Gestational diabetes is a big topic, and with a little person crawling all over me and my laptop, I won't have time to address every aspect of it. Okay, standard mother disclaimer over...
This article from the BMJ, Should we screen for gestational diabetes?, addresses some of the main issues about GD: when and how is screening or treatment effective (health-wise and financially)? Michel Odent's overview of GD in my previous post also raises some interesting questions and issues.
One objection many women have about GD testing is that the test itself is an intervention that changes the body's normal physiology (it involves drinking a large amount of sugar, then testing blood sugar levels X amount of hours afterwards). It also has the potential to create additional stress and worry during pregnancy and, as Michel Odent notes, its possible nocebo effect is something to take into consideration.
Zari needs more attention right now, so I'll have to cut this post short. I'd be interest/ ed to hear other input about GD screening/treatment: benefits, risks, alternatives, etc. If you are a midwife or physician, what information to you give to your clients about GD testing? What do you recommend? If you have given birth, what did you decide to do about GD screening and/or treatment?
If I can avoid the GD glucose screening altogether or choose a different method of testing, I will. I had to take it three times with my first pregnancy and I felt so horribly sick each time. I couldn't stand it. Now I know that there's less extreme measures of testing, so I will see how to opt for one of those if my MW decides that I am at risk (which I doubt that I am).
ReplyDeleteI declined the GTT. My GP (laid-back, and a homebirth supporter who often operates as the back-up doctor for our unregulated midwives) asked if I was willing to have a fasting glucose done. I consented and it was normal.
ReplyDeleteThe complete lack of diabetes in my family history made things easier, I think, but my doctor really and truly believes in informed consent and would not have pressured me anyway.
I did this with my first preg, at an OB clinic. I threw up and had to re do it, 3 times I think. Lots of chastising me ("Why did you puke?"--huh??)and time and gas money spent going back and forth to the clinic woozy with nausea and worry.
ReplyDeleteIt is extremely bad for the baby, to fast or to sugar load them and I felt very angry about the whole thing. I did it the second baby, another OB-- and the results were "normal" even though I was shocked since I was sweating, shaking, confused and I was seeing stars from how disgusting and sick I felt with that nasty syrup in my empty stomach-- I think my husband even had to take off work I was too sick to even drive.
3rd baby, homebirth midwife, and we decided to use common sense and how I react to actual food and actual life rather than mess around with soda syrups and fasting. I showed no signs of having GD and ate healthy throughout.
4th baby I didnt do it whatsoever and got very involved in a lot of research along the lines of "The GD test is Bull%&!t" and I felt strongly that I agreed. I did a lot of reasearch about it and I like the Odent piece you shared here, Rixa.
I do believe that many women can have troubles processing sugars and can become "diabetic" at any time in their lives, with pregnancy being a time of compromised pancreatic function for some women. But my opinion right now is that the glucose fasting test has high false positives, is miserbale for the mother, dangerous for the baby, innacurate and mostly useless. Thats my 2 cents!:)
I saw a CNM with a group of OB's for my prenatal care. (I didn't switch to the CNM and her doctor group until 26 weeks when I started doing research--before I was with an OB who gave every patient a copy of the "What to expect" book.) I knew they were going to ask me to take the glucose tolerance test, and so I spent several days before the appointment reading everything I could find about it. I decided that it was not something I wanted to subject myself or my baby too. I didn't meet any of the risk factors, and beyond that I couldn't see how ingesting an extreme amount of sugar on an empty stomach could be very accurate. I don't eat much sugar, and I get sugar highs then really sick very easily. I know that test would have made me so ill.
ReplyDeleteWhen I told the midwife I was going to decline the test, she told me that it was fine with her but that the doctors that over see her would not agree. They sent in the nurse to tell me some long sob story about a women who had a large baby that was still born because the mother had GD. If only she had been tested...then the doctors would have saved the baby's life! My husband actually burst out laughing after the nurse left the room. One of the doctors came in and gave us this long, long lecture about being responsible parents and so on. It was ridiculous. Then, they told me that since I still refused to take the test, I would have to be treated as if I had gestational diabetes for the rest of my pregnancy and also in labor. (Even though I was measuring small for dates and hadn't gained much weight...the doctor told me GD often doesn't show any symptoms (?!?) when I questioned that.) They gave me a referral to the diabetic counselor at the hospital and everything, but I didn't go. When they found out I was still "causing trouble" as they put it, the doctors told my midwife that they had to drop me from their practice! My poor midwife, she was so sweet and loving, and she was definitely caught in the middle. At the last minute, my husband asked them if we could just sign a form releasing them of all liability for complications involving GD. The doctor got a huge grin, and they made us wait an hour and a half while they wrote up a gigantic list of all possible side effects the baby or I could suffer from. We signed it, and that was that.
It was a lot of stress...and my baby was only 6 pounds, 14 ounces. Obviously not huge. Next time around, if I don't go the route of unassisted birth for some reason, the first question I'm asking my midwife is if she requires any kind of GD testing.
Sorry I wrote a novel.
ReplyDelete:-p
I was tested during my first two pregnancies. With my first because the midwife required it and I didn't feel like pushing, the second, for the same reason and I was focused on having a VBAC so I didn't feel as though I wanted to rock the boat and decline testing, but I will not be tested during this pregnancy and my midwife is fully supportive.
ReplyDeleteHey, novels are okay...The stories you've shared so far illustrate why it's worth researching and thinking about, rather than just doing it because your OB/midwife tells you to. I do have serious concerns, like Housefairy and others, about the ill effects the GD test itself can have. I NEVER eat such a large amount of sugar at one time like that, and I am pretty sure my body would spazz out if I did.
ReplyDeleteIf you are concerned about how well your blood sugars are regulating themselves during pregnancy, testing your normal blood sugar levels at various intervals (upon waking, after a nice big breakfast, after vigorous walking after said breakfast, etc) would probably give you a more accurate picture of what is actually going on in your body, rather than downing a large glass of pure sugar.
Anyway, the dietary recommendations for women with GD are wise for all pregnant women to follow: eat small frequent meals, don't eat too many simple carbs/sugars or other foods with a high glycemic index, balance carbs with proteins and fats, etc. Exercise a good amount. All that good stuff that will keep us healthy no matter what!
My body didn't react as badly as Housefairy's, I 'only' got dizzy and sweaty. Disgusting stuff.
ReplyDeleteI was bullied into one with both my pregnancies in exchange for getting other labs done with that backup practice. The deal was: I smile and nod and drink the syrup and then I get my blood panel and don't get harrassed by the CNM any more about an ultrasound.
I'm not sure how that strategy would have worked for me if the GTT had come up positive though. Luckily, it didn't. Well, I did cheat -- I didn't rest for the hour, I took a brisk walk... I needed fresh air and to be away from that place, I was teeming mad.
That was the last time I saw that nurse-midwife. I did do the swab, but switched to an OB in the same clinic and she was awesome. By then of course I had gained even more weight (the CNM got all worried about my rate of gain before she sent me off to the GTT) but this OB was cool as a cucumber about everything. She sincerely wished me luck at my home birth and that was that.
All along, that CNM was extra meticulous about my chart. I have a feeling she was under more scrutiny than the OBs. Too bad.
I've always opted out.
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ReplyDeleteI have mixed feelings about screening for Gestational Diabetes. My personal perspective is that, in the population we tend to work with, our moms tend to have decent diets and risk of "true" Gestational Diabetes is very very low. In the homebirth practice, I've never seen it. But almost every woman I know cared for in hospital has been diagnosed with it. I think the test done in the lab is disgusting and very hard on the body and is off-base on what it ought to be measuring. Assuming there really is a risk for Gestational Diabetes, the test challenges your system with far more pure sugar than anyone really ever consumes. There's a reason people feel sick after doing that test --its because their bodies would NEVER tolerate that kind of sugar attack. In our practice, we offer a pancake breakfast. If they want to test for Gestational Diabetes, we suggest they eat pancakes with syrup and drink some juice, then we do a 2 hour postprandial. The thinking is that, while we cannot accurately mesure the units of sugar eaten, this is likely equivalent to the most sugar-saturated meal they are likely to eat in a normal circumstance. If they can tolerate this, then no one should worry. If they can't tolerate it, then we look at diet, make suggestions on what better food choices might be, and re-evaluate as necessary. The upside of this test is that its a test that I think more accurately reflects real life, mom is getting some protein and fiber along with the carb load, and so her body doesn't feel so awful afterwards, and hopefully she can let go of any concerns about growing a baby that's "too fat" to get out of the hole. The downside is that its not medically "accepted" protocol, so it isn't considered standard of care.
ReplyDelete(Reposted with spelling correction)
Hi, I read this post yesterday or the day before but am just now able to post my comment!
ReplyDeleteJust this week, I shared two links with a pregnant friend:
http://www.gentlebirth.org/archives/gdhgoer.html
http://parenting.ivillage.com/pregnancy/pcomplications/0,,9z3m,00.html
My brother has Diabetes Type I. I opted to take the glucose tolerance test during my first pregnancy (2003) on an intuitive hunch. Because of growing up with my brother, I feel blessed that I already understood a lot about blood sugar and diet and managed quite well throughout my pregnancy.
With my second child, I opted not to test (I knew a bit more about GD and the test by then; also, my husband and I were taking a "no tests" attitude during this pregnancy). I just continued eating a lot of protein and fat with complex carbs and monitored my blood sugar levels intermittently. During late pregnancy, I always felt best after getting some low-key exercise.
Also, an interesting side note: at almost exactly 26 weeks in my second pregnancy, I actually felt BETTER than I had before. It was as if my increased resistance to insulin helped stop my blood sugar from crashing so hard and my constant nausea also subsided. I finally felt a bit more even-keeled.
I think the screening and GTT followup should be scrapped. Instead, women who have risk factors for GD should have their fasting blood sugar tested early in pregnancy and, if normal, again at 20 weeks or so and then monthly, to check for increasing blood sugar (outside of the *normal* range of blood sugar while pregnant, of course). Even women who do not have risk factors should be encouraged to have a fasting blood glucose level done at 24-28 weeks and to check periodically for spilled sugars in urine. Those women who seem to be having problems with controlling blood sugar should use a home glucometer to get a handle on how their bg levels react to different foods, and meet with a nutritionist to help with an eating plan that is appropriate for pregnancy but will also minimize blood sugar "spikes".
ReplyDeleteWhen fasting glucose is consistently in a very high range, I do think the use of insulin or oral diabetes drugs such as Metformin is warranted. However, my blood glucose "targets" (in the world where I am queen) would be much more "liberal" than those that are often used. I would NOT consider a woman with GD to be "high risk" unless there are exceptional circumstances. There is a big difference between a fasting glucose of 95 and one of 140. There is a big difference between a post-prandial reading of 140 vs. 300. Women with GD should be empowered to learn as much as possible about it instead of cowed into unnecessary interventions by the use of scare tactics.
I'm not a midwife or health care professional of any kind. However, when I was diagnosed with GD in my pregnancy I used my husband's university access to medical journals to read just about anything that has ever been written on the subject, so my views are (IMO) somewhat informed.
To sum up: the GD screening test (the "1-hour") and the GTT (the "3-hour") are IMO not good tools for finding the small subset of pregnant women who truly have a problem with blood sugar *that needs treatment*. They do however drag a host of people into the net who do NOT need additional monitoring or treatment, and the "treatment" they are given does not statistically affect outcomes - however, their identification as GD or "high risk" certainly does raise their risk for unnecessary interventions and the iatrogenic complications that go along with them.
And, the tests also seem to miss people who have a real problem that might benefit from additional monitoring and perhaps even blood sugar-lowering drugs.
Just to add my personal experience with the 3-hour glucose tolerance test: I only "failed" one of the draws (and was borderline on one other, enough to give me the diagnosis) but my blood sugar plunged to 41 in the last hour and I nearly fainted. My husband had to basically carry me out of the office and to the car. This was clearly NOT good for my baby. It was brutal for me.
ReplyDeleteWhen I was pregnant, my body was very in tune its needs and demanded that I listen to it. Which meant I was eating every 1-2 hours and drinking water throughout the day. The GD test was not tolerable for my body at that time and I didn't see how messing with my body's healthy needs was going to benefit me or my baby. When the test I took came back high, I felt very strongly that it was unnatural and difficult for my body and my baby to submit to it again. This time the over night fasting and 3 hour test. I refused because I knew I would not be able to keep the syrup down and it would lead a great deal of discomfort for me and probably a very hyper and hungry baby. In the future, I will decline all GD tests since I understand the physiology better now and I don't have any of the "risk factors."
ReplyDeleteI blogged about this as well and found quite a hostile response from it (9 responses to my blog post have been 'not approved' for posting. lol)
ReplyDeleteI agree that the benefits do not outweigh the risks. I have a severe reaction to the testing (1st pregnancy) and didn't do it with the others... There are no benefits that I can see as a healthy diet and exercise will improve all health of anyone (GD, pregnant, or not) and treatment is not effective - so why do it? Just talking blind here as I am way tired and going to go nap now. :o)
Yeah...
ReplyDeleteI think that test is a load of crap, and frankly, there is very little they can do for it except watch the size of your baby and test you...over and over...and over again.
I am almost 32 weeks with my fourth child. Every fiber of my being told me to refuse the glucose test as we had refused the other tests throughout this pregnancy. A first for us. I had the glucose drink with the other three and was fine. Because I am overweight and older now
ReplyDelete(35), I caved and took the test. I got so sick I could hardly stand it, for the first time ever. I had already had a huge headache before hand and had vomiting and massive migraine for remainder of that day. I was not too surprised when my level came back at 150 but I wasn't concerned. The team of people 'caring' for me however, felt this was "serious". I was put on a glucometer 4x a day and though I was told after a week that my numbers weren't horrible I had to continue the multiple daily sticks because they were diagnosing me GD. I am so uncertain of what actually qualifies someone as GD for real but what I get from it is consistently over 150 is a problem. My levels are no where near that.From what I have heard and read I seem more mildly over than in 'serious' range. Morning fast levels are normally 115 range and after meals, range from 80's to 119 if I watch what I eat ( I have found the worst triggers on my own). I have been threatened and strong armed by this team of practioners and 'specialists' about how my baby will get stuck during birth and possibly have brain damage from low blood sugar at delivery or even die if I don't start an insulin therapy regimen immediately. I haven't even had a chance to try a different diet as this was such an important issue (???)that it took them almost two months to get me into see the specialist and then the nutritionist. I am so upset about this whole thing. Everything I have read says that with or without insulin, the outcome will be the same no matter what that outcome is, that insulin therapy does not provide any benefit due to the baby's size or any reduction in the other possible outcomes. I so do not want to inject insulin, I don't even see the need to test on my finger 4x a day for all this time. My baby is measuring no bigger than the last three, who were big anyway and I tested fine with them. His heart beat is strong and he is constantly kicking around in there. I am looking into another hospital but I am not sure how to approach them. Should I not even tell them I am having this "issue" or should I tell them and get their protocol in such matters?
BTW, the 'specialist' all but bawled me out for questioning the test, results of the insulin therapy and any outcomes from such a thing. She couldn't tell me enough that she was the 'specialist' and wouldn't even consider my information. I am very nervous now to give birth in such a hostile environment where everyone seems to be mad because I don't want to just shut up and take there word for everything. I have done some research on this and found so many articles that said these tests are potentially harmful or contorversial or both. One of which said the American College of Obstetrics and Gynocology says "no data support the benefits of screening". Not only did I find another article stating the same thing in a magazine right in their waiting room but every doctor on this team is a member of the American College of Obstetrics and Gynocology!! Go figure.
Now I am under a ton of extra stress which is definetly not good for the baby and I am scared to follow my gut that they are being over vigilant about the whole thing. Has anyone gone through this with what I consider to be 'borderline' levels like mine?
I know this WAY after the fact but Jenne sent me this link when I asked about GTT being evidence based.
ReplyDeleteBefore getting pregnant with my dd I was diagnosed with PCOS and Insulin resistance which I treat with Metformin and diet. During my pregnancy continuing on Metformin for the first trimester is considered necessary to prevent miscarriage but when I wanted to continue on a half dose of the Metformin for the rest of my pregnancy I was told by a midwife that I would develop "undetectable Gestational Diabetes." I switched to a different practice.
During my pregnancy I had to do the glucose tolerance test twice (16 weeks and 24) and passed (and nearly passed out as well). I had no indications during my pregnancy that I had GD and I gave birth to a 7lbs. 13 oz. baby at nearly 42 weeks gestation.
For my next child I will refuse the test but continue to be vigilant for symptoms and continue with diet and exercise. I cannot imagine that this test is good for either the mother or the baby since so many people report negative reactions.