearly 50%. The capacity of the renal tubules to reabsorb
filtered glucose decreases. Because more glucose is reaching the kidney,
and less is being reabsorbed, glycosuria is a normal finding in
pregnancy.
I think one can substantiate the statement "occasional glycosuria -
trace to one plus - is normal in pregnancy", but large amounts and on every
occasion is pretty unusual.
I would have to disagree (respectfully, of course [grin]). I've had three women in the last year who've consistently spilled large amounts (+3 to +4 on our dipsticks) of sugar in their urine. One came to care late from a family doc, with normal blood glucose results in hand, saying, "Yeah, I did this last pregnancy, too". The other two I tested, and both were fine. One of my partners has had one or two this year as well, with the same results. I've got another one right now, who says the same thing....that she spilled sugar her last pregnancy.
My complaint, frankly, is the 1 hr. 50 gm. glucose challenge. I'm almost
at the point where I'd like to say, trash the damn thing. Almost every
woman that I've sent for the challenge (or screen, whatever you call it)
has come back high (>7.8 mmol/L). Then I send them for the 3 hr OGGT, and
it's fine. Strikes me I should just save them the misery and cut to the
chase.
I agree, It's a stupid test. Unless a mom has risk factors for DIABETES
(the REAL thing!) there is little point in doing one. I believe that some
women are "silent diabetics" and we might discover the disease during her
pregnancy; but I don't believe we should be tagging normal women who have
unusual gtts with the "gestational diabetic" label.
It may be unusual, but I have seen several women over the years like
this. I have one young woman I've attended 4 births for who has off-the-stick
glucose on every visit. Her blood sugar levels are always normal and her
babies are in the 8-9 lb. range.
Glucometers have an area in which they are very accurate and at the upper and lower ends of the scale, they are not. All tests have "linearity" which is a range of values which are acceptable. Most test methods are not accurate above and below the stated linearity. For example, a glucometer might read numbers 0-30, but those values are NOT accurate when the meter's linearity states accuracy from 30-350. So , a value of 28 might actually be 12 or 38.......and the same goes for upper ranges. Often a reading over the linearity is actually higher than the machine reports.
Diet Preparation for the Three-Hour Glucose Tolerance
Test
Discussion of jellybeans as an alternative to
a cola beverage containing fifty grams of glucose
Jelly
beans as an alternative to a fifty-gram glucose beverage for gestational
diabetes screening.
Lamar ME, Kuehl TJ, Cooney AT, Gayle LJ, Holleman S, Allen SR.
Am J Obstet Gynecol. 1999 Nov;181(5 Pt 1):1154-7.
CONCLUSIONS: Jelly beans may be used as an alternative to the 50-g glucose
beverage as a sugar source for gestational diabetes mellitus screening.
The 2 sources provoke similar serum glucose responses. Patients report
fewer side effects after a jelly bean challenge than after a 50-g glucose
beverage challenge.
I agree that food is different than lab-made glucola-- so my protocol
is to do a 1 hour GCT with juice-- either apple, orange, grape or cranberry,
soda or jellybeans. If they have above 140 on the GCT we get a 3
hour and a consult with MFM. Less false positives this way-- but
we do find diabetic moms.
I send my clients to McDonald's for breakfast: Egg McMuffin is 30 g carb plus, 12 oz. OJ is 33 g carb for a total of 63 g OR Hot Cakes with 2 pats of margarine and 1 pkt of syrup is 26 g carb plus 12 oz. OJ is 33 g carb for a total of 59 g.
If they need a 3 hour challenge, they go to the lab for glucola.
I don't think it is valid to use a mixed protein/carb diet as a substitute
for a pure carbohydrate load, as in the GCT. Protein and/or complex
carbohydrates will greatly alter the metabolism of glucose. The fact
that the diet contains the same amount of carbohydrate does not mean that
it will be metabolized in the same way as 50g glucose. Maybe just
the hotcakes with syrup would be closer to an accurate test.
One alternative is simply to get a fasting glucose level:
Am
J Obstet Gynecol. 1999 Nov;181(5 Pt 1):1158-61.
Alternative methods of diagnosing gestational diabetes mellitus.
Atilano LC, Lee-Parritz A, Lieberman E, Cohen AP, Barbieri RL.
CONCLUSION: An elevated glucose loading test result was associated with
but not highly predictive of gestational diabetes mellitus. Omission of
the 3-hour glucose tolerance test measurement resulted in failure to diagnose
13% of gestational diabetes mellitus cases. A fasting plasma glucose
concentration >/=105 mg/dL was highly predictive of an abnormal glucose
tolerance test result among patients with an elevated glucose loading test
value.
Some people are doing a one-hour or two-hour postprandial glucose blood
draw. Page
9 of this handout has instructions.
We are doing early 1 hour glucose testing on pts with a first degree
relative with a history of DM. If you are also doing this, does it make
any difference when the first degree relative developed or was diagnosed
with DM?
I think this is an interesting and useful discussion to have, because I struggle with this one quite a bit. I don't normally do the 50 gm GC (as it's called here), but will if there are risk factors (such as e.g. first order relative with type II diabetes, or persistent, heavy glycosuria). My problem is that I have, again and again, seen the 1 hour come back with a high value, and then have the woman have to move onto a 3 hour GTT, which almost always comes back with normal values. Makes me question the value of this screen a whole lot. There's not a lot of good evidence about how useful it is, yet community standards often dictate that we look better if we do it.
I have to say that I know that, a couple of times, the values on the
1 hr have been altered because of the woman's stress levels (one had to
be poked by the lab tech 4 times, and had almost passed out by that point...which
astounded me because she has great veins). We don't do the 1 hr ourselves,
because we don't have the glucola. Does anybody do a 2-hr pc instead, and
if so, is it "acceptable" by the powers that be?
I talk to my clients about the 50 gm glucola screen - let them know its standard of care and can help pick up a problem with glucose metabolism that they may have no other sx of. Most, however, don't eat much concentrated sweets and really don't want the glucola. There are other 50gm meals out there that I might try (just found a list of them in a conference syllabus), but I usually offer the option of a 2 hr PP glucose after a GOOD meal. I tell clients that this is not standardized and there isn't a firm desired result, but it does give us a good idea of how SHE metabolizes her own food.
Just had a primip who said she'd take the glucola - result came back
141 (and we're supposed to do a GTT for anything >140). She said the glucola
made her feel awful for the next 24 hours and basically refused to do a
GTT involving fasting and drinking 100 mg. So we compromised with a fasting
BS and a 2 hr PP - will see if those two are normal and go from there.
Again, she's another one that doesn't eat much sugar and almost no fruit
due to allergies.
Routine GTT testing - we offer all clients @ 28 weeks a 1hour postdose GTT screening test. We explain this is the medical model standard of care, if they don't want it and they do not have risk factors that is fine with us, but I feel it is my job to offer it to them. Only if they have multiple risk factors we really push the test or if they don't want the test we have them follow a modified GDM regime, just in case. Our modified regime is really good for anyone: reduce/eliminate processed sugars, limit/dilute fruit juices, eat a complex carbo every 4-6 hours and exercise everyday.
Speaking of GDM, anyone using chromium with GDM management?
[from ob-gyn-l]
We are doing early 1 hour glucose testing on pts who have a first degree
relative with a history of DM. If you are also doing this, does it make
any difference when the first degree relative developed or was diagnosed
with DM?
I might consider it if the relative was under 60; but I think it's pretty
irrelevant if older.
we only do early 1 hr screens on women with prior hx of gestational
diabetes (just to make sure they weren't real diabetics who just
happened to be picked up during pregnancy). We don't screen early for family
hx, large babies etc.
I going to give an unpopular opinion here. I believe in Gestational diabetes (GDM), and highly recommend all women with risk factors be screened, (listed below).
I have seen too many cases over the years. Only a few were severe, but I have seen lots of mild cases. Adult onset diabetes is rapidly growing in the US. Women who get it in pregnancy have an increased chance of getting it later on in life, however it can be prevented through diet and exercise. I think screening women with risk factors is a way to positively contribute to a woman's lifetime health outlook. As a type 2 diabetic myself, with a son with type 1, I am more than aware of all the potential negative health consequences to this illness. Preventing type 2 diabetes is a long term process, we have the opportunity to intervene in a positive way with young women to help prevent a potentially very serious disease. Not to mention increased risks to both mother and baby during pregnancy.
GDM is a condition in pregnancy that is treated with nutritional changes. Often that is all it takes. Reducing sugars and simple carbohydrates, eating whole grains, frequent small meals, protein in the morning, are all healthy changes. I tell my client that not to treat GDM as a pathology but a tool for making dietary changes.
Listed below is the screening methods and values taken from the practice guidelines at Community Midwifery. From everything I have read glucometer readings are not accurate as a method of screening.
+++ Risk Factors for GDM include: +++
1) Previous GDM or abnormal blood sugars
2) Previous LGA infant (greater than 9#'s or 4000 gms) or macrosomia
or suspected LGA fetus.
3) History or presence of polyhydramnios
4) Present or anticipated maternal weight of greater than 200
lbs.
5) DM in parents or siblings
6) Previous unexplained stillbirth, anomaly, or greater than
2 previous SAB's.
7) Polyuria, Polydipsia
8) Recurrent vaginitis or UTIs
9) Recurrent glycosuria
10) Women over 35% overweight
11) Women over 30
+++ I. Screening test +++
A. Procedure for the one hour GTT is as follows:
1. Client need not be fasting & FBS need not be obtained
2. 50 gm glucola (or equivalent glucose load) is given
orally,
3. One hour later blood glucose is sent to the lab.
4. Clients with a confirmed blood glucose over 140mg/dl require
a three hour OGTT.
II. Population to be screened, and timing for testing
A. Only women with risk factors will be offered screening for
GDM at 26 to 28 weeks gestation by a one hour post 50 gram dose glucose
tolerance screen.
B. Women at high risk for gestational diabetes may be screened
with a one hour post dose GTT at the first prenatal visit. If this
is initially normal, the screen will be repeated at 26-28 weeks as in (A).
III. Follow-up for abnormal values
A. Women with abnormal values will have a three hour GTT performed
and be scheduled to be seen by MD and by nutritionist if the three hour
GTT is abnormal.
B. The following values will be used to interpret the test, all
referring to plasma glucose (not whole blood) after a 100 gram oral glucose
load.
IV. Normal values for 3 hour GTT (100 gm glucose load)
· FBS less than 105 mg/dl
· hour less than 190 mg/dl
· hour less than 165 mg/dl
· hour less than 145 mg/dl
V. Diagnosis of Gestational Diabetes
A. Two or more abnormal values of a 3 hour OGTT is considered
diagnostic for Gestational Diabetes, (Class A1).
B. A fasting Glucose greater than 120 is indicative of a
need for insulin (Class A2 or B or greater)
well, I believe in GD, too. I just think it is the diagnostic criteria are sloppy and not based on solid research -- and as a result diagnosing it seems to be almost at the whim of the care-provider.
the 50 gm carbo is a pretty good all around screen. Wouldn't hurt any of us to have one of these every five years or so. It might help if we could identify those at risk of developing type II diabetes early enough to make a difference in preventing it.
I just think the diagnosis -- and management - of "gestational diabetes" is still in its infancy.(unlike the diagnosis and treatment of diabetes mellitus). As such it is cause for confusion and still subject to errors in interpretation and implementation.. and has some possibilities of harm.
However, we both agree on the point that women with risk factors should be screened. I understand the view of screening ALL women -- even those without risk factors -- but I think of it as more of a public health issue rather than a midwife issue in my own practice. I'll watch carefully for s/s symptoms of diabetes in pregnancy - and test as needed.
In a perfect world every woman would get health screens and health
education at every stage in her life... diabetes screens, mammograms, paps,
etc. etc. Those midwives who expand into women's health are nicely
set up for that aren't they? What a great opportunity to make a difference
in a woman's life!
I think the key is to identify insulin resistance (the root of type 2 diabetes) before it develops into overt disease. We don't have any real good markers yet, except in a small subset of women (PCOS) and the gold standard for diagnosis of insulin resistance is not a good clinical tool (the insulin clamp technique). However, there is some preliminary research seeming to indicate that the ratio of the fasting glucose level to the fasting insulin level is a good surrogate marker. If the insulin is high, even though the glucose is normal, the pancreas is working overtime. A certain degree of insulin resistance is normal during pregnancy (human placental lactogen mediated) as insulin is a growth hormone (probably more significant than human growth hormone). The basic study I would like to do is to measure glucose and insulin levels with every blood draw during pregnancy for a large universe of pregnant women, and compare trends to outcomes, and see what is normal and what causes pathology. alas, no funding
amen! Double AMEN! Because THAT is at the root of the mess we've made of gestational diabetes! We know that pregnant women are insulin resistant -- and we know that this is a NORMAL STATE in pregnancy (heck, that's very old research) ... but we just really don't know "how" normal, and which levels should be used as markers to detect the abnormal.
There is not enough research and we need a hell of a lot more. Considering
that pregnant women are sort of a "captive audience", it seems rather surprising
that there is not more research into establishing normal values for pregnant
women.
Not surprising if you think about the diagnosis of GD as being one more woman who isn't eligible to receive midwifery care!
Well, call me a curmudgeon, but I don't believe enough in the research on "gestational diabetes" or believe in the validity or effectiveness (as far as preventing macrosomia) to believe in encouraging routine post-prandial testing.
The only client I can imagine "I:" think should be monitoring her glucose levels -- would be a woman with overt diabetes -- and then, she would NOT be my client, but would be referred to a specialist!
So... I can't give you any advice on which numbers to use. The fact that the numbers vary so widely in recommendation is because the research is so dang lousy. Really disgustingly lousy. And I like to quote -- or paraphrase -- The Guide to Effective Care which complains that the issue of "gestational diabetes" has been adopted with so little data that it is essentially experimentation on pregnant women and "in any other field would be considered unethical"!
Here's the deal.... research shows that restricting calories and carbohydrates will not make a statistical difference in size of the baby. Restriction of calories and carbs PLUS INSULIN "will" make a difference, but only of about 4 to 8 ounces which is not likely to be "obstetrically significant".
Any "research" you see which claims otherwise is probably based on a dozen or couple dozen moms -- read the abstracts yourself -- or on "I had this client once".
Diabetes is diabetes. A woman has it or she does not. Diagnosing gestational diabetes based on a the rather arbitrary numbers developed for GTTs is not accurate - - because the test itself is inaccurate and because there are no "normal" values set for pregnant women (who metabolise sugar differently from non-pregnant testees) There are only "abnormal" numbers based on non-pregnant people (white men) and on the guesses of various care-providers.
Diagnosing GD because the woman has a history of big babies makes no sense to me! It DOES make sense as a marker for diabetes --- because diabetic moms may tend to have larger babies -- but what about the very normal moms who are genetically programed to have big babies? they WILL have big babies -- if those babies are genetically programed to be big -- and we risk harming the mother and the baby by restricting the calories they need for their best health. They WILL have big babies anyway! Those are the facts -- and that's what the data shows.
Research does show that "normal" pregnant women need a certain level of calories and carbohydrates for optimal pregnancy health. Are we gonna deny the research proven to be true, and manipulate her diet -- depriving her of the optimum nutrition -- based on flimsy research and anecdote -- in spite of data which PROVES that diet manipulation is not effective at preventing macrosomia? [Editor's note - Macrosomia is defined as a big body relative to overall size, i.e. a "really fat" baby. Macrosomia has nothing to do with head size. "Big babies" have proportional bodies, which aren't truly macrosomic.]
A diabetic woman needs careful monitoring -- including blood-checks after every meal -- because her bloodsugars will swing wildly and jump HIGH HIGH HIGH - -- probably well into the two hundreds. But the woman called "gestatational diabetic" doesn't swing outside of the normal swing -- she has NORMAL bloodsugars for a pregnant woman -- yet the numbers are arbitrarily lowered BEYOND the normals (even normals for non-pregnancy) -- in order to "control" a nonexistent problem!
I'm sorry to grumble, whine, and complain like a petulant child. Just call me the "GD Curmudgeon".
I test my clients for DIABETES by running a random venous blood sugar when I do their labs... or if they are high risk or symptomatic I send them for a venous postprandial. IF those results are abnormal, then we deal with it -- by consultation and referral -- because she has diabetes.
If she doesn't have diabetes, then she doesn't have diabetes. And that
is the end of tests as far as I'm concerned -- unless some overt
signs/symptoms appear or there is some clinical reason for further testing.
So, I'm a bit confused at all the varying values available for pregnant women in regards to blood glucose. I have a client who feels she has blood sugar issues (last baby was 10#2), and after careful discussion, has opted to go with using a glucometer to check her values fasting and two hour postprandial. While I feel that she could easily birth another large baby, we do have concerns about wildly fluctuating blood sugar levels (if this is the case for her) and the effect it has on baby.
My question is this: I have about three different sets of values that
are supposedly for pregnant women - from the ADA to the WHO. In addition,
when I consulted Anne Frye's Diagnostic text, there are two that make sense
to me, but they vary greatly in values.
Some of the confusion could be because the blood sugar values/number differ by about 15% between glucometer (capillary glucose) and the testing they do when they draw blood from the arm and analyze it in the lab. Also, some places measure it in mmols, which is different than the mg/dl that I am more used to.
When I have a lady test her sugar with a glucometer, I use the same values they would use if they actually were GDM and monitoring their blood sugar. There is still some variance in the recommended values, but it's not huge. The fasting value for that is less than 95-105 (depending on whose standard you use; ACOG says 100); 1 hour after a meal should be less than 140, and 2 hours should be less than 120-130. Most glucometers are not especially reliable (see article in a recent Consumer Reports), so I have them check one of each of those values for 2 days, and figure if they all come out ok, the odds are pretty good that their sugars run WNL.
The folks that make the Hemocue for hgb measurements also make a similar
machine for measuring glucose which has FDA approval as being as accurate
as laboratory measurements. The catch is that the little plastic
cuvettes, that you get the blood in, outdate rapidly, I think within a
month of the time the container of 25 is opened, and for most of us, our
volume isn't great enough to use that many, and they are expensive.
They are supposed to be working on another machine and packaging with fewer
cuvettes for the lower volume user, but it has not yet passed FDA approval.
[from ob-gyn-l]
Was one of the values on the GTT abnormal??? Langer has shown that people
with one abn value on the 3 hr GTT who are called normal and not treated,
have a higher incidence of fetal macrosomia than do Gestational diabetics
who are treated. He recommends starting these people on a diabetic diet.
As far as I know, nobody else agrees with him.
Even according to ACOG or ADA there should be 2 values off on
the 3 hour GTT. in order to Dx GDM anyway. The rise of the SECOND IS NO
WAY AN INDICATION OF GDM..
In our practice we take care of many international students and faculty. We've been observing an interesting trend among our Japanese women. Surprisingly large numbers of these healthy, thin, young women with outstanding low-sugar/low-fat diets have abnormal glucose screening and then have a single elevated value on their 3 hour GTTs. The babies are normal sized. Frequently maternal weight gain in pregnancy is low by our standards, despite our exhortations for the women to eat more.
Is glucose screening based on American and/or European standards? Is
there a different standard for Asian (specifically Japanese) women? Has
anyone shown an innate difference in glucose metabolism between these groups
or might the very different diet cause a difference in glucose metabolism?
The standards that I am aware of were established on the East coast
by O'Sullivan in Boston. I think Langer in San Antonio has his own based
on his mainly Hispanic population.
Are you giving your patient a 3 day carbohydrate load preparatory to
their GTT ?? If you don't, you will have an increased number of false positives.
Especially in patients who are on the type of diet you describe.
Yes, we give a handout with the 3 day carbohydrate load and instruct
all women with abnormal glucose screening to follow that diet prior to
their GTT. I'm not sure the women in question actually adhere to the diet,
though. Their eyes kind of glaze over when they read it and they clearly
think that we're asking them to add an enormous quantity of food -- more
than many of them believe they can eat.
There is no such thing as GD. When we are looking for sugar we are looking
for the women who have overt diabetes. They say there is no sense in doing
urinalysis for sugar. Are they going to change what they check for in their
clinics? NO!! Are they going to have us stop checking for sugar?? NO!!!
But I particularly like the following line: "As no benefit has yet been
established for glucose screening during pregnancy, the method used for
this screening is irrelevant" GECPC pg 59)( and I always feel a bit like
giggling, because it's really a cute way of saying it)
The research on this topic has shown no different outcomes, regardless of treatment. Also, GD is poorly defined, as it is normal for Blood sugar values to rise during pregnancy, so a woman may test ok in early preg, and have high values later, be diagnosed with GD, even though she has had a normal rise in BS.!!!
We have decided no routine testing, (it just makes the labs rich, and doesn't help our clients at all). We would drop urine testing for glucose except its a community standard, so that's a hard one.
If mum spills sugar there, we do a fasting ac and 2 hour pc sugar, and
consult. Haven't decided if there is any other time we would test. Probably
previous GD, more for our protection than anything else.
This is my protocol for testing for diabetes.
No risk factors- no testing. Risk factors would include previous GDM, sister or mother with GDM, glucose and/or ketones in urine sample.
If a test is indicated I do a 1 and 2 hour PP in my office. I have the
client eat a "normal" meal (including a protein source, a vegetable, a
fruit and a complex carbo) an hour before her appointment. I stick her
finger as soon as her appointment starts and an hour later. If these results
are within normal range (<140) I do nothing more unless the mother wants
more testing, if the results are borderline (140-160) I do another 1 and
2 hour PP test in my office at her next appointment, if the results are
under 160 I discuss having a 2 hour glucose challenge done or I will teach
her how to do her own checks at home for a few weeks with instructions
to call me if any of her results go over 160. If the results of the 1and
2 hour PP are high (>160) I suggest she have a 2 hour glucose test at the
lab. If this test comes in high, I have her make an appointment with my
back-up doctor. The few times this had happened he has retested them and
advised them to "eat better" and to call him if a problem comes up......so
far none of my clients have needed insulin to control her high blood glucose
levels.
Some of the hospitals in our city have diabetes classes that teach people
how to do their own tests and how to eat properly. If my client can keep
her levels normal and no other signs of problems arise, we continue with
the home birth plans. If she is unable or unwilling to get this under control,
I will transfer her care to a doctor. Period.
No risk factors- no testing. Risk factors would include previous GDM,
sister or mother with GDM, glucose and/or ketones in urine sample.
I would not consider mother or sister of GDM a risk factor, since I think the vast overdiagnosis makes it worthless[Grin] . I would of course consider DM a risk factor if in close family -- or appearing under age 60.
I would probably not test for only one spill of glucose either -- unless it was accompanied by ketones (then I want a full test!). Repeated glucose in the mom who is not gaining - - test! Glucose and ketones-- test today! Mom who is not gaining in spite of good diet -- or who has repeated ketones -- test! Any mom with symptoms of diabetes (thirst, frequent urination, hunger, fatigue, poor weight gain or weight loss) -- TEST
I'm more concerned about hidden DIABETES in pregnancy than in simple "glucose intolerance of pregnancy" which is what our American definition of GD is all about anyway....
If I'm getting a blood sample anyway, I will run a random glucose on it (if mom has enough money for it[Grin]). It might tell you something -- if mom really has diabetes; it probably WILL tell you something....
If I'm worried about a mom, then I like the two hour postprandial, best!
I have had several women in the past who have had huge amounts of glucose
in their urine (as in off the pee strip chart), but every glucose test
comes back normal (or even low sometimes). These women have had super fast
labors (the word precipitous works!), big babies and no problems at all!
Anyone else see this?
yeah..... I guess by definition they might have GD, but I don't care
(about the definition[Grin]). The only risk associated with low renal threshold/
glucose intolerance/GD is a big baby.. nothing else... Big baby/no problem
-- I can live with that, nicely!
One of my clients always has +glucose. Is there something in her diet
that could be causing it even if she's not eating any sugars? I've heard
vitamin C can cause false +, but she's not taking any. Any ideas?
If you test her ascorbic acid and it comes out high, it could be a false
positive from vitamin C, or possibly some kind of juice she's drinking.
Speaking from experience, some of us just have kidneys that filter sugar
back into the blood less efficiently during pregnancy. In both of my pregnancies,
I had amazingly colorful urine dipsticks - the glucose could go out of
sight after a bowl of cornflakes and milk. But my blood glucose was always
okay, and I have 8 pound kids. I guess I wouldn't worry about it. I didn't
even bother changing my diet, nor would I advise clients to unless the
blood glucose was also high or their diet was bad anyway.
I have a 39 yo G 2 P1 now at 36 wks who has been spilling glucose in her urine since 31 wks. Her 1 hr/50 gm glucola was 108. She tends towards hypoglycemia. She's been working on her diet- eliminating all refined carbos, eating 125 gms protein a day, and small frequent meals- but still gets between trace and +2 glucose on her urine dip every time.
The only significant med hx is that she's on a small dose of Synthroid,
.112 mg a day. She has been thyroid tested twice this pregnancy and levels
were all normal.
Just suggestions --
1: perhaps a three hour test??? (I hear rumors that sometimes a true diabetic can pass the one hour test, and if we are still suspicious then we should go for a three hour will show what's going on).
2: try cutting down on the protein to perhaps 80 (certainly adequate!) - - for a week and see what happens. She may be consuming far more calories than she needs. And does "eliminating refined carbohydrates" mean that she is still using honey, syrups, corn sugars etc? ASK ABOUT JUICE OR SOFT DRINKS -- fruit juices contain a LOT of sugar!
3: Postprandials? maybe running a few be more valuable than GTTs.
4: Evaluation by ophthalmologist for "sparkles"??
5: perhaps the Synthroid is the culprit. Why is she taking it? (was there a distinct need?)
Some women just spill glucose -- no problem for them. It's important
to rule out other conditions though before we conclude that she is "just
one of those women". I usually don't worry much about women who spill a
trace or +1 from time to time -- but this woman who seems to do it everytime
up to +2 would concern me some.
I had heard somewhere that women who work too hard can have a problem
with their kidneys being overtaxed and thus not able to filter all of the
sugar out of their urine.
I only test moms with risk factors, and then we start with a one hour challenge. We do a 3 hour only if necessary.
Chromium works great for borderlines.
We offer 1 hour, nonfasting 50 gram screens to all women. We do not do FBS, with the rationale that with gestational diabetes, FBS would not be elevated anyway.I know this is controversial. I think our midwives have made significant inroads in the past years in rx of GD. In the past, most of the women with abnormal 3hour GTTs were referred to an endocrinologist, and most were put on insulin. With greater emphasis on evidence based practice and the GECPC book, the midwives have become more assertive, rarely refer to endocrinologist for GD, put women on ADA diet and things are just fine.
I think the issue is maternal weight, anyway. i.e. heavier women are
far more likely to have macrosomic infants and heavier women are more likely
to have abnormal 3hour GTTs.
[from ob-gyn-l]
I work in a not for profit HMO situation as a CNM, we have a group of
physicians who are very involved in evidenced based medicine (none of whom
do OB) and are looking at many of the "standard of care" and "routines"
that are done in our setting and have recently looked at screening for
GDM (gestational diabetes mellitus) and have come to the conclusion that
routine screening is not beneficial or cost effective, that no reliable
evidence exists that GDM screening prevents macrosomia, and that no randomized
trials of screening have been published. They did mention an article by
Santini in the Surg Gynecol Obstet 1990;170:427-436 that determined that
"the process of screening not only failed to decrease the rate of large
infants, but also failed to improve otherwise pregnancy outcomes and was
associated with more intensive surveillance during pregnancy and a significantly
higher rate of primary cesarean delivery." What thoughts do any of you
have on this subject?
I have not reviewed the literature on this topic for several years. The following is my opinion.
I believe some years ago a study showed that the majority of women who develop GDM do not have risk factors (family history, prior pregnancy with large baby, etc.) suggesting that they are at risk for GDM. Thus, in order to identify GDM you must screen for it. Using the 3 hour GTT is not cost effective and puts patients through an unpleasant testing procedure.
The 50 g. glucose screen was "invented" as a screening test to determine who should be subjected to the 3 hour GTT. A normal screen test implies that the 3 hour GTT will be normal and that the patient is at extremely low risk for GDM. An abnormal (elevated) 50 g. screening test means that the patient may have an abnormal GTT and is at increased risk for GDM. Thus, further testing is indicated to exclude GDM.
I see the glucose screening test in the same light as the MS-AFP. They indicate if further testing is indicated or not indicated.
You can not relate the screening test to the development of a macrosomic baby nor any other problem associated with GDM, but only to the probability that a pregnant lady will have or not have an abnormal GTT.
Whether or not a pregnancy with an abnormal GTT will have problems is
another story.
I have a heart problem that was incredibly exacerbated by my last pregnancy...of course nobody wanted to believe it was my heart (I'm too young, and I'm a woman, so naturally there can't be a problem with my HEART!!), and they scheduled me for a GTT just to see if there was a problem there. (I should have said no as soon as I heard it was "just to rule out this and that," but I was at my wit's end!) Gawd, it was horrible! I could barely stand about twenty minutes after drinking that garbage, was sweating and about to throw up. When I approached the nurse to ask for help, she said, "Oh, you're doing great, we have lots of women pass out by now."
And this is a "routine" test!!
See also: Newborn Hypoglycemia
It is important that you ask your care provider how the baby will be
treated differently because of a diagnoses of gestational diabetes in the
mother. Will the baby routinely be taken to the nursery? Will
the baby's heel be stuck with a lancet to collect blood to check glucose
levels after the birth? How often will this be done? If the
baby's blood sugar is low, will the nurses emphasize breastfeeding as the
best treatment, or will they recommend glucose water instead? If
glucose water is given to the baby, can it be given in a sippy cup or with
an SNS system so that the baby does not have to suck on a bottle and be
vulnerable to nipple confusion when breastfeeding?
"The findings suggest that the nervous system of newborns of insulin-treated
diabetic mothers is less mature than that of babies born to healthy mothers,
the researchers say. Diet-managed diabetes is a milder condition than insulin-managed
diabetes and, therefore, the impact on sucking behavior is probably smaller,
they add."
I have a friend who took cinnamon to lower her blood sugar levels - she was actually on insulin for her gestational diabetes but was unhappy to have to keep upping the dose. SHe found that cinnamon measurably reduced her blood sugars but not to unsafe low levels. There is some actual objective research on cinnamon.
1/4 tsp 2 to 3 times daily - in food if possible (like on oatmeal) .
Just plain old cinnamon powder.
Any pregnant woman will benefit from the recommendations given to women
who test positive for "gestational diabetes": good nutrition and regular,
moderate exercise. Here's are some Diet
& Weight Gain
The AtLast System
from Amira Medical is the first blood glucose system designed to eliminate
painful fingersticks.
My labor coach client, diagnosed with GD, told me that her nutritionist
recommended she have no more than 1 oz/hr of Gatorade during labor.
Has anyone been giving B6 100mg with meals to lower blood sugar?
I have used this experimentally on patients with type 2 DM and have found
a blood glucose drop of 25 from their previous averages. {The original
research for the use of B6 was for use in GDM and Glucose intolerance in
pregnant women}
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