Gestational Diabetes: What If I Need Insulin?

by KMom

Copyright 1999-2000 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. This particular web section is designed to present more than one view of a controversial subject, pro and con. It should be re-emphasized that nothing herein should be considered medical advice.  Please also note that Kmom has had no personal experience with insulin injections; she has relied on others' experiences with it as well as gd guides for the information in this FAQ.   

CONTENTS

 

Who Needs Insulin?

In some gd pregnancies, a woman's body is not able to compensate adequately as the pregnancy progresses and administration of outside insulin ('exogenous' insulin) must be instituted. This is because insulin resistance tends to increase as the pregnancy progresses and placental hormones increase. Although 4 of the 5 most diabetogenic hormones peak at about 26-28 weeks (this is why gd testing usually occurs at this time), the fifth hormone, progesterone, does not peak until a month or more later. Most women's bodies are able to compensate enough for the increasing insulin resistance if the mother regulates her food intake and timing, but some women will need extra insulin from outside sources at some point in the pregnancy.

Basic Information

According to the Amercian Diabetes Association, about 15% of women diagnosed with gd will go on to require insulin in order to keep their bG levels within desirable levels; however, many research studies show much higher rates of insulin use, some more than 50%. A great deal depends on the philosophy of the provider, the diagnostic levels at which the provider begins insulin use, and whether alternative therapies are attempted first. In addition, many providers are experimenting with prophylactic ('preventative') use of insulin, even in cases where women do not quite meet the usual cutoffs for insulin use. So the percentage of women needing insulin during the course of a gd pregnancy can vary greatly.

Some women who need insulin are diagnosed immediately upon testing, but most start with dietary control and only come to need exogenous insulin as the pregnancy progresses. The sooner you need insulin in the pregnancy, the more difficult bG levels often are to control and the more serious your case is. For example, if you need insulin in the first trimester, most providers would assume that you were in a pre-diabetic or borderline diabetic state already before the pregnancy began, and therefore your baby is at a greater risk. More tests would be ordered to check on the baby's well-being and more monitoring of labor and delivery will be required. However, the majority of women who need insulin are diagnosed later and are able to control bG levels at first with diet alone. Over time, however, some women's bG levels become harder and harder to control, necessitating insulin be added to the dietary program.

Most Commonly Used Cutoffs for Insulin Use

Different health providers can have vastly different standards as to when insulin becomes necessary. Generally, most providers would prefer your fasting numbers to stay at or below 90-95 mg/dl (around 5.0 mmol/L) but will not put you on insulin unless you have two or more fasting numbers over 105 (or if your GTT fasting result was over this). 105 mg/dl is the cutoff used most often by American College of Obstetricians and Gynecologists (ACOG) members. However, there are providers who are more aggressive and will place you on insulin if your fasting numbers go over 100, 95, or even 90. There is some limited evidence that a fasting cutoff of 95 might be more desirable in preventing macrosomia, but this issue is still under debate.

Be sure to ask your provider what their insulin standards are and why. It must be your own personal decision whether to stay with a provider whose insulin cutoffs are lower than the generally accepted standard of care. It is unknown whether this is more beneficial to the pregnancy or whether it introduces more problems. The issue of cutoffs is a very controversial one within the field with many advocating to lower the cutoffs and others staunchly refuting the reasoning behind lowering cutoffs. The best thing to do is to research the issue closely, discuss your provider's reasoning, and then make your own informed decision. However, it is very important to know that providers do differ on this issue and your choice of provider makes a critical difference in your care regimen.

A routinely elevated fasting number is generally considered strongly indicative of a need for insulin, and tends to be the least responsive to other measures such as dietary control and increased exercise. However, sometimes it can be helped by these measures, and if it is borderline, should be given a trial of a week or two of diet and exercise programs to see if it resolves with treatment. If the fasting numbers are high enough, however, insulin is probably the treatment of choice, since very high fasting numbers may increase the risk of perinatal mortality.

Postprandial (after meal) readings, on the other hand, tend to be more amenable to treatment through diet and exercise changes. Some providers will allow more leeway with borderline post-prandial readings, but some will not. It used to be traditional to test only before meals, not afterwards, but some research has found that postprandial elevations are associated with macrosomia, and that watching postprandial readings more carefully can help. The typical testing routine nowadays is usually post-meal instead of pre-meal, although a few providers may have you do both.

Borderline postprandial numbers can sometimes be attributable to variables such as whether you ate your protein with your carbs, whether your meal got too spread out over time, whether you had a 'trigger' food that gives you a particularly high reading, whether you had excess stress or an illness, etc. If you have a high or borderline reading, always go wash your hands and retake your reading again to be sure it is accurate. Note any special foods or circumstances that may have contributed to this high number. Most providers look for a pattern, for very high numbers, or successive high/borderline numbers. An occasional borderline number here and there is not usually considered grounds for prescribing insulin by most providers, but of course remember that providers do not all follow the exact same guidelines. (For more information on things that can cause aberrations in bG readings, see the websection on Troubleshooting High Numbers.)

Post-prandial (after meal) reading recommendations vary a bit, so inquire closely as to your provider's guidelines on timing and measurement. The most common guideline is for <120 mg/dl (6.7 mmol/L), two hours after the start of your meal (be careful not to drag your meal out too long!). Some providers vary this and call for a reading of 140 mg/dl (7.8 mmol/L) after a meal, with some requiring that this reading be done an hour after the start of the meal and others requiring the reading be done an hour after the end of the meal. It can get confusing, so be sure you have all the timing issues clearly explained to you.

In addition, there is a wide variation of the requirements for postprandial standards. A few providers are reportedly relaxing the post-prandial requirements considerably, as long as the fasting numbers remain perfect (preferably below 95). One mainstream OB even quoted 180 mg/dl as the post-prandial number at which she would begin insulin, as long as the fasting numbers were fine! However, many providers are also tightening the post-prandial requirements. Some are requiring levels of 130 or 120 one hour after the meal. A few providers are demanding even stricter levels, such as 107 postprandial. However, the vast majority of providers still follow the 120 (after 2 hours) or 140 (after one hour) rule.

 

The Basics of Using Insulin

All About Starting Insulin

If you are diagnosed as needing insulin, you will need extensive education in how to manage your diet, exercise, injections and monitoring for low blood sugar reactions. You will probably see a diabetes educator, and possibly an endocrinologist. When teaching you to handle the insulin, you may go to a doctor's office, a special clinic or outpatient program, or they may hospitalize you. The rationale for hospitalization is that although rare, some people can have reactions, either to the insulin itself (like an allergic reaction) or to the amount they give you. They need to be able to get some glucose solution into you quickly if your blood glucose (bG) levels plummet. They often put in a heparin lock so that they have an open vein if needed. You are usually not permitted to leave the hospital or clinic until you can demonstrate that you can do the injections and self-care required. However, more and more providers are abandoning routine hospitalization for starting insulin in favor of out-patient programs; you may not need to go to the hospital at all if you end up starting insulin.

The amount and types of insulin will be adjusted quite a bit at first until you get a good 'fit' with your dosage; expect that these will change as pregnancy progresses. Some women need to have their insulin dosage adjusted as often as every week to ten days. They usually need to increase the dosage as the placental hormones increase, but by the last 1-2 weeks of pregnancy, a few insulin-dependent women need to have their dosages decreased a tad. It is important to watch for this, as some women can experience hypoglycemic episodes if their dosages need adjustment but go unchanged.

Only synthetic human insulin is used now, since it is better tolerated and animal insulin can cause resistance or allergic reactions. Insulin must be injected (into the skin, not a vein). It cannot be taken in pill form because it is a protein and would be broken down during digestion before it could work. Non-pregnant diabetics can often take oral medications that improve blood sugar before having to resort to insulin, but this is not an option for pregnant women because these can cause birth defects. So if your bG numbers cannot be controlled through dietary means, insulin is your only other choice, and you will have to do the injecting. While this sounds terrible, most insulin-users say it is not too bad once you get used to it.

It is beyond the scope of this FAQ to discuss dosage requirements; this is information you need to get from your provider and diabetes education team. Finding a balance of type of insulin, amount, frequency, and timing is extremely tricky. Simple cases that respond well to basic insulin protocols can often be handled by an OB, but many OBs prefer to consult with an Endocrinologist, and this is particularly important if you have trouble controlling your bG or get uneven results.

You need to pay extremely close attention to how to balance intake and timing of food, insulin, and exercise. These can be very tricky to balance at first and if you are not careful, you can get a low blood sugar reaction which is not good for you or for baby. Exercise can play a very important role in managing gd but you must consult your provider carefully about it first.

Types of Insulin

There are two main types of insulin used for pregnant women, regular (R) and intermediate-acting (NPH). The difference between these is how quickly they act on your blood sugar, and how long their effect lasts.

As noted above, animal insulin is not used anymore because of the potential for allergic reactions. Only synthetic human insulin is used today, as it tends to be purer, absorbed faster, and causes fewer problems than animal insulins.  Other types of synthetic insulins exist but are not usually used for pregnant women at this time. 

You should store the bottle of insulin you are currently using at room temperature; cold insulin can make injections more painful. Never freeze insulin or put it in direct sunlight; insulin should not be exposed to extremes of temperature. However, extra bottles of insulin not in current use can be stored in the refrigerator, as long as you let the next bottle warm up gradually before you use it. It is important to always check the expiration date on insulin; never use insulin with an expired date. Most NPH insulin is cloudy, which is normal, but your insulin should not have crystals or frosting on the bottle or in the insulin.

Your doctor will determine the dosage and combination of insulins you will need; many gd moms start out on a combination of the two insulin types, but your needs may differ. Some gd mothers do fine on one insulin injection per day, but most do best with multiple injections at various times of day. Consult your provider and be sure to ask plenty of questions. There will probably be a period of frequent adjustment and experimentation at first; it's not unusual to have your insulin dosage and timing changed every week or two, especially at first. In very very rare cases, some women have a lot of trouble with bG levels despite their insulin regimen; a few providers will occasionally consider an insulin infusion pump in these cases, as this delivers a continuous flow of insulin. However, this is mostly seen during Type I pregnancies, and even then it is unusual. Most gd mothers do just fine on daily injections instead; almost never do gd moms get an infusion pump.

Once you have delivered the baby and the placenta, your bG will probably return to normal pretty quickly--within a day for some women, within a few days to a week or so in others. Breastfeeding tends to return bG to normal more quickly in many women, especially insulin-dependent ones. However, a few women (usually between 2-10%) remain diabetic or borderline diabetic even after pregnancy, so your provider should arrange to have your blood tested at 6-8 weeks postpartum.

Hints for Easier Injections

The needles used to inject insulin are usually very, very small and fine. Most women do not find the process to be painful or objectionable once they master the technique. Many women are greatly stressed in the beginning at the thought of injecting themselves with insulin, but most report that the insulin injections are not really that big of a deal, and often much less traumatic than the daily finger-sticks that accompany testing the blood!

Different providers give slightly different instructions on how to inject the insulin. Some tell you to avoid the belly area because you are pregnant, but many advise women to inject there instead. The folds of skin in the legs or arms are often another good choice. Choosing an excellent quality needle can often make a big difference in comfort for you; ask your diabetes educator for input on brands and types. Some gd moms have reported anecdotally that Becton Dickison Ultra-Fine II Short Needles (3/10 cc) are the least painful of all the needles they tried; of course your mileage may vary!

The following hints for injecting insulin are taken from the booklet, Gestational Diabetes: What to Expect, put out by the American Diabetes Association. Sometimes, recommendations vary somewhat; consult your provider and diabetes education team for their suggestions. However, these general suggestions seem to be very common:

Your diabetes team can also give you hints about making the injections less bothersome; common hints include injecting into skin and not muscle, not using cold insulin, taking great care with the needle angle, inserting the needle quickly, checking to see if the needle is blunted, etc. If your insulin injections are painful, something is amiss with your technique and you need to consult your diabetes team as soon as possible.

Watch for Hypoglycemia

An insulin reaction (hypoglycemia, i.e. low blood sugar) can occur if there is not a balance between the food you eat, the exercise you do, and the insulin you inject. Timing is critical when using insulin, so be very careful to adhere religiously to a set schedule. In particular, skipping or delaying a meal when on insulin can cause problems, as can exercising without sufficient energy reserves.

Symptoms of a reaction can include:

It is very important to test your bG as soon as possible if you experience these symptoms. Protocols for what constitutes hypoglycemia in the mother vary, but most sources say that if your bG drops below 60-70 mg/dl, you should take action. It is also important to record the incident in your bG diary/journal, along with details of when/how it occurred, and what you did to take care of it.

Treatment includes ingesting something to raise your bG fairly quickly, such as raisins, orange juice, milk, hard candy, or glucose tablets, but you need to discuss with your doctor or dietician beforehand exactly what and how much to use and what protocol to follow afterwards. Women who are using insulin should probably carry around a quick source of energy (such as glucose tablets, available at most pharmacies) at all times, so they can take action if they begin to notice hypoglycemia symptoms. This is especially important while you are exercising or traveling!

Ask your doctor whether you should also carry a card or bracelet/necklace that identifies you as needing insulin. If you are questioned about carrying hypodermic needles or if you have a hypoglycemic episode, this could be important to you. It's important to remember that hypoglycemic episodes in gd are NOT like those in type I diabetes; those in gd are not life-threatening. However, neither are they good for you or the baby, so it's important to watch for symptoms in yourself and alert those around you to possible signs.

Treatment for a hypoglycemic episode is generally more efficient if it includes a protein source with the bG-raising food; this helps the bG rise more slowly and steadily. Otherwise, you may experience a strong spike in bG from treatment with food, and then a steep crash later on, possibly precipitating another hypoglycemic incident. For women who have a tendency towards reactive hypoglycemia, it is particularly important to emphasize small frequent protein intake in order to prevent hypoglycemic episodes.

Differences in Blood Glucose Testing Protocols

You will probably be told to measure your blood glucose (bG) more often once you need insulin. Women who do not need insulin are usually instructed to measure their blood sugar 4x per day: fasting and once after each meal. Women who need insulin must usually measure their bG much more, though the recommendations do vary some from provider to provider. Typically, fasting measurements plus readings before and after each meal and a reading just before bedtime are used. Sometimes a reading in the middle of the night is added under certain circumstances (a woman who has a lot of ketones in her urine, etc.). So most women on insulin will be measuring their bG between 5-9 times per day, and may occasionally need to add even more readings during times of extra stress, exercise, or other special concerns.  A very few providers demand measurements as often as 12 times a day (fasting, before each meal, 1 hour after each meal, 2 hours after each meal, bedtime, and middle of the night), but this is quite unusual and you are not likely to encounter this demand.

All of this can be exhausting! Combining shots with bG measurements 9x a day plus eating 6x per day and getting in regular exercise can sometimes overwhelm women. If you have the financial flexibility, it might be wise to consider leaving work early if it's at all possible. The stress of having to deal with all of these protocols and the pregnancy and the job can be just too much sometimes, and it's important to remember that stress has an enormous impact on bG levels. You need to do EVERYTHING possible to reduce stress in your life. For some women, work will become too great a burden, although others are able to handle it fairly well. You must be the judge of your own situation.

 

Differences in Delivery Protocols

Because you are on insulin, your birthing choices are generally a bit more limited with most doctors, though not with all.  Insulin-dependent gd moms tend to have more prenatal testing, more procedures, more inductions (and at earlier times), and a higher rate of c-sections.  However, as with other areas of gd, a great deal depends on the protocols of the particular doctor you are seeing.  Some doctors are much more aggressive than others.  

Prenatal Testing

GD women who need insulin start prenatal testing at a very early stage, sometimes as early as 32 weeks (earlier if signs of pre-eclampsia surface). Most providers start testing at around 34 weeks or so, and use a combination of fetal kick counts, Non-Stress Tests (NSTs), and fetal BioPhysical Profiles. You can also probably expect at least one ultrasound, and probably more. If early delivery before 39 weeks is contemplated, you can probably also expect to have an amniocentesis performed to be sure the baby's lungs are mature enough.

The goals of testing are basically to ensure normal growth patterns for baby, adequate development of the baby, and adequate nutrition, blood supply, and oxygen to baby.  Again, the amount and type of testing will vary greatly from one provider to the next, but nearly all researchers agree that gd moms with extra risk factors (high blood pressure, insulin-dependent, or history of stillbirth) should receive early and frequent prenatal testing. Mothers with well-controlled, diet-only gd and no other risk factors will probably undergo much less testing, started much later.

Timing of Delivery

The timing of delivery in gd pregnancies is an area of great variation in care and great controversy. However, there is more consensus when insulin is involved. Most providers prefer to deliver an insulin-dependent pregnancy at about 38-39 weeks, sometimes a bit earlier. The rate of placental deterioration/fatigue is thought to be higher when exogenous insulin is necessary, and the high rates of fetal hyperinsulinemia can tend to depress oxygen levels, possibly risking stillbirth in extreme cases (this is rare). The tendency towards macrosomia (extra-large baby) may be higher in insulin-dependent pregnancies as well, so providers often want to induce early in order to avoid the baby getting to be 'too big'.  The current American Diabetes Association recommendations include induction at 38 weeks.  If the baby does not look to be big, some doctors are fine with waiting to induce until term at 40 weeks.  In rare cases, it is possible to find doctors willing to go past 40-41 weeks if all looks well, but this is very unusual in insulin-dependent cases.  

The risks of delivering early include a high rate of c-sections and also respiratory distress for infants whose lungs are immature. If the mother does not have good blood sugar control, the high levels of insulin produced in the baby tend to slow the maturing of the baby's lungs by delaying the development of surfactant, a substance needed for baby's lungs to be able to work. The amniocentesis at 38 weeks is designed to establish that the L/S (Lecithin/Sphingomyelin) ratio in baby's lungs is adequate; the PG level should also be checked. An L/S ratio of 2.0 or more is generally thought to indicate a low risk of Respiratory Distress Syndrome (RDS), but the presence of the acidic phospholipid phosphatidyglycerol (PG) is considered to be the final marker of fetal lung maturation. There are reports of RDS occurring in women with a mature L/S ratio but absent PG. So if early delivery (before 38-39 weeks) is deemed necessary, documenting lung maturity with both an L/S ratio and the PG marker is important.  If these are not optimal, then delivery may be delayed to allowed development, or the mother may be given a shot of steroids that will help the baby's lungs mature faster so delivery can proceed.

Some doctors are challenging the need for an amnio at 38 weeks. Before 38 weeks, it is probably necessary, and after it it is probably not necessary in women with excellent control. However, in women right at 38 weeks, it is still unclear from research whether documenting lung maturity is truly necessary. If you are at 38 weeks, you can either choose to wait another week to induce or discuss with your provider whether an amnio is really needed in your case. If in doubt and if early delivery at 38 weeks is really that important, most providers seem to feel it is probably better to err on the side of testing, just in case.  Since an elective c-section puts a baby more at-risk for Respiratory Distress Syndrome, if you choose an elective c-section you should probably have an amnio or choose to wait until 39 weeks for the surgery.  If you are inducing, labor tends to help the lungs work better, so the choice is more ambiguous.  Discuss the latest research with your provider when making a choice.

An issue which must be balanced against the maturity of the fetal lungs is the sufficiency of the placenta in gd pregnancies. In 'true' diabetic pregnancies, placentas do tend to age faster and may be insufficient for the fetus beyond term; one risk in the past of diabetic pregnancies was sudden fetal death close to term. With much more careful monitoring and bG control these days, this is not quite the danger it once was, but remains a strong concern.  However, it is unknown whether the placental risks for 'true' diabetic pregnancies are really applicable to gd pregnancies; the data is often simply extrapolated to include gd pregnancies.  At this time, insulin-dependent gd pregnancies are generally treated as if placental sufficiency is a vital concern, thus the push for early delivery. 

Many gd mothers experience a drop in blood sugar levels/insulin needs in the last week or two of pregnancy.  The question is what this means.  Traditionally, doctors dealing with 'true' diabetic pregnancies treat this as a potentially ominous sign of the placenta beginning to calcify and fail.  However, in gd this seems to be based mostly on extrapolation rather than careful research.  An alternative explanation is that the hormonal levels change as the body prepares for labor; progesterone levels strongly decrease in order to help the body get ready to deliver.  Since progesterone is one of the most strongly-diabetogenic hormones in gd, it seems only logical that the dip in progesterone typical of the end of pregnancy would result in a decrease in blood sugar/insulin needs without necessarily meaning the placenta was about to fail.  However, this has not been sufficiently studied or considered as an alternative explanation.  At this time, the assumption is that a decrease in insulin needs implies placental aging.   Certainly, careful testing to assure the well-being of the baby and the placenta near term and beyond is justified, but it is also clear that more study and clarification of this important issue is needed.

Another issue in early delivery is whether the estimated fetal age is actually correct. Quite a number of cases of elective induction or delivery of "39-40" week fetuses have actually been found to have involved 37-38 week fetuses. If the mother has irregular menstrual cycles or longer-than-average cycles, the Estimated Due Date (EDD) may well be incorrect and the fetus is probably younger than previously thought. To proceed with delivery of a baby younger than predicted probably strongly increases the c-section rate due to failed inductions, and certainly raises the rate of Respiratory Distress Syndrome. Any gd mom who has had irregular cycles or longer-than-average cycles should be very careful to weigh all the issues of possible prematurity before considering early delivery.

Ultrasounds in late pregnancy are notoriously inaccurate for estimating due dates, size, etc., so it is best not to use late ultrasounds to adjust the expected due date unless it was impossible to date the pregnancy earlier. For women whose cycles are pretty regular but significantly longer than average (averaging 33 days or more), the due date should generally be adjusted one day for each day exceeding a 28 day cycle; i.e., if your cycle is 35 days on average, you should add a week to the usual due date given. Many doctors, however, are reluctant to adjust the due date and refuse to use anything but the Last Menstrual Period (LMP) to calculate the due date. This leads to many women with longer cycles being induced unnecessarily, and perhaps having unnecessary c-sections due to 'failure to progress' when their bodies simply weren't ready yet for labor.  An extra week may seem like nothing, but it can mean a great deal in terms of lung maturity and the body's 'ripeness' for labor. If your cycles are 33 or more days, you should lobby to have your due date adjusted accordingly.

Induction of Labor

Most of the time, early delivery includes an artificial induction of labor. This usually means an application or two of prostaglandin gels of various kinds in order to ripen the cervix ahead of time. If the cervix is not 'ripe' (soft, partially effaced/thinned, and partially dilated), then the induction is not likely to work, although it does sometimes anyway! If you can, ask your provider what your "Bishop Score" is----this is the rating developed by providers to express how 'ripe' your cervix is for labor. If you have a low Bishop Score, then your chances of a successful vaginal delivery are fairly low. If you have a high Bishop Score (i.e. your cervix is riper), then your chances are much better. If you have had a vaginal delivery in the past, the success rate for induction is higher. If you are a first-time mom being induced on an unripe cervix, then your chances of a c-section are very significant, though it should be noted that some of these women do have a vaginal birth anyway!  You never know.  

One fairly new labor induction drug on the horizon that has been more successful with women whose cervices are not fully ripe for labor is misoprostol (trade name: Cytotec).  This is an ulcer drug which contains another type of prostaglandins (which is why it can be helpful in pregnancy).  It is not approved for use in pregnancy, but many doctors (and a few midwives!) are using it in pregnancy anyhow.  It comes in 100 mcg tablets, which are then cut to the dosage that your provider prefers.  These are inserted into the vagina; they have the distinct advantage of both ripening your cervix and then starting labor contractions.  Misoprostol inductions sometimes succeed where other inductions do not; in some studies (but not all) it is associated with a lower c/s rate than pitocin.  However, it is also often associated with a higher rate of hyperstimulation of the uterus and/or abnormal fetal heart rates, perhaps due to too-large and  too-frequent dosages, so many many studies are currently underway to document the best possible dosage/frequency protocols.  It is probably particularly useful in first-time moms or those whose cervices are not yet ripe but need induction.  However, it must be used with great caution (if at all) in women with previous c-sections, since it has been implicated in a higher rate of subsequent uterine rupture in VBAC moms.  Again, dosage and frequency is a critical issue, and use at this time is largely an experiment.   

Many women feel that they can improve their chances for a successful induction by actively pursuing herbal remedies, acupuncture, natural techniques such as sex and nipple stimulation, etc., before resorting to the industrial-strength drugs and protocols used by doctors.  Although doctors tend to know little about these (because they refuse to study them) and therefore are very reluctant to consider using them, many women and midwives have anecdotally found great success with them. Women facing a mandatory induction may want to explore some of these options, but they should know that most doctors will tend to be unsupportive.  

It should also be noted that 'natural' methods also are not totally free from risk; ANY time you force an unnatural timing, there are risks involved.  The difference may be in the degree of risk; pitocin and other induction agents used by doctors tend to be used at extremely high dosages and over very short time periods, which may increase the risk.  'Natural' methods tend to be successful because they take a more gradual approach in dosage and timing, pay close attention to ripening the cervix beforehand, and often utilize the body's own methods for preparing for labor.  They tend to be most successful if started several weeks before a hospital induction; they tend to be less successful if used only a week or so before a 'traditional' induction.  It is important to consult an expert in their use as well so that they can be used most judiciously.  More information on these options can be found at www.gentlebirth.org (under Natural Induction), at www.nurturing.ca/labor.htm and in the upcoming FAQ, "All About Induction" on Kmom's site.  [Note: Mentioning these options does NOT constitute endorsement by Kmom, it is simply the presentation of more information.]

Another option used by some women is that of 'serial induction'.  This means trying to induce with pitocin and other reversible options at the desired time, but being willing to stop the induction and go home if no progress is made over a set amount of hours.  Sometimes when the body does not respond to an initial dosing, it does trigger a natural cascade response anyhow, and women often go into labor on their own a few days later if allowed to go home and wait.  If not, another pitocin induction can be tried.  However, it is important in this option to emphasize NOT breaking the bag of waters, since this puts women on a timetable to deliver in a set amount of time due to the risk of infection and fetal distress.  Also, it is possible that your bag of waters may break on their own during the first induction, at which time you must stay and complete the process, either vaginally or by c-section.  So this protocol is not without its drawbacks, but may offer another option to consider.  At this time, serial induction is unusual, but it has been used successfully by some gd moms.    

In the past, most women were induced regardless of their Bishop Score because many providers felt uncomfortable letting 'diabetic' women get close to term. Nowadays this is beginning to be relaxed.  Deciding the appropriate delivery protocols for gd pregnancies is very complex and involves many factors.  A lot depends on the circumstances of your specific medical condition, how big the doctor estimates your baby to be, how conservative your doctor is, whether this is your first child, how ripe your cervix is, how mature the baby's lungs are, etc. Discuss the relevant issues with your doctor and see if there is room for flexibility and negotiation; sometimes providers are willing to compromise.  

During Labor

As with all other aspects of gd, your management during labor will vary from doctor to doctor.  Some doctors are very stringent and some are much more loose and flexible.  It is important to discuss these issues ahead of time with your provider so that you know what your options are (some doctors are willing to be flexible about some protocols).  Be very well-informed and assertive about labor options and good labor support if you want the best possible chance of avoiding a c-section!

During labor itself, gd delivery protocols should not generally be all that different from other labors. Although some providers maintain a more intense level of monitoring and labor restrictions, this is not based on any official recommendation. A gd mom does not generally need constant fetal monitoring or to be restricted to bed or in certain positions, although sometimes they are told this (or inductions make it necessary). However, it is likely that a higher degree of monitoring will accompany insulin-dependent pregnancies or ones complicated by high blood pressure or previous stillbirth, which seems sensible.

During labor, you may be required to have an IV so that if you need insulin in labor it can be given quickly, but not all doctors insist on this.  Not all insulin-dependent women require insulin in labor; since labor is hard work some women do not require any additional insulin in labor.  However, other moms find that the stress of the situation tends to override the hard work they are doing, and their blood sugars start to rise.  These women need to have insulin added to their treatment, since high blood sugar in labor can increase the occurrence of neonatal hypoglycemia after birth.  

Blood sugar is generally measured during labor every 1-2 hours; some providers prefer that plasma glucose levels should be kept <90-100 mg/dl (up to 15% higher with home monitors) in order to decrease the risk or severity of neonatal hypoglycemia. Some critics have questioned whether these strict protocols actually lead to more hypoglycemia and fetal distress due to lack of energy reserves in the mother, and some providers do allow higher readings (up to 120-140), especially if they are flexible about eating during labor. Consult your provider.

One area of significant concern is keeping up the energy reserves of the gd mom in labor without raising her glucose level unduly. Most hospitals, unfortunately, do not permit eating or many liquids during labor (this is considered outdated by most critics but still exists in many places); a gd mom in a long or induced labor may be without nourishment for a long time. In order to avoid ketones and to help maintain energy, sometimes glucose will be given by IV. However, this raises the mother's risk for a spike in bG, and does not address her need for other nutrients during a period of extended hard work. 

Most gd moms are not given any nourishment during labor, even by glucose IV, raising her risk of energy depletion and exhaustion. They are being asked to run a marathon while starving, in essence, and this may be particularly difficult with gd. Different providers have different protocols to help with this; ask your doctor. However, negotiating for some food intake during labor if possible (or laboring at home for as long as possible and eating lightly during early labor) may be an option to consider. You'll do your best work if you have adequate nutrients and energy through the process. Keeping well-hydrated is particularly important since dehydration tends to increase fetal distress and maternal exhaustion.

Since you usually don't know ahead of time when you'll go into labor or how long it will last, it's VERY important to keep excellent and frequent eating patterns during the end of your pregnancy (and into early labor if possible)---you don't know how long it will be before you can eat or drink again! Many women slack off in their eating and fluid intake in the last week or so of pregnancy due to fatigue and 'fullness', but this leaves many women with low energy reserves and near-dehydration at the start of the hardest work of their lives! It is especially VITAL for gd moms to take care of these issues, since she is less likely to be able to have energy foods at the hospital and because the degree of her glycemic control in the week or two before labor greatly influences the rate of hypoglycemia in the baby after birth. It's a nuisance to have to push frequent eating and liquids in the last few days of pregnancy, but it's VERY important to the health of you and your baby, particularly with gd.

Other tips that might aid your chances of a vaginal birth include keeping an upright and mobile position to help labor progress better. Sit in a chair, walk extensively, kneel, labor on hands and knees (especially if you have back labor), rock your hips back and forth, use nipple stimulation, sit leaning forward with your back rounded (like when getting an epidural but without the drugs), have your partner use counterpressure on your back, sit on the toilet, lean over the edge of a chair or bed, lay on your left side when tired, kneel on one knee but keep the other foot up, etc.---all of these are excellent ways to help labor along. The use of water through either showers or getting into jacuzzis tends to really relax you and help dilate you faster and handle pain better (Kmom can attest to that!)

Research has also shown that a professional labor assistant ('doula') reduces the risk of c-section by as much as 50%, as well as the length of labor and the need for pain meds, and may be especially valuable in an induction situation. So in addition to varying your labor coping patterns, strongly consider hiring a doula in order to have experienced, professional labor assistance that knows from experience the best coping techniques and will help you stay relaxed in the face of pressure.

However, it should be noted that although some women are able to do induced labor without drugs, it is not an easy thing, especially with the very aggressive dosing practiced in many hospitals.  You should plan ahead of time to be as flexible and prepared as possible to use alternatives to drugs (given the risks associated with them), but also with the recognition that it may not be possible to avoid pain medications.   Although Kmom is not a fan of epidural usage in most labors, it can sometimes be a blessing in induced or very difficult labors, enabling the mother to finish dilating when it might not be possible otherwise.  If you truly feel you need an epidural or other drugs, try to wait until you are dilated at least 4-5 cm first; some studies shows that this decreases the resulting c/s rate.  Also, the 'curved C' back position necessary for getting an epidural often results in a great deal of dilation on its own; although it's very uncomfortable, you might want to try this before resorting to an epidural (since you'll have to do it for an epidural anyhow!).  However, if you need an epidural, don't feel badly or like less of a woman for getting one; induced labors generally ARE harder than natural ones (Kmom can attest to this too!).  Sometimes, an epidural can help make an induction or very difficult labor more successful.  

Although some doctors and nurses will tell you that the above  laboring techniques are contraindicated for a gd mom, the truth is that many doctors permit them and it is largely a matter of protocol.  See "Dee's" birth story (GD: Birth Stories) for a great story of an insulin-dependent gd mom induced at 38 weeks achieving a successful Vaginal Birth After Cesarean (VBAC) against great odds, largely because of her own grit and strength, the support of her doula and doctor, and the flexibility of her labor protocols.  There are other stories there along the same lines as well. These measures can really help!

Cesarean Sections

In the past, c-section rates were often extremely excessive for Type I insulin-dependent women. Today, the rates are still very high (50-80% or more in Type I's, 25-45% in gd pregnancies on average), but a great deal depends on other factors such as how interventive your doctor is, whether he/she is willing to consider alternatives such as serial induction, natural cervical ripening techniques, etc., and how big your baby is predicted to be.

Elective c-sections are often recommended in diabetic pregnancies when macrosomia is suspected. Your doctor is likely to get nervous if they suspect your baby is over 9 lbs., although just how justifiable this worry really is is open to debate. The critical issue in diabetic pregnancies is the PATTERN of growth. Maternal hyperglycemia and fetal hyperinsulinemia can often lead to asymmetric growth in the baby, with extra-large shoulders and extra adipose (fat) tissue around the trunk. This makes the threat of shoulder dystocia (where the baby's head is delivered but the shoulders get stuck) more common.  Although this can usually be resolved by the provider and rarely results in permanent injury to the infant, it is a potential emergency and very occasionally does result in a poor outcome, even death. So extra caution is warranted with very large babies of diabetic pregnancies. However, experts vary on the definition of 'large' and what level of caution is needed.

In theory, nearly all experts recommend an elective c-section in diabetic women (gd or otherwise) if the baby is estimated to be >4500g (9 lbs., 14 oz.); some recommend an elective section in diabetic women with fetuses at weights of 4250g (9 lbs., 6 oz.) or even 4000g (8 lbs., 13 oz.). In practice, most doctors strongly err on the side of conservatism and choose an elective c-section at estimated weights of about 4000g or so. However, since the accuracy of fetal weight estimation is generally poor, especially at higher weights, this policy will result in a number of unnecessary c-sections being done on women whose babies were not actually macrosomic. Furthermore, since the majority of marginally macrosomic babies, even in diabetic pregnancies, are actually delivered without shoulder dystocia or injury when given a vaginal trial of labor, many more of those 'elective' c-sections will have been unnecessary.  At what level the tradeoff (potential injury in a population at high risk for such injury vs. the very real morbidity associated with major abdominal surgery) is justified is highly debatable and will also undergo a great deal of research in the near future. 

The potential risks with shoulder dystocia and difficult births include injury to the baby's shoulder/arms and nerves (Brachial Plexus injury/Erb's Palsy), other birth trauma such as clavicular fracture, etc., or in very rare cases, fetal death.  It can also be difficult for the mother.  Research confirms the higher rate of shoulder dystocia in diabetic pregnancies compared to non-diabetic pregnancies with infants of the same birthweight. Although some of this can probably be attributed to iatrogenic or doctor-caused problems (for example, forceps quadruples the risk), not all of the higher rate of problems can be thus attributed. Doctors ARE correct that more caution is justified in macrosomic babies of diabetic pregnancies due to potential injuries; the question is just WHAT the best treatment is, where the line should be drawn, and what the potential risk trade-offs are.

The risks and problems of a c-section, for example, are also considerable.  The maternal death rate from c-sections, although small, is at least 2-4 times higher than with vaginal birth (some studies show much higher rates than that).  In addition, there are other significant risks such as wound infection, traumatic surgery, excessive blood loss, anesthesia problems, embolisms/blood clots, fetal respiratory distress syndrome, poorer initial fetal response, and increased rates of problems in future pregnancies (such as uterine rupture, ectopic pregnancies, placental problems, and perhaps infertility). In addition, all of a woman's future pregnancies will subsequently be considered 'high-risk' and subject to many more interventions and restrictions simply because of her previous cesarean surgery, a serious long-term implication not taken seriously enough by the obstetric community. Furthermore, estimating fetal weight by ultrasound, even a series of ultrasounds over time, is subject to a strong margin of error, especially at higher birthweights. Thus, a woman may be electively 'sectioned' (with all its attendant risks) for a suspected large baby that in actuality is not even >4000g. [This has happened many times.]

Finding a balance between preventing the real risks of the occurrence of shoulder dystocia versus the real risks of major abdominal surgery is a very difficult balancing act, presenting a real dilemma for the gd provider. Currently, almost all providers recommend considering elective sections in gd if the fetal weight is estimated to be 4500g (9 lbs., 14 oz.) or more. Although some babies of diabetic pregnancies have been delivered safely vaginally over this weight, the rate of shoulder dystocia and problems is high enough that most providers agree that the risk of trying vaginal delivery outweighs the risk of major surgery. Again, the weakness of this policy is that estimated fetal weight can be highly inaccurate, but at this point most providers currently feel that this cutoff is justified.

Generally, most providers generally 'default' to the lowest possible guidelines due to the extreme conservatism typical of most doctors dealing with 'diabetic' pregnancies and their grave concern over potential injuries. Most use a threshold of a fetal weight estimation of 4000g (8 lbs., 13 oz.) to determine the 'need' for an elective c-section. As noted above, that means that a significant number of the resulting c-sections will be 'unnecessary', but these providers feel that this is preferable to even a small risk of shoulder dystocia and birth trauma.  More providers today are actually beginning to consider raising this threshold to 4250g (9 lbs., 6 oz.) instead, in order to lower the rate of unnecessary c-sections resulting from the 4000g cutoff, and some research on this looks promising. However, it is also difficult to dismiss the real concern for potential injuries. At this time, the standard of care among most care providers is to consider elective c-section when fetal weight is estimated to be 4000g; whether this is justified is a matter of significant debate.

If your doctor suspects that your baby may be 'big', he/she will order an ultrasound to estimate the baby's size.  You should strongly consider having a series of these, as having several tends to help reduce the significant margin of error somewhat.  If the baby's size looks big continually, then you face a choice between inducing early (38 weeks or so) with all the risks that can entail, or going straight to an elective c-section with all those attendent risks.  Studies show that doctors tend to choose elective c-section more often with heavy women; you may have to campaign significantly to even try an induction.  It is difficult to choose between an induction (which can be a long hard labor and carries its own risks to mother and baby) and an elective c-section (which carries significant risks, especially for the larger mother). Which choice is best for you depends on your own unique situation and your values.  

Although the odds do favor a vaginal birth even when an induction takes place, for some women inducing means a long and difficult labor, and some women still end up with a c/s afterwards anyhow.  On the other hand, laboring usually prepares the baby better for birth, is usually good for both mother and baby, tends to jumpstart breastfeeding hormones, and helps the baby be ready to breathe better.  And since most inductions still do end up in vaginal births (and some are a snap!), most women choose to try inducing.  If you choose induction, there are things you can do to help make the experience easier and more likely to succeed (i.e., try to ripen the cervix ahead of time, hire professional labor support to help you through [doula], negotiate for more flexible protocols, etc.).  

On the other hand, for some women an elective c-section can be a better choice emotionally.  If you choose elective c-section, there are many things that can be done to make it a more 'birth-like' experience, and most surgeons are generally quite cooperative if you approach them early enough. You might want to request things like having calming music on during the surgery, treating the surgery as a birth (no business chit-chat!), having your partner get to hold baby as SOON as possible after the birth, having one hand free so you can caress or even hold the baby (with help) while the surgery continues, delaying non-necessary procedures till later, avoiding automatic supplementation of the baby at birth,  having additional support for the mother in the surgical suite if possible (so that Dad can go with the baby if there are problems and Mom still has support), having immediate breastfeeding access as soon as you are in recovery, etc.   

Be sure you have a written birth plan in place for either scenario so that the staff knows your wishes and can try to help you towards them.  It's important to be well-read on baby care issues so that the baby does not experience a multitude of unnecessary procedures after birth (please read the websection on GD and Breastfeeding!), and to be emotionally prepared for many different birth scenarios.  Expect the most optimal outcome (it is likely afterall!) but be prepared to deal with other scenarios as well.   For more information on delivery issues, see the websections on GD: Basic Treatment Protocols, GD: Delivery Issues (forthcoming), All About Inductions (forthcoming), and GD and Breastfeeding: A Special Relationship.  

Summary of Delivery Issues

The recommendations for timing of delivery, liberal use of inductions, and use of early induction or elective section with suspected macrosomia is the subject of a significant amount of debate. At this time, most women with insulin-dependent gd can expect to induced at 38-39 weeks (sometimes 40 if the baby looks to be of average size); women with babies that are estimated to be >4000g (about 9 lbs.) can probably expect a great deal of pressure for an elective c-section.  However, as with all other issues in gd, the amount and timing of delivery protocols can vary significantly from one provider to the next, and what one provider might recommend may differ completely from another provider.  Some women may want to seek more than one opinion.  

It is also important to note that the current standard of practice at this time on delivery issues in gd pregnancies is mostly based on custom, not a great deal of research. Much more work remains to be done before optimal, evidence-based recommendations for timing and mode of delivery can be made.  Some of this research is being done now and may change the picture over time; gd moms should probably do their own inquiries to see the latest research findings on this issue before approaching their providers. 

 

Why GD Moms Should Strongly Consider Breastfeeding

Women with insulin-dependent gd should strongly consider breastfeeding their babies.  This is because breastfeeding has been shown to return insulin-dependent women to normal blood sugar levels sooner after birth than formula-feeding, probably because of more demand on the metabolism.  GD moms who are breastfeeding after 6-8 weeks have lower blood sugar levels and better 'good' cholesterol levels than women who were not breastfeeding at that point.  In addition,  breastfeeding generally helps women lose more pregnancy weight postpartum (with less effort), and weight gain between pregnancies has been shown to be a very strong risk factor for recurrent gd and earlier onset of true diabetes.  Breastfeeding also lowers your risk for several reproductive cancers such as breast cancer, which insulin-resistant and/or heavy women may be more at-risk for.  

Breastfeeding also helps your baby.  In addition to the well-known and very strong protections towards ear infections, gastrointestinal problems, and respiratory illnesses, breastfed gd babies tend to have less insulin resistance than formula-fed babies.  They also tend to be less obese as they grow older (especially the longer they are breastfed), which may help lessen their risk for diabetes.  In addition, at least one study also showed that babies breastfed at least 2 months had only about half the occurrence of early-onset diabetes compared to formula-fed babies.  Although more studies are needed, there is some preliminary evidence that breastfeeding may help prevent or minimize a tendency towards diabetes.  

So breastfeeding may offer additional benefits to both the gd mother and gd baby, especially those who needed insulin in pregnancy.  If possible, most gd mothers should consider breastfeeding their babies as much as possible and as long as possible under their circumstances.  Further information about this can be found in the websection, GD and Breastfeeding: A Special Relationship.  

 

The Debate About Stricter Treatment Protocols: A Brief Overview

The debate over which protocol regimen to use is a very hot and controversial topic of research these days. Some research supports instituting more stringent protocols ('prophylactic insulin') and some does not. Furthermore, the methodological design of many gd studies has come under fire and the 3rd International Workshop-Conference on Gestational Diabetes called for more definitive studies with impeccable design in order to try and clear up the matter. A few of these studies are currently under way, but no permanent results are available yet, and there are many factors to consider. This section is intended to give a brief overview of some of the arguments; the GD: Controversies section will cover this more thoroughly and with even more research references than here. Readers are strongly encouraged to pursue their own research in this area.

Proponents of Prophylactic Insulin

There are two types of treatment sometimes referred to as "prophylactic insulin" use. The first approach is to institute insulin use at levels lower than current official recommendations; for example the move to use insulin at fastings of >95 instead of the official recommendation of >105. This may or may not be considered true 'prophylactic' use of insulin, but since a fair number of sources use the term that way, we will also.

The second approach to 'prophylactic' use of insulin is to use insulin aggressively with ALL gd women or those in subgroups identified as being particularly high-risk for macrosomia. This approach was popular in the 70s and early 80s but its use for ALL gd women is generally not done anymore. However, there is a resurgence of some researchers now who are promoting extremely aggressive use of insulin in subgroups (such as obese gd women or women with prior macrosomic babies), regardless of normal numbers through dietary treatment alone.

Researchers who defend these approaches (use of insulin at even lower numbers, or aggressive treatment for subgroups like the 'obese') contend that it reduces macrosomia (thus hopefully preventing birth trauma), normalizes the metabolic intrauterine environment of the fetus (thus theoretically preventing a host of future metabolic problems like obesity and diabetes), and will therefore lessen the amount of metabolic aberrations a gd newborn might experience (like hypoglycemia, jaundice, polycythemia, and hypocalcemia). They contend that the gd pregnancy represents an intrauterine environment where the maternal fuel substrates levels are so abnormal that they imprint a harmful pattern of growth and pancreatic development. They feel that children of gd pregnancies are more at risk for obesity, hypertension, impaired glucose tolerance at very young ages, and perhaps even motor, neurological, or learning difficulties. They feel that the uterine environment is so unbalanced that it produces a child likely to be at high risk of health problems, and at earlier and earlier ages. They see their mission as one of prevention of diabetes and a host of other metabolic difficulties for a future generation by 'normalizing' the uterine environment through aggressive use of insulin. Basically, they feel that the ends justify the means; though little research exists yet to address whether aggressive insulin use actually accomplishes these goals, they feel that what little research there is supports this position.

To support their point of view they point to research that shows that more aggressive insulin use does indeed tend to lower levels of macrosomia, and in a few cases, even the c-section rate. They note that macrosomic babies of diabetic pregnancies tend to have high rates of shoulder dystocia (where the head is delivered but the shoulders get stuck) which can result in higher rates of birth trauma injuries such as brachial plexus injury or clavicular fracture, or even very very rarely, fetal death. They feel justified in promoting aggressive protocols for insulin and elective delivery in order to hopefully prevent these rare but possibly serious consequences of difficult birth.

They furthermore point to a few new studies that seem to show that babies of gd pregnancies tend to be more obese and more hypertensive as they grow up, and to get diabetes or impaired glucose tolerance at much younger ages. Little long-term follow-up has been done till now on the mothers and babies of gd pregnancies treated aggressively, but of the very little study that has been done, some of it has seemed to show that mothers treated prophylactically with insulin may progress to diabetes less slowly, and that their babies may tend to be less obese after a couple of years. However, this research is still extremely sparse, it has methodological problems, and its followup has been minimal; little can be concluded from it at this point. But proponents feel so strongly about its possible benefits that they question the ethics of letting a generation of babies go untreated or 'undertreated' when it may be possible to lessen the coming epidemic of diabetes and its consequences.

Proponents also further point out that the current cutoffs for diagnosing 'gd' were arbitrarily chosen decades ago, but they were chosen for their ability to predict future diabetes in the mother, not for their ability to prevent complications to the fetus. Because of this, proponents feel that the mediocre results of gd treatment thus far have not resulted from a failure of gd treatment itself but because the treatment has not been aggressive enough, and not based on numbers that reflect improved fetal outcome instead of the mother's future prognosis for getting diabetes. This is an excellent point; the cutoffs were originally derived for analysis of the mother's future risk, not the baby's risk. However, it's also important to point out that conclusive research either to support or refute the hypothesis that lower cutoffs will normalize outcome does not exist at this time. Much research remains to be done, but proponents feel that it is only a matter of time before it is proven and that not treating aggressively in the meantime discriminates against a whole generation that could benefit from the intervention.

Critics of Prophylactic Insulin

Critics of aggressive or prophylactic insulin use point out that the research supporting aggressive insulin use has been extremely mixed, much more than proponents want to admit. While some results have seemed to indicate its benefits, other research shows a totally different picture. Some research has shown that aggressive use of insulin did not lower macrosomia at all, nor improve outcome in any way. Other research shows that while aggressive insulin did lower macrosomia rates, it did not in turn lower the c-section rate or the rate of complications in the newborn at all. In fact, some research shows that the using insulin aggressively actually RAISED the c-section rate, despite having lowered the size of the babies. Reducing the rate of macrosomia should have lowered the c-section rate, but in most studies it did not, and sometimes it raised the rate instead. This is a very serious problem. Proponents like to point to the few studies where both the macrosomia rate and the c-section rate were diminished, but in reality, most research has not borne out this trend, and has often even shown the opposite effect.

Part of the problem lies in the fact that once a gd mother is put on insulin (generally called class A2), she is considered even more high-risk and subject to ever-more interventive protocols, experiencing far more prenatal testing, early induction, and aggressive management protocols. The c-section rate for some insulin-dependent gd moms in some studies exceeds 40%, a HUGE rate. Critics question whether using an aggressive insulin protocol is a quick way to buy a one-way ticket to a c-section for a significant number of gd moms. Proponents of prophylactic insulin insist that the gains in lowering risk by lowering baby size outstretch the rise in risks that come from an increased number of interventions. However, studies of this question have either not been done or have been methodologically flawed. The idea of reducing rates of macrosomia is to reduce the high accompanying rate of c-section, yet aggressive insulin use seems to negate part of its very purpose for use in most cases. This is a burning question in the field of gd.

Furthermore, although the rate of macrosomia was lowered in a number of studies, the amount that it was lowered was not terribly significant. Several studies managed to lower the average birthweight, but the average difference in size amounted only to a few ounces. It is questionable whether this is of any real benefit to the children, and whether it is clinically significant in terms of preventing difficult births or problems. Again, studies have showed a variety of responses; some showed more significant reductions in size of more than a pound, most showed the reduction of only a few ounces, and some showed no difference in birth weight between groups.

Proponents counter, however, that though the overall average birthweight was not reduced by a great deal, the percentage of babies falling in the range of 'Large-for-Gestational-Age' and "Macrosomic' did decrease, and that this is meaningful. Critics would respond by noting that the cutoffs for LGA and macrosomia are artificial constructs and that most of the babies must have fallen very close to this border for a fairly small overall reduction to have reduced the number of LGA and macrosomic babies so much. Just because some of them now fall a few ounces below the arbitrary cutoff, is the clinical difference in risk really that great from a few ounces? Do a few ounces really translate into a measurable difference in mode of delivery or birth injury or other outcome? Or is it simply a measurable difference in the physician's perception of risk and therefore their treatment? Some studies show improvement in shoulder dystocia and birth injuries, and some do not, even when birth weights were reduced.

Another criticism of the macrosomia/shoulder dystocia concern is that the labor and delivery protocols of providers can strongly influence the amount and severity of shoulder dystocia or other problems; that the restrictive way these women are forced to labor due to gd and macrosomia protocols tends to cause more problems, which then get blamed on the gd. These iatrogenic (doctor-caused) problems include forcing early induction, using forceps or vacuum to 'speed' up births, restricting mobility and positions, and forcing the woman to push in ways that may exacerbate a more snug fit (semi-reclined, stirrups, etc.). Many critics contend that the main problem with macrosomia (increased c-section rates and other birth trauma) simply means that physicians have lost the knowledge on how to best handle the births of macrosomic babies and how to resolve shoulder dystocia in low-tech ways that tend to reduce the number of complications and injuries. It is clear that diabetic women DO have a higher rate of shoulder dystocia and that some of this is intrinsic, so caution IS definitely justified. However, the restrictions and interventions commonly used in these women and the lack of skills on the part of doctors in handling macrosomic babies well probably has inflated the mathematical risk scenarios for suspected macrosomia/shoulder dystocia and because of this, it is very difficult to know at what point concern is truly justified and intervention necessary.

Proponents would also claim that simply by lowering the rate of macrosomia, they have probably prevented a whole host of problems for the child as it grows. In reality, there is no way to know if that is true yet. There are no studies showing this conclusively; in fact, there is VERY little long-term follow-up of gd children at all, let alone comparing the long-term outcome between modes of treatment. This raises one of the most troubling questions of all: what is the long-term effect on the children given this extremely aggressive insulin treatment? Most of the time, researchers simply note that the babies turned out smaller, congratulate themselves, and pat themselves on the back in the journals. But is this REALLY better for the babies? Are there any consequences to using large amounts of exogenous insulin during pregnancy, at levels mostly unexperienced by the majority of women? Is it proven to be SAFE to use such aggressive treatment?

Another troubling question is whether it is healthy to try to alter a baby's birth weight. Henci Goer, a strong critic of traditional gd treatment protocols, says "The price of reducing macrosomia is the manipulation of the primary growth mechanism of infants, roughly 80% of whom would not be LGA if they were left alone. And this, like GD itself, presumes without evidence that this physiologic variation in birth weight is pathological." In other words, artificially reducing the natural birth weight of a baby may be dangerous. Nine pound babies may just be a variation of normal, not necessarily an indication of abnormality, disease, or macrosomia caused by excessive blood sugar and hyperinsulinemia. Genetics may play a role as well, and what will using unneeded insulin do to babies that nature intended to be larger anyhow?

Numerous studies have shown that low-birthweight babies are at especially high risk for diabetes, heart problems, and other health difficulties later in life, and other studies have shown that *extremely* tight diabetic protocols have caused an increase in the number of SGA [Small-for-Gestational-Age] babies. What if extreme treatment to bring a normally 9 lb. baby down to an 'acceptable' level of 7.5 lbs. actually exposes him to this same type of risk? In essence, a baby who is genetically supposed to be 9 lbs. but whose birthweight is reduced through aggressive treatment is being born 'underweight'. Is that baby's health going to be improved or vastly put at risk? Do these aggressive protocols to reduce the size of 'macrosomic' babies really improve the baby's health in the long run by preventing a 'misprogramming' of its metabolism, or does it skew its metabolism by trying to alter its primary growth rate? These are very troubling and confusing questions, but the most troubling problem of all is that THESE QUESTIONS ARE NOT EVEN BEING ASKED BY RESEARCHERS.

Furthermore, as Henci Goer pointed out, not all babies of gd pregnancies are macrosomic; in fact the majority are not. Since macrosomia of whichever type only occurs in 20-30% of gd pregnancies anyhow on average, treating all gd patients aggressively assures that 70-80% of gd patients receive treatment to reduce birth size that wouldn't be a problem anyhow. We know that this aggressive treatment is more likely to lead to more c-sections, but what are the effects of aggressive treatment on babies not likely to be macrosomic? Are any babies being harmed long-term by this? No one knows, because no one is asking the question. Researchers are, however, beginning to recognize that not all gd babies need aggressive treatment, and are starting to recommend targeting the more aggressive therapy instead to those statistically more likely to have macrosomic babies.

However, even this presents problems. Obese women, who do have more macrosomic babies as a group, do not all have macrosomic babies as individuals by any means. Even women who have had macrosomic babies previously do not all have macrosomic babies subsequently; in fact, the majority do not! Targeting even just these groups for aggressive intervention means that a number of babies that would not have been macrosomic will be receiving extremely aggressive treatment. What effect will this have on those babies, and can they assure these mothers that it will be benign? And how many more unnecessary c-sections will be performed on these women because they are in the 'aggressive' treatment category?

As for those babies who will be macrosomic, it is QUITE clear that 'pathological' macrosomia (where baby clearly grows asymmetrically and has an extra-large trunk and organomegaly) is something that ABSOLUTELY needs to be prevented and that this DOES happen in some babies of diabetic pregnancies, but it is unclear at this stage whether every or even most babies of gd pregnancies over 9 lbs. are really 'pathologically' macrosomic or whether some so-called macrosomia is just another variation of normal, especially among many obese women who may just genetically tend to have larger babies (just as tall people tend to have longer babies). At this time, few researchers distinguish between 'pathological' macrosomia (clearly problematic) and 'constitutional'/genetic macrosomia that may simply be a variation of normal and not necessarily problematic. Are all large babies from gd pregnancies really a result of 'failed' control, treatment goals that are not strict enough, or failure to use aggressive enough intervention? Or do genetics play an additional role?

A related point that is absolutely critical is whether insulin is more effective on obese women or not. In a few studies, prophylactic insulin has appeared to nearly normalize macrosomia rates and improve outcome, and especially in obese women. In other studies, however, it has apparently much less effect on obese women and their babies, or little effect at all. Even the most stringent of treatment plans has not really been able to reduce the number of large babies from obese mothers down to desired levels, raising the question of whether this is really possible. Is expecting the same rate of fetal size from obese women as from average-sized women really a realistic treatment goal? If so, how aggressive a protocol is justified to try to achieve this goal? Is it really safe or even desirable for the babies? And are they even asking these questions?

In large women, is the high rate of macrosomic babies due to abnormal metabolic factors, simple genetics, or a combination of the two? How can we distinguish between these? If the contribution to fetal size is metabolic and truly shown to be harmful, then aggressive therapy is probably justified and may help prevent a host of future problems. However, if the contribution of size is simply an example of normal genetic variance, then tinkering with a baby's natural size could have very serious consequences indeed. If both genetic size and metabolic abnormalities contribute to the generally greater size of babies born to larger women, then how do we define how much reduction in birthweight is appropriate and possible, and how much aggressive correction might be harmful? Researchers always seem to assume that with larger-than-average people, smaller is always better. But do they know this for sure? And how much is too much?

The extreme emphasis placed on reducing the larger birthweights of babies of obese mothers in research is particularly troubling philosophically, because it smacks of putting a baby on a diet before it is even born. This all-out emphasis on reducing the birthweights of babies that are larger-than-average, especially those of obese women, has very troubling implications. Is an entire generation of children of large women being put at risk, or are they being 'saved'? And how much of the researchers' answers to these questions being influenced by the typical anti-size bias in the medical community?  Is it really a matter of health or is it more a matter of size-phobia?  

Much more definitive study needs to be done on these questions. DOES aggressive insulin use really benefit obese women more, or does it have less effect on them instead? How much of the overall larger size of babies of heavy women is due to genetics vs. 'abnormal maternal milieu'? How safe are aggressive efforts to reduce infant size? What are the long-term effects of aggressive treatment? Only time and more research can answer this, but unfortunately, at present, most researchers are ASSUMING that it will be helpful and targeting ever more aggressive treatment to the obese gd mother. Some researchers have advocated giving ALL obese gd mothers insulin, even when they have had good control with diet alone. There have even been anecdotal reports of obese mothers WITHOUT gd being pressured into using insulin if they've previously had large babies, even when their gd tests are not even close to borderline positive. This raises a lot of troubling ethical questions.

Other researchers have also been troubled by the ethics of some of the most aggressive insulin protocols. Enkin et al. in their book, A Guide to Effective Care in Pregnancy and Childbirth, make the following very strong statement:

Trials comparing the use of insulin plus diet with diet alone show a decrease in macrosomia, but no significant effect on other outcomes such as use of caesarean section, the incidence of shoulder dystocia...perinatal mortality...[or] neonatal jaundice or hypoglycaemia...The available data provide no evidence to support the wide recommendation that all pregnant women should be screened for 'gestational diabetes', let alone that they should be treated with insulin. Until the risks of minor elevations of glucose during pregnancy have been established in appropriately conducted trials, therapy based on this diagnosis must be critically reviewed. The use of injectable therapy on the basis of the available data is highly contentious, and in many other fields of medical practice such aggressive therapy without proven benefit would be considered unethical.

Critics feel that much more research needs to be done to clarify the issue of prophylactic insulin use and its effectiveness, especially in groups at higher risk for macrosomic babies. Furthermore, it's not enough to simply reduce the baby's birthweights; it has to be shown to be beneficial to the child in both the short-term and the long-term. And few have addressed the most important question of all: what are the tradeoff risks in prescribing extreme protocols such as hypocaloric diets or prophylactic insulin? Has the long-term effect on the baby really been studied? Critics believe that the purported 'benefits' of aggressive treatment have not been proven at this point, nor has its lack of harm. Therefore, they strongly question the appropriateness and safety of aggressive therapies like prophylactic insulin.

Summary

Past studies on whether aggressive prophylactic insulin treatment successfully reduces macrosomia and related problems have had mixed results. Some studies clearly showed improvement, while others did not. Even when the macrosomia rate was decreased, c-section rates did not usually decrease with it, though it should have. A few studies showed drops in the c-section rate, but most did not, and some even showed strong increases. Furthermore, the drops in birthweight were sometimes not very clinically significant, and critics question whether baby was really better off after all that aggressive treatment. They also point to the many methodological flaws of the studies promoting stringent protocols.

Proponents of more aggressive treatment basically point to a few studies that have shown stellar results (including lower c-section rates) and charge that the mediocre results of other studies have been because the treatment hasn't been aggressive enough, and that high rates of c-sections even when macrosomia is reduced may be due to anticipatory treatment on the part of physicians (who may have a lower c-section 'threshold' for gd patients than for non-gd patients). They also hold gd patients to be high-risk, who probably could not achieve 'normal' c-section rates anyhow, and they question whether it is realistic to expect any treatment to reduce the c-section rate to completely normal levels in gd mothers. (Critics note that this certainly provides a convenient excuse not to try!)

Not treating gd patients at all does tend to raise the amount of macrosomia present, and the cases of true 'pathological' macrosomia would not receive treatment, something that could be potentially very harmful. So dietary treatment and insulin at previously identified levels seems a reasonable choice to many (though not all). However, whether such treatment should be extended into use of insulin at even lower levels, or use of insulin aggressively in so-called 'higher-risk' groups even when all bG numbers remain normal is very controversial. Proponents of 'evidence-based medicine' or the 'minimal school of management' feel that until prophylactic insulin use has been proven unequivocably to be beneficial and also shown to be not harmful in the long term or short-term, aggressive insulin protocols should not be adopted. Proponents of prophylactic insulin (the 'maximum school of management') feel that they are preventing EXCESS size in babies, possible birth trauma, and a whole host of future health problems, and that preventing the worst possible outcome justifies more intervention.

Carr and Gabbe (Clinical Diabetes, 1998) take a middle course in their excellent summary of current treatment standards for gestational diabetes. They note that "the ACOG criteria for initiating insulin therapy include a fasting plasma glucose level of >105 mg/dl and 2-hour plasma postprandial levels >120 mg/dl. It is important to recognize data suggesting that insulin therapy may achieve lower rates of macrosomia if initiated when fasting blood glucose is >95 mg/dl. However, prophylactic insulin treatment in patients whose fasting and postprandial values remain within the recommended range is not advised." In other words, they believe there may be merit in the argument to initiate insulin treatment at lower fasting values than previously used, but they do not suggest aggressive treatment with insulin for patients whose readings are all normal. There are certainly experts who disagree with this opinion, but this article is from leading experts in the field and appears in a journal designed to guide physicians in their treatment choices in diabetes. It probably represents the most common view of the issue at this time (bearing in mind that there is not a great deal of consensus on gd!).

All this simply reinforces once again that choice of provider and guidelines is one of the most difficult decisions you will make with gd. Many women abdicate their responsibility to be informed and let their providers decide for them, though they might have gotten exactly the opposite advice had they happened to choose a different provider! Other women will research for themselves, interview providers to see what their beliefs are and why, and then choose. It is a very difficult position to be in, either way. The medical community should be urged to work strenuously to resolve these issues more clearly.

Kmom's Opinion (insert medical caveats here!): In Kmom's non-expert, non-medical opinion, all the various protocols actually have some distinct arguments to be made for them, as well as potential risks associated with them; at this time it is very difficult to judge which is the best protocol to follow. However, if forced to take a position, she would probably not choose prophylactic insulin for herself at this time. In particular, Kmom is troubled by the proposal to treat all obese gd moms with insulin universally, by the lack of credence for the idea that genetics may have some influence on fetal size, by the opinion that all macrosomia must be 'pathological', and by the lack of long-term follow-up to determine the safety of aggressive treatment. Specifically, Kmom would not accept prophylactic insulin based simply on her size and her children's birthweights, especially since there was no real difference in size between the child of her gd pregnancy and the child of her non-gd pregnancy, probably indicating a genetic component. As far as using lower fasting values for starting insulin, Kmom would decline absolute judgments and consider the situation first. If she had only a very occasional fasting over 95, she would not consent to insulin treatment. However, if she had fastings consistently around 100 on a regular basis, she probably would strongly consider it. Situations between these two scenarios would have to be considered on an individual basis.

These are the choices Kmom would make for herself at this time, based on her understanding of the issue. She would also carefully consult her provider before making these choices, since recommendations can change over time or there may be other issues pertinent to the choice. Remember that Kmom does NOT offer medical advice or suggest courses of action for other people, and she does not pretend to be a medical expert. However, neither does she believe that laypeople should never offer their own opinions on medical controversies or share their experiences and choices. These are simply Kmom's opinions, clearly marked as such, and readers should not see them as medical advice or expert opinion. Other mothers might well choose different courses of action on this issue, which is also fine. There are arguments to be made for both sides!

 

GD Moms' Insulin Stories

L's Story

The two types of insulin I was on were "R" and "NPH". My endocrinologist said to think of R as regular and NPH as nighttime. The R is faster acting and you get an effect from it 30 min to an hour after you take it. This is the one I took first thing in the morning to counteract high bg levels quickly. Most people seem to have the most trouble with high numbers early in the day. The NPH takes a couple of hours to get an effect. I took this one at bedtime to counter the high fasting numbers I had been getting.

In the hospital they will check your sugars at least 4 times a day. To do this they will take a vial of blood from a vein. If you require insulin you are going to need some sort of monitoring system once you leave the hospital. I had the option of buying a glucometer and test strips to go with it, or buying a different kind of strip that did not require a glucometer. To use the strips you had to place a drop of blood on them, wait a certain amount of time, wipe it off, and compare the color change with a chart on the bottle of strips. This seemed to me to be less accurate and more of a hassle, but it was cheaper. I opted for the glucometer. If you opt for the glucometer I urge getting it while you are still in the hospital, and using it there. For the first day, compare your glucometer's results to the hospital's lab results. If they are close (they will not be exactly the same) you may be able to convince your dr to allow only readings from your glucometer. You can then avoid the blood draws. This was important to me because I have "difficult" veins and they had a hard time finding one.

The next big hurdle is learning to inject yourself. It really isn't difficult to do it correctly, because insulin is injected subcutaneously; you don't have to worry about finding a vein. You only have to worry about finding the courage to jab yourself with a needle. But you will be amazed what you can do when you have no other option. I started injecting myself the first night I was there. I was really hesitant to do it, but the nurse told me if I didn't get the hang of it, they wouldn't discharge me! I'm not sure if she was serious; she probably was. The sites you can inject are thighs and upper arms. Type 1 diabetics can also use their abdomen, but that is not recommended for pregnant women. I found it difficult to inject in my arms so I always used my thigh, top and outer sides. You should rotate the sites and not always inject in the same place. There's a reason for that that I can't remember, but will look up. [Kmom's note: I believe this is because it can cause 'pits' or depressed areas if the same spot is used repeatedly.]

I was started on 10 units of R and 10 units of NPH. This was adjusted upward each of the three days I was in the hospital until I had fastings below 80 and 1 hr post-prandials below 130. I was given a revised diet to follow and had a discharge consultation with the dietician. I was given instructions to call the endocrinologist every week.

Once I was back home I tested my bG levels 4 times a day and wrote the results on a little chart. Each week I would phone the endocrinologist and read my numbers to his secretary. Then she would call back with the doctor's instructions. For the first few weeks I was constantly having my insulin dose changed. Late in the pregnancy, the dose needed adjusting again, only this time it was downward and not up.

Update: Lj was induced at the end of pregnancy and ended up with a c-section. In planning her second pregnancy years later, she researched the issues very carefully and chose to follow some of the alternative opinions about gd treatment. She also nursed her first child throughout her second pregnancy (as did Kmom).

By being extremely proactive in diet and exercise, she was able to avoid needing insulin in the second pregnancy, an extremely unusual occurrence! Brava! However, because her blood pressure began to rise at the end of pregnancy, she was again induced but the baby was malpositioned and she again needed a c-section. The baby had developed an infection in utero (it is unknown whether it occurred before labor or instead during the induction, a very common time to get an infection due to all the vaginal exams) and had to have special care at first but improved after a while. All are doing well now.

Lisa H's Story

At my first appointment with my obstetrician, she told me that because of my weight I'd be at a much higher risk of getting gestational diabetes.  I figured that at 365 lbs. (my weight at 8 weeks along) she was probably right, so I was prepared when the 1-hour glucose tolerance test came back high.  I was even prepared for the 3-hour to come back high, which it did.

I figured that there was nothing I could have done to keep my body from reacting the way it did to sugars, so why stress out about it.  I mean, stressing out would only make things worse.  So, I went to the endocrinologist, saw the nutritionist and got the low-carb diet to follow.  

It was hard, mainly because I normally ate almost twice as many carbs as they had restricted me to, and I wasn't used to eating 3 meals and 2 snacks a day.  I would eat only when hungry, and really only 2 meals a day--combining breakfast and lunch, grabbing something small while I cooked dinner, then eating dinner with my husband when I got home from work.  

After trying the diet for a week, my bG numbers were all over the place, and I had only 3 counts were the numbers were normal.  I had to go on insulin.  It was at that realization that I kinda freaked out.  I really felt that I had failed because I wasn't able to control my blood sugar through the diet.  I also was scared because I hate needles--I can't even watch someone on T.V. having something injected.

Needless to say, I was a bit of a wreck when I had my follow-up appointment with the endocrinologist.  She sat down with me and went over the numbers, and told me that she'd be starting me off with a single injection of insulin at bedtime in order to bring down my fasting blood sugar levels.  She also pointed out to me that I was very sensitive to carbohydrates.

I then saw the nutritionist again and we made some modifications to the diet, reducing the servings of carbohydrates and increasing my protein intake slightly.  The nutritionist agreed with the endocrinologist that I was insulin-resistant (due to my PCOS) and that it was this condition that was making the gd worse.

The endocrinologist also sent me to get a glycosylated hemoglobin test done (which tests the average blood sugar levels for the past couple of months).  The test came back normal, so that went a long way to reassuring me that I was not diabetic before the pregnancy, and that I had a really good chance of not ending up a full-blown diabetic afterwards---if we kept the gd under control.  

Then it was time to see the nurse who was going to instruct me on how to inject the insulin.  Man, was I scared.  It seemed like going on insulin was admitting defeat and the possibility that I was going to stay diabetic despite what I had been told.  Anyway, I told the nurse about my fear of needles---and my concerns about diabetes in the future--and she assured me that the injections wouldn't hurt.  Yeah, right, I thought.

She had me go through the motions of the injection, using saline rather than insulin.  When it came time to do the injection, I balked.  I was scared.  I sat there, staring at the needle.  Finally, I screwed up the courage and inserted the needle into the fat on my belly.  I was shocked.  If it wasn't for the fact that I knew there was a needle sticking in me, I would never have known.  The gauge of the needle was so fine that I didn't feel a thing.  

It was at that point that I realized that it wasn't the insulin that I was afraid of, but the thought of actually having to do the injections, possibly for the rest of my life.  It really was easy--and painless--to do.  The most difficult parts were getting the caps off the syringe, and holding the insulin bottle upright while getting the dosage I needed.  And even those weren't bad.

I feel kind of silly now about how scared I was, as what I need to do (and go through) on a daily basis seems trivial when I think about all the future complications I'm helping prevent from happening to my unborn son.  

As far as giving insulin injections goes, here's what my limited experience has shown me.  First, make sure that you've got everything that you need together, and find somewhere comfortable to do it.  I like to sit on the sofa in the living room or on the bed in the spare bedroom.  As for where to inject, the best (and easiest) place I've found to do it is in my tummy, where I've got ample "padding" of fat.  Make sure that when you do the injection that you're not hitting muscle directly, or at the tender area around any stretch marks.  I made the mistake of doing that once and the injection DID hurt.  Do it where you've got an inch (or more) to pinch and you'll do just fine.  And make sure you follow your doctor's instructions on when to do your injections, otherwise they won't work properly.  

Perhaps the most important thing is the philosophy that I try to follow: "Don't worry about what you can't control."  You can't control what your body does (producing hormones that cause gd), but you can control how you deal with it.  Remember that you're doing this so that you will have a healthy baby, and that it will be in all likelihood something that you will have to do only for a short time.  

If you're scared, talk to your caregiver about it.  If they're not being helpful, find someone who is.  Find a friend.  Read everything you can, but take what you read with a grain (or two) of salt.  What's true for full-blown diabetics isn't always true for gestational diabetics.  But most of all, be aware of your body.  If things are happening with your blood sugar that seems to be related to what you're eating, talk to your caregiver about it.  The more you know, the better you will be able to deal with the problem in a healthy manner.  

Gestational Diabetes is not a "death sentence"----it's a temporary condition that can be overcome by working with your caregiver.  

Update:  Lisa H. had a healthy baby boy.  Her blood sugar levels continued to fluctuate strongly throughout the pregnancy, so she ended up taking insulin several times a day and in quite high dosages.  Because of the concern over the stress of these fluctuating blood sugars and their effect on her placenta, her OB chose to induce her early.  Fortunately, the induction worked and the birth went fine.  Her blood sugar returned to normal within days of the birth.  Her complete birth story can be found in the BBW Birth Stories and in the GD: Birth Stories sections.

 

References

General GD/Insulin 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. 

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. 

Stephenson, M.J. Gestational Diabetes Mellitus. Canadian Family Physician. 39:745-8, April 1993.

A must-read article for those serious about understanding gd treatment options. Covers fairly both philosophies of treatment, both the maximum and minimum schools of management. An excellent overview of the controversies. This should be one of the first articles read about gd.

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. 

Proceedings of the Fourth International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes Care. August 1998. Volume 21 (Supplement 2). http://www.diabetes.org/DiabetesCare/Supplement298/B161.htm

The entire issue of this Diabetes Care journal is devoted to the recommendations and papers from the 4th International Conference on GD. Many important issues are discussed, from contraception for gd mothers, long-term effects on the child, screening issues, recommendations for insulin therapy, delivery protocols, etc. Generally very conservative views but a must-read for those wishing to stay abreast of this field. Although it is extensive and lengthy reading, it is worth the time involved, but does tend to conveniently ignore the criticisms and studies that contradict their conclusions. One-sided but still valuable.

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. 

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. Third Edition (revised in 1997) now available.

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, very conservative in guidelines, and does not contain any discussion of gd controversies. 

Goer, Henci. Obstetric Myths vs. Research Realities. Westport, Connecticut: Bergin and Garvey, 1995. Can be ordered online from http://www.efn.org/~djz/birth/obmyth/

This excellent book reviews common obstetrical practices and analyzes which practices are truly justified by medical research. One chapter in the book is on Gestational Diabetes, where she examines the history of its discovery, treatment, and variations in protocols. She extensively reviews the medical research available on gd and concludes that many common gd protocols are questionable. She is one of the strongest voices critical of the assumptions of the traditional medical view of gd and backs up her opinions with research citations. She sometimes engages in rhetoric and should be less dismissive of research that shows some success with gd intervention, and she does exhibit some size prejudice in her writings. Still, Kmom would highly recommend reading this to get one alternative view of gd, remembering this is just another viewpoint to consider and being aware of her assumptions about size and weight loss. A must-read.

Goer, Henci. "Gestational Diabetes: The Emperor Has No Clothes." Birth Gazette. Spring 1996: Volume 12, Number 2.

A shorter summary of the gd chapter from the above book. A must-read. Can be found at www.gentlebirth.org/archives/gdhgoer.html.

Javanovic-Peterson, Lois, M.D. The Diagnosis and Management of Gestational Diabetes Mellitus. Clinical Diabetes. pp32-39, March/April 1995.

A very technical journal article covering the basic information in great detail, including lots of information on hormonal influences. Very conservative guidelines are used for deciding when to start a mother on insulin. Very dense reading, with lots of technical detail, but good for those strongly interested in further detail.

Jackson, E.A. et al. Management of Gestational Diabetes by Family Physicians and Obstetricians. Journal of Family Practice. 43(4):383-8, October 1996.

The charts of 813 women with gd were retrospectively examined to see if management practices and outcomes differed between family practice doctors and obstetricians. 33% of OB patients were placed on insulin, while only 24% of FP patients were placed on insulin, even though patients exhibited similar demographics. Even more striking was the difference in c-section rates----OB patients had a c-section rate of 33% while family practice patients had a c-section rate of only 11%. There were no significant differences in neonatal outcome (including macrosomia) between the two groups, despite treatment differences.

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 test protocols Kmom has ever seen, and some of the most extensive prenatal treatment protocols for the mother, too. Definitely worth reading for a representation of an extremely conservative view of gd treatment.

Jornsay, D.L. et al. Answers About Gestational Diabetes. Boehringer Mannheim Corporation. 1993.

Another general review of gd for the patient who wants mostly basic information. Good review of insulin injection technique and general insulin info.

Blank A., Grave G.D., Metzger B.E. Effects of Gestational Diabetes on Perinatal Morbidity Reassessed. Report of the International Workshop on Adverse Perinatal Outcomes of Gestational Diabetes Mellitus, December 3-4, 1992. Diabetes Care. 18(1):127-9, January 1995.

Another must-read article, a report of some of the findings from the 3rd International Workshop on GDM. (The 4th took place in 1997.) A quick summary of some of the problems associated with gd; notable for acknowledging some of the research controversies such as possible alternative causes for some of the problems, the problems with reproducibility of gd testing, the lack of cost-effectiveness of aggressively trying to reduce macrosomia on a wide scale, and the problems with research design and data of previous studies. Strongly promotes the need for further well-designed research.

Prophylactic Insulin References

Coustan DR and Lewis SB. Insulin therapy for gestational diabetes. Obstetrics and Gynecology. 1978. 51:306-10.

Small but randomized study that found that instituting daily insulin therapy reduced the incidence of macrosomia. However, according to other sources, no differences in rates of operative delivery or birth trauma could be demonstrated.

Coustan DR and Imarah J. Prophylactic insulin treatment of gestational diabetes reduces the incidence of macrosomia, operative delivery and birth trauma. American Journal of Obstetrics and Gynecology. 1984. 150:836-42.

The classic, must-read study that really intensified the prophylactic insulin movement. Retrospectively examined 445 charts of gd women delivered over a 5 year period. Examined the rate of macrosomic infants (>4000g), the rate of operative delivery (forceps, vacuum, c-section), and birth trauma (shoulder dystocia, injury) in the gd women, stratified by treatment modes (no treatment, diet alone, diet plus insulin). Found that insulin treatment significantly lowered the rates of macrosomia, operative delivery, and birth trauma. One of the few studies that found that lowering the macrosomia rate also lowered the c/s rate. The rates for macrosomia among gd women with no treatment, diet-only treatment, and diet+insulin treatment was 17.8%, 18.5%, and 7%. The rates for operative delivery for each group respectively were 28.5%, 30.4%, and 16.3%. The rates for birth trauma for each group respectively were 20.4%, 13.4%, 4.8%. Note that this was a retrospective study, not randomized. Still, one of the best results from prophylactic insulin use on the books yet. Critics note that using insulin reduced the birthweight on average, a total of 6 ounces (170g) and question whether that is clinically significant, but the percentage of very large babies *was* reduced significantly. Authors were fair enough to note at the end that it was appropriate to question the safety of prophylactic insulin use, but they only addressed a couple of areas of maternal safety and did not at all address fetal safety. Finally the authors note, "It would thus seem appropriate to offer prophylactic insulin therapy as a possible means of lessening the likelihood of a difficult delivery or cesarean section. The gestational diabetic woman should not be made to feel that this is a life-or-death issue for her fetus but rather a quality-of-delivery issue."

Thompson DJ et al. Prophylactic insulin in the management of gestational diabetes. Obstetrics and Gynecology. 1990. 75:960-4.

Randomized gestational diabetics into diet alone or diet plus insulin groups, with equal numbers of obese and average-weight women in each treatment group. Babies were delivered between 40-42 weeks, generally. Among 68 women successfully treated for a minimum of 6 weeks, the mean birth weight, macrosomia rate, and ponderal index were reduced significantly in the insulin group. Unlike in some studies, insulin significantly reduced the size of the babies of obese women, by an average level of about a pound and a half (very significant). However, the birth weights of the babies born to obese mothers on insulin were still heavier than those of non-obese women. Despite the big reduction in birth weight in the insulin group in both average-sized and obese mothers, their overall c/s rate was actually higher. The diet alone group had a c/s rate of 35% while the insulin group had a c/s rate of 41% (overall c/s rate for both groups was 38%, very high). Nor was morbidity reduced, raising the question of the value of treatment. No shoulder dystocia occurred in any patient, including the obese patients with macrosomic babies. Study advocates more aggressive insulin use in obese women based on the yet-unproven speculation that a decrease in macrosomia at birth may lead to less obesity and early diabetes among the offspring. Contains a good review of other prophylactic insulin studies.

Persson B, Stangenberg M, Hansson U, Nordlander E. Gestational Diabetes: Comparative Evaluation of Two Treatment Regimens, Diet Versus Diet and Insulin. Diabetes. 1985. 34:101-5.

Randomized 202 pregnant women with gd into diet-only and diet+insulin treatment groups. "The two treatment regimens disclosed no differences regarding achieved degree of maternal blood glucose control, hemoglobin A1c at delivery, obstetric or neonatal complications, infant's size at birth including skin-fold thickness, or C-peptide concentration in cord serum. Routine treatment of pregnant women with mild carbohydrate intolerance with insulin seems unnecessary."

Santini, DL and Ales, KL. The Impact of Universal Screening for Gestational Glucose Intolerance on Outcome of Pregnancy. Surgery, Gynecology and Obstetrics. May 1990. 170: 427-436.

Looked at the debate over universal screening and its impact on treatment and pregnancy outcome. Retrospectively studied 1307 pregnancies at Cornell University Medical Center over 5 months, where some providers did universal screening and some did not screen at all. Compared the screened population vs. the unscreened population to see if screening and treatment helped reduce the number of large infants, and how treatment and outcome differed. "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." The c/s rate for those unscreened for gd was 21%; the c/s rate for those screened for gd was 27.6%, and the c/s rate for those screened and treated was 32.5%. The c/s rate for those screened and treated with diet alone was 30%; the c/s rate for those screened and then treated with diet plus insulin was 38.5%. "The process of screening is itself linked with more intensive surveillance during pregnancy...even in the absence of the diagnosis, labeling or treatment of gestational glucose intolerance." Furthermore, only about half of the women labeled as having gd actually met the criteria for having it. The rate of large infants was not significantly different between the screened and unscreened groups. No difference was found, either, in the rate of metabolic complications in newborns. A few explanations could be made; physician style probably impacted the difference in c/s rates some, and the unscreened population tended to be less obese, so perhaps that is why they had less large babies than expected. However, the unscreened population was more likely to be parous and to be older (factors which generally make for bigger babies) and to have private doctors (a factor which would tend to increase the c/s rate, not decrease it). C/S was also more common in women with larger infants in either group (31.5% vs. 23.9%), raising the question of how much is due to actual physical problems of having a larger baby and how much is due to physician bias and interventions for larger babies. Examines the difficulty in setting up a randomized, controlled trial with enough power to determine the value of universal screening and gd treatment to reduce infant size---it would have to have a very large amount of participants. Notes that up to now, screening and treatment both were assumed to have no significant adverse effects, but that this needs to be strongly questioned.

Langer, O. et al. Glycemic Control in Gestational Diabetes Mellitus--How Tight is Tight Enough: Small for Gestational Age versus Large for Gestational Age? American Journal of Obstetrics and Gynecology. 161(3):646-53. September 1989.

334 gd mothers (and 334 controls) were studied to find out the relationship between optimal levels of glycemic control and perinatal outcome. Extremely tight control (mean blood glucose values <87 mg/dl) increased the number of small-for-gestational-age babies significantly, while high blood glucose values (mean > 104 mg/dl) had significantly more large-for-gestational-age babies. The middle group (mean blood glucose between 87-104 mg/dl) was similar to the control group. Critics have used this study to point out that excessively low bG goals may introduce risk and may lead to more SGA infants.

Garcia-Patterson, A et al. In Pregnancies with Gestational Diabetes Mellitus and Intensive Therapy, Perinatal Outcome is Worse in Small-For-Gestational-Age Newborns. American Journal of Obstetrics and Gynecology. August 1998. 179(2):481-5.

821 pregnancies of gd moms receiving intensive metabolic therapy were examined for the relationship between perinatal outcome and birth weight. 7% were Small-For-Gestational-Age (SGA), 85% were Appropriate-for-Gestational-Age (AGA), and 8% were Large-For-Gestational-Age. After adjustment for preterm delivery, rates of adverse fetal outcome were about 3x as likely in SGA babies than in AGA or LGA babies. "Among women with gestational diabetes mellitus who are receiving intensive therapy, perinatal outcome is worse for small for gestational age neonates than for appropriate and large for gestational age neonates." Critics have used this study as well to point out that excessively low bG goals may introduce risk and may lead to more SGA infants.

Kitzmiller, JL. Sweet Success with Diabetes: The Development of Insulin Therapy and Glycemic Control for Pregnancy. Diabetes Care. December 1993. 16(3):107-21.

Mostly a very technical history of the treatment of type I diabetic pregnancies, it does contain a few notes of interest here. It traces the modification of Pederson's Hypothesis (about maternal hyperglycemia increasing fetal insulin levels, causing macrosomia); it is now thought that other maternal substrates, notably Free Fatty Acids and Beta-Hydroxybutyrate, may be responsible for some of fetal macrosomia. Notes that higher doses of insulin may decrease macrosomia by decreasing these levels. Also examines the controversy of whether ketones impair IQ or cause learning problems, and notes that insulin requirements often decrease in the last few weeks in type I pregnancies. Finally, notes the potential dangers of adding excess insulin to the mother and the lack of research on its safety. "An important point...is that hyperinsulinemia is produced by clinical methods of insulin treatment of diabetic women...There has been little investigation of the effects of this iatrogenic hyperinsulinemia on placental physiology, blood vessels, or the tendencies toward hypertension in pregnant diabetic women."

Langer, O. Maternal Glycemic Criteria for Insulin Therapy in Gestational Diabetes Mellitus. Diabetes Care. August 1998. 21(Supplement 2). Available for viewing at www.diabetes.org/DiabetesCare/Supplement298/B91.htm.

Supports a very aggressive approach to insulin therapy, especially in obese women. Contends that many women qualifying for insulin are actually receiving too-small doses, and highlights the need for studies to compare optimal insulin dosage. Recounts a study showing that the majority of specialists studied were not instituting insulin at even the ACOG target range (105 fasting/120 post-prandial)--it's doubtful whether this is really true of all OBs. Blames the use of too-liberal insulin standards and the under-dosage of insulin for the lack of improvement of macrosomia rates in many gd studies. Advocates insulin use if fastings are >95, treatment goals of <95 fasting/<115 postprandial/<95 pre-meal, and mean blood glucose readings of 90-100 mg/dl. Also strongly advocates use of self-monitoring by patients and contends it is being vastly underused (questionable, but promotion of self-monitoring is a reasonable position). Theorizes that the rate of insulin use will be about 50-60% in this regimen but that providers should not shy away from this percentage--that normoglycemia is more important than avoiding insulin. Fails to address the issue of higher c/s rates in groups given insulin, or the issue of safety of aggressive insulin use. Makes a reasonable case for study of insulin dosage (are the doses being used too low?), and a decent argument for lowering the fasting requirement to 95, though the point is still debatable. However, he concludes that "patients with fasting plasma glucose on the OGTT of <96 mg/dl (and ideally nonobese) be assigned to diet therapy. Obese women or those with fasting plasma glucose >95 mg/dl on the OGTT should be referred to insulin therapy in order to minimize exposure of the fetus to a hyperglycemic environment." This seems to be saying that ALL obese women should be placed on insulin, regardless of favorable bG results on the OGTT or dietary treatment. If the results are <95, then by his definition they are not 'hyperglycemic', yet they would still be assigned to insulin. Does not make a case to justify the use of insulin for successfully treated obese moms, just makes the sweeping recommendation for it.

Garner, P et al. A Randomized Controlled Trial of Strict Glycemic Control and Tertiary Level Obstetric Care Versus Routine Obstetric Care in the Management of Gestational Diabetes: A Pilot Study. American Journal of Obstetrics and Gynecology 177(1):190-5, 1997.

One of the largest and best-designed studies of the effectiveness of gd care; is a pilot study designed to be followed up with a multicenter trial of sufficient sample size to confirm their findings. Criticizes the inadequacies of other clinical trials to date and points to the need for further prospective randomized controlled trials of larger size. Its preliminary findings based on the pilot study is that intensive treatment of gd (insulin started at fastings of 80!) may have little effect on birth weight, birth trauma, operative delivery, or neonatal metabolic disorders, but emphasizes that the sample size (though one of the largest of its kind so far) is insufficient to allow any recommendations on the effect of treatment vs. no treatment in gd. A must-read for anyone serious about researching gd.

Simmons, D and Robertson, S. Influence of Maternal Insulin Treatment on the Infants of Women with Gestational Diabetes. Diabet Med. September 1997. 14(9):762-5.

Examined the long-term impact of insulin therapy on the adiposity of the offspring. Looked at the degree of fatness at about age 2.5 of babies of moms treated for gd. Babies of insulin-treated women had less subscapular fat and less biceps fat than diet-treated moms, despite insulin-treated moms being more obese, older, and more hyperglycemic. "Insulin therapy in gestational diabetes may reduce the incidence of obesity in the offspring of women with gestational diabetes and this should now be tested by a larger, randomized controlled trial." Note that sample size was extremely small, significantly limiting the power of this finding, and that children were only examined at the age of about 2.5 (difficult to make long-term generalizations from). Also, it is unclear if this is meaningful at all, i.e. will having less subscapular and biceps fat translate into less or more diabetes later in life? Still, it is an interesting finding and one of the few studies to study the results of insulin on the child. Its call for further studies with adequate methodology is very important.

O'Sullivan, JB and Mahan, CM. Insulin Treatment and High Risk Groups. Diabetes Care. May-June, 1980. 3(3):482-5.

Follow-up study of 615 gd mothers by the author whose classic works were most instrumental in early gd research. Followed these mothers over 16 years. Half of the group were randomly assigned to insulin therapy originally, half were not. Evaluated whether initial treatment with prophylactic insulin potentially reduced the rate of subsequent diabetes in mothers; it did not. However, a sub-analysis found that among women who bore a baby of large birthweight or who had a family history of diabetes, "subsequent decompensated diabetes was found to be significantly reduced" among those who had been treated prophylactically with insulin. "This finding suggests the possibility of long-term preventive benefits from insulin treatment in high risk subsets of women with gestational diabetes." However, it's important to note that O'Sullivan's original study groups were notable for having multiple risk factors that muddy his original analyses; it is difficult to know the significance of these early findings. Still, an interesting study.

Sacks, DA. Fetal Macrosomia and Gestational Diabetes: What's the Problem? Obstetrics and Gynecology. May 1993. 81(5, part 1):775-81.

A truly outstanding, well-balanced review of the issue of macrosomia and gd pregnancies. Reviewed 79 articles through 1993 relevant to the subject, then summarizes the difficulties in drawing conclusions from them and suggests strategies for further investigation. For example, found that some studies clearly found a relationship between maternal glucose levels and fetal macrosomia, while others did not. Notes all the confounding variables possible, and the differences in study design and observational content---"because of these differences, meaningful comparison of data between studies is exceedingly difficult." Notes the problems even defining what macrosomia is, but treats seriously the potential for shoulder dystocia and injury. However, it still notes that this concern should be "placed in clinical perspective. Only a small proportion of LGA infants of diabetic mothers will develop shoulder dystocia. Brachial plexus palsy...usually resolves during the neonatal period. Physical and sonographic estimates of excessive fetal weight carry substantial margins of error. Furthermore, cesarean delivery introduces a significant risk of maternal morbidity." Regarding prophylactic insulin, the study has multiple observations. "Despite insulin treatment, obese women had a higher incidence of macrosomic neonates, even when the data were stratified by maternal glucose levels...[other] data suggest a potential benefit of routine insulin administration to certain gestational diabetic women. However...the lack of uniformity in reporting and control of variables that may influence birth weight makes it exceedingly difficult to draw definitive conclusions."  A must-read study.

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 technical (see above). Re: prophylactic insulin, it says, "It is important to recognize the data suggesting that insulin therapy may achieve lower rates of macrosomia if initiated when fasting blood glucose is >95 mg/dl. However, prophylactic insulin treatment in patients whose fasting and postprandial values remain within the recommended range is not advised."

Ratner, RE. Clinical Review 47. Gestational Diabetes Mellitus: After Three International Workshops Do We Know How to Diagnose and Manage It Yet? Journal of Clinical Endocrinology and Metabolism. July 1993. 77(1):1-4.

An excellent if conservative review of gd and many of its controversies. Notes that more than just glucose levels are implicated in the possible morbidities associated with gd. Discusses many of the treatment issues of gd, and notes the need to balance aggressive glycemic control with possible risks to the mother and fetus from overly aggressive treatment. Does favor moderate caloric restriction for obese women, though it notes that this is "one of the most contentious issues in the literature" and that "long-term effects, however, remain unknown and require additional investigation." Regarding prophylactic insulin, it states that "controlled trials comparing diet plus insulin to diet alone in GDM reveal mixed results...preliminary data may support revision of these [traditional] goals to initiation of insulin when fasting plasma glucose levels exceed 95 mg/dL but prophylactic insulin treatment is not convincingly beneficial."

Metzger, BE. Treatment of Mild Gestational Diabetes: Is It Time for a Controlled Clinical Trial? Editorial in Diabetes Care. 11(10):813-16. Nov/Dec 1988.

Reviews a number of studies where intensive insulin therapy has been used and finds that "insulin therapy has not always been more successful than dietary treatment, and corresponding improvements in obstetrical outcomes and reductions in neonatal morbidities have not been found to be consistent." In some studies, intensive insulin use reduced the c-section rate, while in others it either had no effect or actually increased the c-section rate. Calls for a large-scale, multicenter controlled clinical trial with a large number of subjects and rigidly defined protocols.

Enkin, Murray et al. A Guide to Effective Care in Pregnancy and Childbirth. Second Edition. Oxford: Oxford University Press (Oxford Medical Publications), 1995.

Based on the conclusions and research from the Cochrane Database of Systematic Reviews, which examined the research of 60 key journals. Careful attention was paid to the methodology of the research design, with an emphasis on the 'gold standard' of research, randomized controlled studies. "Evidence-Based Medicine" at its best. Found significant reason to question the current aggressive approach to gd. "There is no convincing evidence that treatment of women with an abnormal glucose tolerance test will reduce perinatal mortality or morbidity. Trials of dietary regulation... do not demonstrate a significant effect on any outcome, including macrosomia. Trials comparing the use of insulin plus diet with diet alone show a decrease in macrosomia, but no significant effect on other outcomes such as use of caesarean section, the incidence of shoulder dystocia...perinatal mortality...[or] neonatal jaundice or hypoglycaemia." They further go on to make the very strong statement that "The available data provide no evidence to support the wide recommendation that all pregnant women should be screened for 'gestational diabetes', let alone that they should be treated with insulin. Until the risks of minor elevations of glucose during pregnancy have been established in appropriately conducted trials, therapy based on this diagnosis must be critically reviewed. The use of injectable therapy on the basis of the available data is highly contentious, and in many other fields of medical practice such aggressive therapy without proven benefit would be considered unethical."

 

 


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