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Gestational Diabetes
- May 19, 2008 at 6:16 PM
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- Comments (9) Total Views (486) Everyone can see this journal post.
This is from the fabulous Gail Hart - Midwife and Researcher in Oregon. : )
Now the myths and risks of GD can be dispelled. : )
GESTATIONAL DIABETES Gail Hart (Gist of Midwifery)
A certain portion of people are unaware they have diabetes Mellitus until their symptoms become severe enough to send them to the doctor or hospital.
Some of these unknown diabetics are women who will become pregnant, and their diabetes will first be discovered during routine prenatal care.
A certain portion of women with very mild diabetes – often unknown diabetics – will demonstrate symptoms of diabetes only under the stress of pregnancy.
Diabetes can be a dangerous disease with serious risks for the baby and for the pregnant woman.
Diabetes mellitus
Diagnosed by symptoms and clinical signs, confirmed by lab results
“Gestational diabetes”
Diagnosed solely by lab values (elevated screens or GTT)
No symptoms or signs
Risks of Diabetes mellitus in pregnancy
fetal malformations (possibly caused by medications). Most common is poorly formed hips.
A baby who is under-mature for his gestational age (still “premie” at 37 weeks, lungs not mature)
Maternal high blood pressure, PIH, pre-eclampsia more common, more severe
Stillbirth more common
Very large baby more common (risks of birth trauma)
Unexplained late term stillbirth risk increased if diabetes poorly controlled
Risk of hypoglycemic baby after birth (cure is to feed baby!)
Diabetes mellitus symptoms, signs, and blood sugars all increased in pregnancy.
Increased symptoms require increased insulin
Risks of “Gestational Diabetes”
No risks to mother or baby
SOLE risk is of having a larger than average baby (above 9 pounds)
Discussion:
Women metabolize sugar differently when they are pregnant. The swings between high and low are larger (it’s one cause of morning sickness). The normal blood sugar levels are slightly elevated from non-pregnant. This makes it harder to distinguish between normal elevation and mild diabetes.
Diabetic women frequently spill glucose, but occasional glycosuria is common in pregnancy among non-diabetic women. Daily testing shows that most women will spill sugar a few times during pregnancy (generally after a high sugar meal).
Diabetes Mellitus can elevate maternal and fetal risks in pregnancy. Every effort should be made to discover the “hidden diabetic” or the “borderline diabetic” who may develop the condition while pregnant. Testing methods have recently been devised to detect hidden diabetics. These tests rely on large doses of glucose to force a “stress situation” and expose the hidden diabetic. The tests are controversial because it is does not mimic a normal situation, and high numbers of women will fail the test, even though they do not have diabetes. Most of the women who fail the test, will pass it on another day (test is not reproducible).a better test to detect Diabetes Mellitus is the A1c. The A1c will be normal in many women who fail the Glucose Tolerance Test.
Even though normal non-diabetic women’s blood sugar NORMALY runs higher, the levels used to “discover” diabetes in pregnancy are actually set LOWER than when not pregnant! (the levels seem to be rather arbitrary. I can find no data to support lower ranges in pregnancy; the levels are based on theory)
The test recommended by the ADA to discover diabetes in non-pregnant people is the 75 gram two hour screen. Normal values are at:
fasting <115
1 hour < 200
2 hours < 140.
Often, pregnant women are arbitrarily given the 50gm 3 hour challenge, with varying “normal” results listed by different sources (results seem to be based purely on opinion)
NDDG scale
Fasting <105
1 hour < 190
2 hours < 165
3 hours < 145
or another one: (Carpenter and Coustan)
fasting < 95
1 hour < 180
2 hours < 155
3 hours < 140.
Each of these scales is equally acceptable. The decision to call a woman “gestational diabetic” rests upon which chart the careprovider prefers.
Queston without answer: Is this logical? Why should pregnant women be assigned normal values LOWER than the levels which would trigger a diagnosis when they are not pregnant? A “logical” approach would be to assign levels a bit higher – or even a number unchanged from the non-pregnancy “normal values”.
The American Diabetes Association recommends that every pregnant woman be screened with a one hour 50 gram test (values taken at fasting and at one hour).
This test is similar to a simple post-prandial screen (values taken one hour after a meal).
A value over 140 requires a follow-up 3-hour GTT. However, because blood sugars run higher in pregnancy – even in non-diabetic women -- about 15% of women will “fail” the 50 GM screen and become candidates for the 3-hour GTT.
The timing of the test is also important also. The most accurate time for screening is between 24 to 28 weeks – although many people do the tests without respect to gestational age.
According to ACOG, women who fit all the low risk categories do not “need” to be screened:
under 25 years of age,
not “morbidly obese”
no family history
not a high risk ethnic group
A competing view is that EVERY woman should be screened – regardless of risk status – because of the theoretical chance of discovering a case of hidden diabetes.
Gestational diabetes in and of itself – does not actually exist as a “disease process”
Distinction between Diabetes Mellitus and “Gestational Diabetes”
“Gestational Diabetes” is without symptoms, signs or effects on baby
Fasting glucose and post-prandials normal or only slightly elevated
A1c is not elevated
No – or rare – gylcosuria
No ketosis
A woman with diabetes mellitus – regardless of when it is first discovered – has blood values far in excess of those used to diagnose “gestational diabetes”. She will usually have a history of insulin-dependent diabetes among family members, and show SIGNS AND SYMPTOMS of diabetes:
excessive weight loss or weight gain
extreme thirst
poly-uria (increased frequency, and larger amounts of. urine)
glycosuruia. —sugar in the urine
ketonuria – ketones in the urine
Possibly cardiovascular symptoms – leading to high blood pressure
Poor healing of cuts and scrapes
Frequent infections, including vaginal yeast infections
In pregnancy:
the fundal heights will usually be large-for-dates
the baby will be large-for-dates;
excessive amniotic fluid (hydramnios) is common
The rate of large babies is statistically the same even when a woman follows a “gestational diabetes diet” . Studies of women who followed a diabetic diet and also took insulin, show an average reduction in fetal size of about a quarter of a pound –not obstetrically significant.
. Most babies can be born vaginally – even very large babies.
Avoid induction.i
Avoid induction
A prospective study of 262 women with macrosomic babies as predicted by sonography (over 90th percentile). Half (115) had an elective induction with macrosomia as the only indication. induced for macrosomia. With elective induction, the cesarean rate was 57%, significantly higher than the 31% rate with spontaneous labor (P < .01). The induced group also had a significantly higher EFW and birth weight. When logistic regression was used to control for birth weight, parity, and care provider, elective induction was still associated with a higher risk of cesarean delivery than was spontaneous labor (adjusted odds ratio 2.7, 95% confidence interval 1.2-5.9; P < .02) Obstet Gynecol 1993 Apr;81(4):492-6 Elective induction versus spontaneous labor after sonographic diagnosis of fetal macrosomia. Combs CA, Singh NB, Khoury JC.
Induction of labor for “impending macrosmia” raises the cesarean rate, without improving outcomes.ii
“The antenatal prediction of fetal macrosomia is associated with a marked increase in cesarean deliveries without a significant reduction in the incidence of shoulder dystocia or fetal injury. Ultrasonography and labor induction for patients at risk for fetal macrosomia should be discouraged”
Am J Obstet Gynecol 1995 Oct;173(4):1215-9 Fetal macrosomia: does antenatal prediction affect delivery route and birth outcome? Weeks JW, Pitman T, Spinnato JA 2nd.
Tags: big baby, childbirth, diabetes, diabetes in pregnancy, gestational diabetes, glucose tolerance test, gtt, pregnancy
Comments:
"excessive amniotic fluid (hydramnios) is common"
That's all I had. My 8lb, 7oz baby at 42 weeks was supposed to be some giant, 10lb+ monster to listen to my stupid OB. My numbers dropped FASTER than they were looking for, but because I peaked higher, I got diagnosed. My third number was normal-low. And of course, that was just because they wanted to make me "high risk". I'm not falling for that crap this time around. As soon as the pregnancy was over, I was hypoglycemic again and really, my numbers were never that bad while pregnant. Never in the true diabetic range.
That gives me a lot to talk about with my MW. I am over 25 (31 yrs) and this is my 3rd pregnancy and my first with GD. I do have a family history of insulin dependent type 2, but am still pretty skeptical that I have it based on my numbers so far, and that is without having seen a dietitian yet. Thanks for the info.
Shorty...BUT, I saw your fasting levels in the post you did. According to that, you do NOT have GD. For crying out loud, those are awesome numbers for people who AREN'T pregnant! And pregnant women metabolize sugar more slowly than those not pregnant.
This is what happened with me. My dr checked my fundal height and said I would need a c/s before checking an u/s. I told him right there he was scalpel happy and one of two things. He was either an idiot because anyone knows that your uterus will be bigger for subsequent pregnancies and of course you will measure bigger than you would if it were your first pregnancy, or he was trying to assume I was stupid and manipulate me into a c/s and in that case I was highly insulted. I asked them when scheduling my appointments not to give me him anymore.
I've been confused for this past week since I was diagnosed last week with GD. I have been testing my blood 4 times a day as I was told to, but my readings have all been between 95-115, some a little higher some a little lower, but nothing extravagent. I was told at my appointment last week that my reading on the 1hour test was so high that they were diagnosing me without even needing a 3hour test. Now, I am even more skeptical of all this.
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But MY GD test was necessary!
You crazy, malicious woman!! If a doctor tests for something it's to help SAVE YOUR BABY'S LIFE! ! !
I would have DIED if I hadn't been tested for GD!!
;)