Sunday, June 26, 2011

GDM Research Quotes

I had requested copies of the references my doctor's clinic was using for the gestational diabetes care they were mandating (the high alert, the concern about birth weight, the ultrasounds and the weekly non-stress tests).  I am very pleased that my doctor was able to send three papers.

Interesting reading. I feel more settled than ever that my medical situation doesn't warrant the interventions the clinic has required. I thought I'd share some quotes.

from ACOG Practice Bulletin / Gestational Diabetes

"[G]uidelines [within this bulletin] should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient and resources..."  (Thomasin's Note:  The ACOG's guidelines have been provided to me as absolutes, not as variable based on my needs as an individual.)


"Patients should be instructed to follow an unrestricted diet, consuming at least 150 g of carbohydrate per day for at least 3 days prior to the [Glucose Tolerance] test. This should avoid carbohydrate depletion, which could cause spuriously high values on the GTT."  (Thomasin's Note:  I was not instructed to eat at least 150g of carbs/day in the days prior to my test. So I guess the clinic does adjust its procedure from ACOG's guidelines sometimes... [And unfortunately I don't have a food log of what I ate that week, so I am uncertain whether I met that 150g/day or not.])


"Ultrasonography has been used to estimate fetal weight, especially to predict macrosomia prior to delivery. However the reliability of these measures has not been established...In addition, the use of ultrasound-derived measure of fetal weight have not been shown to be superior to clinical measures." (Thomasin's Note:  Yet the use of ultrasound and its fetal weight estimation would be a determining factor in deciding upon whether labor would be induced or not...)

from The New England Journal of Medicine / Hyperglycemia and Adverse Pregnancy Outcomes

"Caregiver bias (i.e. an expectation of adverse outcomes due to gestational diabetes mellitus) may increase the likelihood of disorders or problems due to increased intervention." (Thomasin's Note:  I've bolded this because I find it extremely significant. When someone who assumes there may be a problem goes looking for the problem they're likely to find it, truly there or no. One of the primary reasons I will not be agreeing to the ultrasounds and non-stress tests at this time.)


"Our study had some limitations. The nutritional status and gestational weight gain of the participants could affect fetal growth and other perinatal outcomes; we do not have data on these variables... [Thus,] we cannot conclude that maternal glycemia is causally related to the adverse outcomes observed; however such a relationship is plausible." (Thomasin's Note:  Could this be why my daily nutrition has never been examined this pregnancy? Because they wouldn't know what to do with that information in relation to a GDM diagnosis? Seems weird, right? Also, plausibility isn't strong enough--for me, with my diet being what I know it is, my test results as close as they were, and my excellent daily blood sugar readings--to jump through each and every hoop they are tossing at me.)

from American Family Physician / Diagnosis and Management of Gestational Diabetes Mellitus

"A recent observational study confirmed the association between increased maternal blood glucose and increased birth weight. Further studies are needed to unequivocally support the benefit of universal screening, although most obstetric practices employ this strategy."  (Thomasin's Note: Though they cannot absolutely recommend the universal screening, I--due to my age--fall into the recommended category anyway. But readers should be aware that this GDM screening isn't required during prenatal care, not for me and definitely not for others, especially those younger than I am.)


"Although earlier delivery reduced the risk of macrosomia, it did not reduce rates of brachial plexus injuries, hypoglycemia, or clavicle fractures." (Thomasin's Note:  Emphasis mine. So, inducing labor early = smaller babies [no kidding! You're expelling them from the womb before they were finished growing!] but it hasn't been shown to reduce the adverse affects that everyone worries about. Sounds like induction for the sake of a smaller baby isn't really all that good of an idea, especially since it's understood to increase the risk of cesarean...)

(1) Coustan DR, Gestational Diabetes. ACOG Practice Bulletin: Clinical Management Guidelines for Obstetrician-Gynolgologists 2001; 30:1-14
(2) Metzger BE, et al, for the HAPO STudy Cooperative Research Group. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med. 2008; 358 (19): 1991-2002. 
(3) Serlin DC, Lash RW. Diagnosis and Management of Gestational Diabetes Mellitus. American Family Physician 2009; 80(1):57-62


Elizabeth White June 26, 2011 at 9:47 PM  

When I was induced... the doctor did come in and warn me that it looked like I might have to have a cesarean section... :( She gave me 30 more minutes I think to push before going ahead with it... I was determined not to let that it turns out all I needed was a different position and she came out 45 minutes later. :)

Thomasin June 27, 2011 at 11:37 AM  

Inductions tend to lead to more c-sections (the pain of induced contractions and the restriction of movement that is imposed when you are tied up to the IVs and meds lends itself to getting an epidural which means even less movement and can contributet to fetal distress, etc.). I am just so happy that it worked out well for you and you were able to move into a good position in the end (sounds like you had an excellent nurse!). K is perfect and you don't have to worry about your VBAC status for future pregnancies (which, frankly, as I've discovered, totally sucks).

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