by KMom
Copyright © 1998-2002 KMom@Vireday.Com. All rights reserved.
DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider.
CONTENTS
When you are diagnosed with gd, you have to start testing your blood sugar, often between 4-12x a day. What kind of glucometer is best? Should you buy your own glucometer or just rent one? Does insurance usually cover the cost of a meter and the strips? How do you take a blood sugar reading? How often will you need to test? What conditions could throw off the results of the testing? What kind of maintenance is needed for a glucometer? How can you make the testing easier and less painful? What kind of records should you keep?
All of these are important questions, and this section is an introduction to the care and use of blood glucose meters, and hints on making daily testing easier. Remember, though, that each meter is different, and that technology changes all the time; in fact, improvements and breakthroughs in home diabetes equipment are being made these days at a very rapid pace. The information contained here may not pertain to your equipment or may become outdated over time. Be sure to read the instructions insert on YOUR meter and to consult your diabetes educator. They are the best experts on the subject!
Other questions about meters and testing not covered here can be answered by the newsgroup, misc.health.diabetes. It has a very comprehensive FAQ on diabetes which covers many testing questions, and links to many other sites which could provide answers as well. In addition, posters to the main group would be happy to help you in whatever way they can. Just post to the group and ask your question. (You can request that they answer you through private email, if you prefer.) Few of the group members are familiar with gestational diabetes issues (as opposed to 'true' diabetes issues), but are extremely well-versed in testing and meters, etc. and would be an excellent further resource for questions on equipment matters.
As always, Kmom urges readers to do their own research, consult their providers, and to become a PARTNER in their own care. Take responsibility for learning as much as you can about the process!
If you are diagnosed with gd, you should get a blood glucose meter if at all possible. Self-monitoring has been shown to improve outcome and allows you to participate more in your own care. It give you immediate feedback and gives you an idea of how your blood glucose (bG) control is going. It lets you know quickly if there is a problem, and can help you find out which foods you are most sensitive too, if you are likely to get too low during exercise, or if you need to adjust your food plan somewhat.
In the past, before home glucometers were invented or became accessible to the average person, mothers with gd would have to go into the doctor's office every week or bi-weekly and spend 2-3 hours having an office lab test of their levels. This tended to underestimate the cases that needed insulin, and also only represented a snapshot of that particular day's control. However, it was the only method of monitoring available, so that's what was used.
Once home glucose monitors were available, it vastly improved the amount of data and feedback available to base decisions on, but not all insurance companies would cover rental of a glucometer and coverage of the expensive testing strips. Over time, however, most insurance companies have come to recognize the importance and power of DAILY readings instead of weekly or bi-weekly readings, and most now cover at least part of the cost of a glucometer. Nearly all cover it if insulin is required; most will also cover it for mothers who have good control through dietary means alone.
So rental of glucometers is usually covered under most insurance plans, once a gd diagnosis is confirmed. However, you should strongly consider buying a meter instead. Having your own glucometer would come in handy in a number of ways, both short-term and long-term. You will need a glucometer all through the pregnancy and once pregnancy is over, it can be used to help confirm that your bG levels have returned to normal. You will definitely want a meter if you decide to have a subsequent child (you need to establish ahead of conception that your bG levels are normal, and you should closely track your bG levels after conception, even prior to taking any oral glucose testing.)
Finally, since women with gd have a higher chance of developing type II diabetes, a glucose meter can be used periodically to track bG levels even after you are finished with childbearing. Type II diabetes is a silent disease for many years before any symptoms appear; by the time symptoms show up, a great deal of damage is already done. If you do an occasional monitoring of yourself at home every few months and a more formal monitoring every year with your doctor, then you should be able to tell early on if you develop diabetes. This can help prevent a great deal of the damage diabetes can do, improve your prognosis, and help prolong your life. So owning your own meter is an excellent idea and a good long-term investment that may actually improve your health.
Due to insurance coverage, you might want to rent it first and buy it shortly before delivery, or you might wish to simply outright purchase it. Most insurance companies (but not all) will cover the cost of rental plus the testing strips; if you buy your own, they probably will continue to cover the strips but it's worth inquiring about first. You might also want to ask if your insurance company has a deal with a specific brand that will give you a price break, or if they have any recommendations on the subject.
There are many brands of meters available, and a diabetes educator may help you find a special low-cost deal on one. There are often rebate deals to be had with meter purchases. It is actually the strips that cost a lot of money in the long run, so it behooves the companies to give 'deals' on meters and then they have a customer for their brand of strips for life. A meter generally costs somewhere around $60-100 without rebates; the glucose strips generally cost between $.50 and $1 each.
That doesn't sound too bad, but consider that with diet-controlled gd, you generally must test 4x a day. At 50 cents each, 4x a day for 3 months (most gd cases are found just before the last trimester), the cost adds up to about $180. For strips that run $1 each, the cost is more like $360, if your insurance doesn't cover it. Then consider that gd moms who need insulin are generally supposed to test between 7-12x per day, and the cost rises to between $315 (50 cents/strip, 7x/day) to $1080 ($1/strip, 12x/day). If a mom discovers she has gd early in pregnancy and needs insulin from early on, the cost could rise to as much as $2520 ($1/strip, 12x/day, 7 months) or more. Hopefully you have good insurance!
It should be noted that some strip brands are now touted as getting 'plasma-like results'. Basically, what this means is that the results have been adjusted to reflect the higher numbers usually found in official lab tests. Home monitors test using capillary blood; labs use plasma now. Some sources note that plasma results generally run about 15% higher than home monitor results, so the results you get on your official lab work may be higher than what you get at home. Most of these 'plasma-like' testing strips have results from 8-15% higher than other strips. This makes little difference for regular diabetics, for whom a 10-20 point difference is not that big a deal, but for women with gd in pregnancy, a 10-20 point addition can mean being put on insulin or not using insulin. However, the official cutoffs for needing insulin are generally plasma results, so it could be argued that strips that get 'plasma-like results' reflect more accurate data and might be helpful. Either way, you should know what type of strips YOUR meter uses, and be sure that your provider understands which type you have and clarifies for you what that means in terms of cutoffs and interpreting results.
Kmom is no expert on the different types of meters available; all she can say is that she's personally used both the One Touch and the Accucheck Advantage meters and both were fine. There are many other fine brands available as well. The Accucheck Advantage was cheaper and a bit more user-friendly but tended to run high; the One Touch often comes with more 'bells and whistles' in some of its models--you probably don't need those, but it's up to you. Advances in glucometer technology are coming very quickly these days; anecdotally Kmom has heard that there are new models even less invasive and painful to use than these (see below). So be sure to ask about the latest developments whenever you are in the market for a glucometer.
Some women feel very burdened by the idea of writing all their results down; if you know you are really bad about this and can't trust yourself to keep accurate records, then a meter with a memory chip is probably a good idea. Otherwise, a long memory and the ability to interface with a computer (it can plot your bG for you or report your results to your doctor in a moment) is probably adding unnecessary expense to your meter for your situation. They might make more sense for a type I diabetic or a child with diabetes; a gestational diabetic probably doesn't need all the bells and whistles. Some meters have testing strips that are much more expensive than others, so if your insurance doesn't cover these, cost may influence your decision some as well.
Most meters come with a basic memory, and that's enough for most women with gd. Some need more maintenance than others, and some are more sensitive to extremes of temperature and other conditions. Some are bulkier and more awkward to use, while others are streamlined and very user-friendly. However, most basic models are pretty similar, and you probably will be fine no matter what you buy. Ask your pharmacist and your diabetes educator which brand they recommend and why and that's probably all the input you really need. Most models work very well.
To buy the testing strips for the meter, go to your local pharmacy. You'll need to know the brand and model of your meter, of course. Many insurance companies will have your provider write a 'prescription' for the testing strips if they cover these; just take that to the pharmacy. If not, you will have to cover their cost yourself--take a wad of cash, these puppies are expensive! ALWAYS use the correct brand, always check the expiration dates, and always be sure your computer chips and test strips have matching codes. These things can all make a big difference in accuracy.
Please note that glucometers differ and while the above description fits most glucometers, the procedures for some may differ. Also note that while noninvasive (i.e., bloodless) glucometers are currently being developed, they are of little use to gd moms at the present time. Some of the new noninvasive prototypes rely on infrared light or electric current testing of blood, and some on saliva testing. However, these are not yet approved for common usage, and some may not be deemed suitable after extensive testing programs. Their huge expense and the reluctance of insurance companies to cover them will also be a significant barrier to their use for gd patients, even if they do get approved eventually. They would make more sense for type I or II patients who must test extremely frequently and for a great percentage of their lives. GD patients, who need to test only for short periods of time, will probably be the last to have access to these bloodless devices, when they do come to pass. So while these will eventually become a reality, don't hold your breath waiting for them!
A New Option: The Freestyle Blood Glucose Monitoring System
(Review by "Anne D" for Kmom's site; all rights reserved)
The Freestyle Blood Glucose Monitoring System is manufactured by Therasense, www.therasense.com, 1-888-522-5226). Like other home glucose monitors, the Freestyle system includes a lancing devide, lancets, test strips, and a hand-held glucose meter which determines how much glucose is present in a blood sample.
However, unlike other systems, the Freestyle lancet is used not on the patient's fingertip, but on the forearm or leg, which have far fewer nerve cells. The result is a less painful prick with less chance of bruising and tenderness. Additionally, the days of squeezing and scrunching to get a sizable sample are gone; the Freestyle meter requires only a tiny dot of blood.
When I was diagnosed with gd at 8 weeks pregnant and learned that I would have to test my blood sugar 6-8 times and take 3-4 shots every day for the next several months, I immediately decided that the Freestyle system was for me. I had learned of it through a friend who has a daughter with Type I diabetes. Her daughter had hated using the finger prick machines because, like most of us, she had the good sense to hate pain!
I am thrilled with my Freestyle meter. I am having a complicated pregnancy, and it is nice not to have to inflict pain upon myself several times per day. I use the lancets on my forearms, and it honestly does not hurt! I was impressed that Therasense has a 24-hour information line. The person who took my call was helpful and knowledgeable about the product and about diabetes and blood glucose testing. If I had anything negative at all to say, it would have to be the fact that the machine requires a AAAA battery, which is somewhat non-standard and harder to find. When I called Therasense and asked where to get them, I was given the following list of stories that carry AAAA batteries:
- Acme
- Office Max
- Safeway
- Target
- Circuit City
- Rite Aid
- Ace Hardware
- Radio Shack
- Staples
I bought my system at Walmart Pharmacy. I paid up-front and was reimbursed by my insurer; check with your insurance company. If you don't have insurance, contact your state's medical assistance department; most states have programs for pregnant women. Check with county, state, or regional prescription programs. Ask your doctor or pharmacist how to get help.
In gestational diabetes, the health of both mom and baby are on the line. Like the man on those television commercials says, "You test your blood sugar, and you test it often. There's just no reason not to."
Once in a while, it's important to use a control solution to double-check the accuracy of your meter's readings (the directions that come with the glucometer will give more specifics on how to do this). Basically, the control solution will test to see if you meter is performing within normal parameters. If it is not (and this happens on occasion), then the readings you will be getting will be invalid, and the treatment you are prescribed may be based on invalid data. So it is very important to use the meter the EXACT way it was designed to be used, and to check its accuracy every so often.
If your readings are suddenly abnormal or highly unusual, check the testing strips to see if they are the problem, and then test the meter to confirm that it's operating normally too. If all of these are still correct, see the section on Troubleshooting High Readings to determine other possible causes of problems, or typical guidelines for when insulin becomes necessary. Remember that home monitors are not 100% accurate; it is generally thought that most home meters have a accuracy range of +/- 10 points.
It is important to operate bG meters within certain parameters. For example, they should not get too hot (>100 degrees F) or too cold (<60 degrees F) or the results can be thrown off. It is also important to keep the strips at room temperature, tightly capped between uses, and away from excessive humidity. A too-small blood sample can cause an error, as can a strip used after the expiration date on the can, or one exposed to excessive temperatures/humidity. Only capillary blood should be used (not venous blood, generally), and it should be noted that the results of severely anemic women (hematocrit less than 30%) might turn out falsely high, according to some glucometer inserts.
Other things that can falsely cause high readings include food or other substances on your hands (even in minute amounts), or using testing strips that do not match the computer chip currently in your glucometer. Some glucometers note that high doses of acetaminophen (i.e., Tylenol) can artificially raise bG results. Because of all of these limitations (and new ones are constantly being found), take great care to read the package inserts that come with your glucometer and strips and minutely follow all the directions therein.
Some meters need to be cleaned every so often or the accuracy deteriorates; others boast that little or no cleaning is necessary. Cheaper meters and older models generally need more cleaning. Getting blood on the meter instead of the strip, in particular, can cause problems. For specific guidance on cleaning and maintenance of the meter, be sure to read the enclosed guidelines carefully. It really can make a difference!
To check your blood sugar, you will need a soft pen injector, lancet needles that insert into the injector, the glucometer, and blood glucose testing strips. Usually the strips come with a computer chip that inserts into your meter to program it for your particular lot of strips, etc. Most glucometer kits also come with a convenient and discreet carrying case that everything fits into, which is very handy.
You should also have a pencil and pad of paper or booklet to record your bG readings in; keep these long-term, even after the pregnancy is done, since sometimes the information can be useful to refer to later. Many of the newer glucometers come with memory abilities and you do not have to write down every reading, but Kmom still suggests that you do it anyway. They are easier to refer to, allow for quick and easy comparison, and you can write down important notes regarding exercise or food choices that may have impacted a particular reading. This can be important in tracking down a problem food or establishing a problem pattern at certain times of day. Remember, don't throw them away after the pregnancy; Kmom has learned a number of important items from her bG journals, even years after the gd pregnancy was finished. You never know if they might be helpful at some point later in time! So tempted as you may be to have a ceremonial burning of the bG journal and glucometer, don't do it.
To test your blood sugar, wash your hands first (very important), then get out your meter and set it up. Turn on the meter, and when it prompts you, insert a bG test strip. When it says it's ready for blood, cock back the spring-loading mechanism of the pen injector, then apply the end towards the side of one of your fingertips and press the release button. This causes the lancet to dart forward quickly and draw a bit of blood. You then squeeze your finger gently to get a nice big droplet of blood and apply it onto the test strip in the marked spot. If you have too little blood, it will cause an error and you will have to repeat the whole process, so be sure to get a good hanging droplet, enough to cover the whole yellow mesh area of the strip by drip only (don't wipe it on). However, some sources note that 'milking' the finger a lot will increase the amount of interstitial fluid in the drop and may alter your results somewhat, so be careful not to squeeze too vigorously. A few test strips now enable you to apply a second drop afterwards (within 15 seconds) if the first doesn't completely fill the test area, but not all testing material can do this, so it's best to get it right on the first shot. And besides, who wants to have to prick your finger more times than absolutely necessary?!?
Once you have put the drop of blood on the strip, most of your work is done. The strip is chemically treated and reacts with the blood glucose--the more glucose, the greater the reaction. Then the meter 'translates' the reaction into numbers that reflect your blood sugar level and displays them on the screen. All this usually takes place within 30 seconds or so, so testing really is a quick and fairly easy procedure. The finger-pricking does hurt some, and many women feel it's the hardest part of having gd! (Kmom agrees!) However, there are techniques to make it easier and less painful, and really, it's not that bad, plus over time you will learn how to minimize the initial discomfort. After a while, it ceases to be that big a deal, though it will probably never become your favorite task of the day.
If you have difficulty getting a good drop of blood for the test, there are a few hints that may help. First, wash with WARM soapy water, and then rinse and dry them completely. Warming the hands can sometimes help increase blood flow, as can letting the arm hang down briefly before testing. Some companies recommend pricking the side of the fingertip while holding it down as much as you can, but remember not to squeeze excessively hard to get the drop of blood. Some fingers have more calluses and pad thickness than others; the pinky and ring finger may be more easy to get blood from in some people, while the other fingers may require some equipment adjustment (see below). Finally, pricking closer to either side of the fingertip may be easier for many people. The tip tends to have more calluses, and the center and tip of your finger have the most nerve endings. The edges have lots of small blood vessels and less nerve endings, so it's both easier to get blood there and less painful.
Be sure to write down your test results accurately, and note if your testing is early or late, plus any other factors that might have influenced your readings. Many doctors rely simply on your written notes of your readings, but an increasing number are downloading the readings from your machine's memory in order to double-check your numbers. Some studies have shown that a surprising number of women are lying about their results, a shocking occurrence when you consider that the health of their child may possibly be affected.
One case study even documented a fetal death from patient deceit (back in the days of weekly lab testing instead of daily self-testing); the mother had a severe eating disorder and would eat 'correctly' for the day of the test but binge outrageously during the rest of the week. Her baby was stillborn. In all likelihood, she had a very severe case of gd, possibly pre-existing before the pregnancy, and her bingeing must have been pretty outrageous; prenatal mortality is an extremely unusual consequence of gd, generally found only in very severe and uncontrolled cases. But it's a cautionary tale to the temptation to alter the inconvenient or frustrating test result. Our providers need accurate data on which to base treatment decisions. If you have a high reading, try to figure out why, don't try to hide it. (See the websection on Troubleshooting High Readings.)
Kmom's Precautionary Tales of Testing Woe
I have had falsely elevated results in the past because of several inadvertent testing mistakes. Take warning from the common mistakes that I (and others) have made! These are very easy to overlook.
Several times I have had tested my bG after cutting up some fruit for my toddler, and in the craziness of trying to care for a small child, have forgotten to wash my hands. This strongly elevated my readings! (Oh, boy, did it ever!) ALWAYS wash your hands before taking a reading; if you use alcohol on your fingers, let it dry before starting. (Generally speaking, they don't recommend using alcohol on the site anymore.) I also have used it in too-cold conditions a few times, or have had trouble getting enough blood on the strip, and these have also caused problems in getting readings.
My biggest scare happened between pregnancies. I lent out my meter to a friend with gd, then retested my bG when I got it back 6 months later, only to have my readings come up consistently quite high for me. Since I was planning to start trying for a new pregnancy within a few months, I was afraid I would have to start using insulin BEFORE even conceiving. With great dread in my heart, convinced that I was already nearly diabetic, I saw my health provider, who recommended that we verify the tests before taking any action like starting insulin before pregnancy. So I had my bG tested by a lab, only to find out it was perfectly normal. This was confirmed by the glycosylated hemoglobin test as well.
Turns out that, being cheap, I had used the strips the friend had given back to me without checking the expiration date--they had recently expired. When I switched to a new bottle of strips after running out of the old, my readings immediately dropped significantly to their normal range, thank goodness! Using the expired strips raised my bG by well over 25 mg/dl fasting, and that was only 1-2 months after they expired. 25 mg/dl may not seem like a big increase (and outside of pregnancy, it's not that big a deal), but with the stringent protocols demanded for pregnancy, it would have made a significant difference, believe me. A reading of 80 mg/dl in pregnancy would be considered well within normal range, but a reading of 105 mg/dl would be enough to be put on insulin by anyone's protocols, and would be kicked into the high-risk category, early delivery, and many other unnecessary protocols. All because of forgetting to double-check the expiration date!
Since these strips rely on chemical reactions to measure our bG, we must be very careful to observe scrupulous testing conditions with them, or we may overreact based on false data. I became convinced through those false readings that I had somehow suddenly become diabetic, despite all my numbers being terrific 6 months before. I found this extremely depressing and was devastated at the thought of needing insulin before I even started my next pregnancy. If I had not had a provider that insisted on confirming things with lab tests, I might well have been placed on insulin unnecessarily, and who knows what effect unnecessary insulin has on a pregnancy?
My 'scares' have taught me to know everything possible about the meters and what can influence readings, and to explore carefully the cause of any high numbers. It's quite possible that they may be valid, but it's vitally important to rule out other possibilities. You don't want treatment decisions being based on invalid data!
Most treatment programs have you test around 4x per day (fasting, then after each meal); a few permit less tests if all is going well. If you need insulin it might stay at 4x per day or go up to 6-8x per day (fasting, then before and after each meal and perhaps at bedtime). A few of the most extremely interventive treatment programs even have their patients test up to 12-13 times per day, but this is extremely unusual. 7x per day is the most common figure for insulin-dependent pregnant women; 4x per day for non-insulin-dependent women.
All this testing can play havoc with your poor fingers! Each person develops their own method of dealing with all that finger-pricking, but this is the system that seemed to work for Kmom.
Kmom's Story: Having tested through three pregnancies, there are times when I only had to test 1-2x a day or less, and times when I had to be careful to test religiously 4 or more times a day. The less I needed to test, the more flexible I could be about finger choice, but the more frequently I had to test, the more I used a regimented finger order. For those times, I alternated hands each day. On my bG diary, I wrote down 'R' or 'L' for each day so I would remember which hand to use. Then I designated one finger for each blood test. My pinky was always for fasting, my ring finger for breakfast, middle finger for lunch, and 'pointer' for dinner. For some people that would be too rigid, but I found over time that I tended to overuse some fingers and not others, and designating an order was easier on my fingers. Sometimes the calluses on the middle and index fingers made it hard to get enough blood, so at times I substituted a second prick on a ring or pinky finger, using on the other side of the finger instead.
I also found that the 'soft pen' injectors were less painful than others, and that they often come with different sized buffer rings (caps) to adjust how hard and deep they penetrate. This can make a real difference! I know my husband needs the cap that makes for a more forceful setting, whereas that level is very painful to me (as I found out to my dismay!). Be very sure to use these buffer rings; my diabetes educator warned me that sometimes people forget to fully install these and it makes for a very painful procedure, a warning I can also attest is true from personal stupidity. Choosing the right-sized buffer ring/cap and using it correctly is extremely important in minimizing pain, as is investing in a very good brand of lancet (needles for pricking fingers) and pen injector device. Ask around.
Another thing that can help the pain of testing is where you prick your finger. Off to the side some (but not too much) can be very helpful, and some people find the top ok too (I don't). Over time you will learn how to manage things to minimize the discomfort, but some days you really have to talk yourself into the pricking---or at least I do! It's ok to gripe to yourself about having to prick, but remember that you are doing this for the health of your baby. If you keep that in mind, it's a little easier. Practice over time also eases the procedure some too.
Questions to Ask Your Diabetes Educator About Self-Testing
Your diabetes educator will instruct you in the proper technique for using your equipment and testing. Some instructors tell people to clean the testing site with alcohol before starting, but a few sources have said that this can cause an inaccurate reading (the issue may be letting it dry thoroughly before testing). Long-term use of alcohol on the skin tends to dry it out and may make for more skin problems at the testing site; it's generally acknowledged that using alcohol to 'sterilize' the site ahead of time is unnecessary and that washing your hands with soap and warm water first is perfectly adequate. You will need to clarify your particular recommended protocols with your instructor.
Also ask about procedures for checking your meter's results with a 'control solution' and about cleaning the meter, since some meters need regular maintenance while others need much less. A further question to ask for advice on is the question of needle disposal. Some diabetes educators prefer that you use only a container designed for disposing of 'sharps', though this tends to be more true if you are also needing to use needles for injecting insulin. For lancet needles (for daily bG monitoring), educators tend to be less picky, though of course, advice will vary. Kmom's instructor was agreeable to using plastic juice or pop bottles for used lancets and blood strips and then taping the lid shut. Please do not dispose of needles or used lancets loose in the trash; always place them in some form of protective container. This is simply common sense and courtesy. In some places, it is also the law.
Finally, be sure to keep a VERY careful log of your numbers each day. Note any special circumstances around each number, possible 'trigger' foods or notes on food intake, timing and amount of exercise, and other pertinent information like ketone test results, illness, unusual stress, etc. that might have a bearing on your readings. A careful log of your number patterns can be extremely useful in many different ways, even long after the pregnancy is done, so try to keep the record long-term. Be sure to take your log and meter with you when you see your providers. Some will ask to see it while others will rely on your self-reported results, but having it there to refer to in case there is any question or issue that needs clarification can be very important.
Best wishes on your testing adventure! Self-testing can certainly be a drag at times, but it really offers you a great deal of extra control over your own situation. Be sure to learn all about your own meter (read the package insert for it!) and understand how small changes in condition and use can affect your data. It is critical for your treatment to be based upon ACCURATE information.
How you approach testing is key; having a positive attitude about it really helps. Testing seems like the end of the world and a real imposition at first, but as you get used to it, you'll realize that it as not as bad as it seems at first, and that you really CAN manage to test your blood several times a day without fainting! Good luck, and hang in there!
----Kmom
Home Glucose Monitoring
Langer O et al. Intensified versus conventional management of gestational diabetes. American Journal of Obstetrics and Gynecology. 1994. 170:1036-47.
Studied 'intensive management' (home monitoring on a glucometer 7x/day) versus 'conventional management' of gd (weekly lab tests and testing strips 4x daily) to see if more frequent and exact monitoring resulted in better outcome, or whether the old standard of lab testing at the OB's office every week or two was enough. Intensive management resulted in much lower rates of macrosomia, c-section, metabolic complications, shoulder dystocia, stillbirth, NICU days, and respiratory complications, to levels comparable to that of nondiabetic controls. Both conventional and intensified management had the *same* goals for treatment and insulin cutoffs, and both used diet and diet+insulin treatment arms; the main difference was the amount and type of monitoring used. This was not a study of diet-only vs. insulin, or regular insulin use vs. prophylactic insulin, although it is sometimes mistakenly cited as such. The more frequent monitoring with a more exact instrument (glucometer) led to 63% of the intensive group being put on insulin, as opposed to only 23% in the conventional management group. The more favorable results in intensive management could be because more insulin was used or simply because previously undiscovered high readings were found and treated--that too many questionable blood sugars were 'getting by' without appropriate treatment. "The intensified management approach is significantly associated with enhanced perinatal outcome. This management strategy clarifies the relationship between glycemic control and neonatal outcome." The study has been criticized by peers for not being truly randomized when it should have been, and that the delivering physicians weren't blinded to the treatment group the patients were in, which could have affected delivery decisions and affected c/s rates, etc. However, the main point of the study (that more frequent, exact measurement resulted in better outcomes) remains mostly intact, and is used to justify insurance coverage of home meters and supplies for gd.
Goldberg, JD et al. Gestational Diabetes: Impact of Home Glucose Monitoring on Neonatal Birth Weight. American Journal of Obstetrics and Gynecology. March 1986. 154(3):546-50.
Compared two groups of 58 gd patients each. One group's bG was measured simply by a weekly 2 hour postprandial blood draw at a clinic; the other group's bG was measured with a home monitor 4x daily (fasting, plus 3 one-hour postprandials). Home monitoring apparently 'caught' more patients needing insulin therapy (same standards for starting insulin were used with both groups); 50% of home monitoring group needed insulin as opposed to 21% of weekly testing group (whose fastings weren't taken either). A combination of the home monitoring and perhaps more insulin use lowered the macrosomia and Large-for-Gestational-Age infants (macrosomia from 24% to 9%; LGA from 41% to 12%). However, the purpose for reducing macrosomia was defeated; the c/s rate was INCREASED in the home monitoring group, despite the strong decrease in birthweight (32% c/s in home monitored group vs. 25% in weekly testing group). Still, if presumed physician bias towards c/s could be eliminated, the home monitoring showed it was very helpful in preventing macrosomia. Even more notable is the author's contention that "Home glucose monitoring and selective insulin therapy have made it possible to achieve an overall incidence of macrosomia equal to that achieved with prophylactic insulin treatment of all gestational diabetic women. Thus we recommend the use of home glucose monitoring for all gestational diabetic patients to individually tailor their management and to identify those needing insulin therapy."
General GD References
American Diabetes Association Position Statement: Gestational Diabetes Mellitus. Diabetes Care. Volume 21: Supplement 1, 1998. http://www.diabetes.org/diabetescare/supplement198/s60.htm
Official 1998 position statement on the definition, detection, diagnosis, and therapeutic strategies for gd. However, "Currently there is a committee considering a major revision of this position statement based on the 4th International Workshop on Gestational Diabetes Mellitus."
Carr, DB and Gabbe, S. Gestational Diabetes: Detection, Management, and Implications. Clinical Diabetes. 16(1):4-24, 1998 Jan-Feb. http://www.diabetes.org/clinicaldiabetes/v16n1j-f98/pg4.htm
Outstanding article summarizing gd testing, management, and even some of the controversies involved in gd, though from a traditional medical approach. Excellent overview, but may be too technical for beginners unfamiliar with some of the terminology and issues in gd. Those more familiar with gd terms and issues will find it invaluable, and beginners will want to return to it when their understanding increases.
Diabetes and Pregnancy, ACOG Technical Bulletin (An Educational Aid to Obstetrician-Gynecologists), #200--Decemeber 1994.
The definitive summary from the American College of Obstetricians and Gynecologists; it covers pre-existing diabetes in pregnancy as well as gestational diabetes. Technical but still readable. This is the 'bible' many doctors rely on for advice, and represents the current standard of care in the field. A must-read for those seriously interested in the subject.
Jovanovic-Peterson, Lois, M.D. with Morton B. Stone. Managing Your Gestational Diabetes. Minneapolis: Chronimed Publishing, 1994. To order, write P.O. Box 59032, Minneapolis, MN 55459-9686, or call 1-800-848-2793.
A good introduction to gd issues by one of the leading researchers in the field, who also happens to be diabetic (Type I) and a mother herself. Be aware her treatment guidelines in this book are quite conservative and not all providers use the same guidelines. Her writings also contain some patronizing and fat-phobic statements (fat people "live to eat rather than eat to live"). But she is an excellent introduction to the conservative approach to gd. She happens to be a very prolific writer in the field, so she tends to dominate the available published material on gd. Many more articles and books are available under her name.
Gestational Diabetes: What to Expect, The American Diabetes Association, Inc. Alexandria, Virginia: American Diabetes Association, 1992. To order, write to the ADA, 1970 Chain Bridge Road, McLean, VA 22109-0592, or call 1-800-232-3472.
The standard intro to the subject, written by the leading authorities on diabetes. A good, easy-to-read summary for those not desiring a great deal of detail. It is, of course, the standard medical approach to gd and does not contain any discussion of the controversies involved in gd. Definitely read this text as one of your first introductions to gd, while also keeping in mind that alternative views do exist.
Weller, KA. Diagnosis and Management of Gestational Diabetes. American Family Physician. 53(6):2053-7, 2061-2. May 1, 1996.
A review of gd treatment regimens, though it tends to be much less intervention-oriented than many treatment regimens found in endocrinology and obstetrics literature.
Hod, M et al. Gestational Diabetes: Is It a Clinical Entity? Diabetes Reviews. 3(4):602-613, 1995.
A review of the debate over whether gd is really a problem, with a strongly affirmative conclusion about the dangers of gd and the effectiveness of treatment. Advocates lowering treatment thresholds even further. Has the most astounding list of newborn treatment test protocols Kmom has ever seen listed, and some of the most extensive prenatal treatment protocols for the mother, too. Definitely worth reading for a representation of an extremely traditional view of gd and gd treatment.
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