A while ago I wrote a ‘You Be The Doc’ regarding a patient with borderline gestational diabetes. That patient had her baby recently, and it was something of a white-knuckle affair. Here’s what happened:
The initial test for GDM is a 1 hour glucose tolerance test, and the patient was VERY positive with a score in the 190’s. In the medical world, it’s considered bad form to designate someone as ‘very’ positive, or ‘borderline’ positive. These numbers are cut-offs. If you are past the cut-off, you’re positive. That’s it. No rounding, no data massage. The cut-off for GDM is 140. So the test is positive.
There are lots of reasons why the 1-hour GTT is lame. You can eat virtually anything on the McDonald’s menu, then come to the clinic and take the test and have a pumped up test result. So, because you can’t really trust a 1-hour GTT, we follow it with a similar test that is at least a bit more rigorous (still lame, though). The 3-hr takes 4 blood glucose tests – a fasting, then 1, 2 and 3 hours after drinking a sugar-rich solution. Our patient had normal values for all but the 4th test, and it was only off by about 3 points. 3 points! Everything else was normal. In my last post, I pondered whether or not to bestow the diagnosis of GDM on this patient with this glucose profile.
We did not. We told her she was fine. No intervention.
Hey, we’re family doctors. We’re mellow. A coupla out of range values. So what? No big deal right? Actually, you might ask, what is the big deal? Well, the whole point is to determine if your body can metabolize (that is, put away) glucose correctly. Glucose – sugar – in your blood stream is a BAD thing. It doesn’t belong there, it belongs in your body’s cells. Think of it as energy. Like little burning, flaming, sparking packets of sun-beam radiation (that, incidentally, also taste really, really good). As this stuff flies around your blood stream, it’s like an average 2 year old boy left alone in a glass-blower’s museum (well, at least my 2 year old boy). This is, metabolically speaking, why eating high-sugar foods isn’t healthy…or at least risky. At any point, your body may look at all that glucose tearing apart your capillaries in your eyes and kidneys and brain, start wringing its metaphorical hands and just curl up into an useless whimpering pancreatic fetal ball and give up. If, for some reason, your body can’t vanquish the insane levels of glucose the average American pours into their arteries in a given meal, you have diabetes. High blood glucose levels cause all kinds of problems. The most important of which, in pregnancy, is HUGE kids. We call ’em “macrosomic”.
My patient – who we did not treat for GDM – went into labor around 8pm. Very little cervical change occurred through the first 10 hours. By noon the next day – we’re talking about 16 hours of labor here – she was finally ready to push. After pushing for 5 hours, the baby still wasn’t out, in fact, she hadn’t really moved at all. Imagine, after five hours of the hardest work you’ve ever done in your life…you get to hear your doctor say something oblique and vaguely encouraging like, “You’re doing GREAT! I’m sure things will progress if we keep working.” There’s a thing called the “labor curve” to mention here. Typically, if there isn’t continual cervical change, and steady descent of the baby once the patient starts pushing, the patient is said to be “falling off the labor curve.” When this happens, docs need to start looking for a problem. In general we look for one of 3 P’s: Power – mom just can’t push hard enough or uterine contractions not strong enough, Pelvis – is the “chute” too small?, and Passenger – is the kid too big? In this case, the patient was off the curve, and we couldn’t be sure that any of the P’s were adequate.
We were able to see the baby’s head well enough to allow us to use a vacuum, which did help bring the baby into the base of the pelvis. At that point, we had an OB in the room to evaluate for C-section. She was particularly concerned with our decision to not treat for GDM based on this patient’s glucose profile. Almost certainly, she said, this baby was macrosomic because she, by definition, had GDM (remember, our 4th value was out of range by 3). She also said that she would have treated the patient for GDM based on her very high 1-hour test, forgoing the 3 hr. entirely, since it had been “very” positive.
You can imagine my handwringing concern at this point. I let this patient sit around for MONTHS, cooking up a huge baby that was not going to get stuck in her pelvis. Bad things happen when babies can’t fit through pelvises. To think I could have prevented it by just being more aggressive early gave me the opportunity to experience some new emotion – as yet unnamed – that combines stark fear with wistful, sharp regret and a sticky sort of guilt all mashed together with insecurity and self-castigation. We’ll call this feeling FRGIS. Mid way through this experience, I felt extremely “Frgis-y”. That is, quite terrible. I’d, perhaps singlehandedly, resigned this mother to surgery (best case), or perhaps something more terrible due to shoulders, head or neck getting stuck in the birth canal.
In the end, the vacuum (which only adds about 10% more power than the uterus and mother already provide) created just enough extra oomph to get the baby’s head through. The shoulders were a tight squeeze, but there was no distocia (shoulders caught on the pubic bone…can be REAL bad). The mother hemorrhaged and required 3 different medications to get it stopped, and she had a pretty good-sized laceration that took about a hour to repair. But the baby did fine. Actually, rather cute. I usually think they look like aliens.
The upshot was that the baby weighed around 8 lbs. This IS NOT MACROSOMIA! This is a big baby, but not medically large. In the end, we had nothing more than a difficult delivery, which probably had more to do with the mother being new at pushing and not really knowing how to do it than anything else. More stringent glucose management may have helped keep the baby a bit smaller, but she wasn’t especially large even without management. And the patient got no shots, no medications and no extra worry about having a metabolic disease while she worried about just getting through her pregnancy.
In the end, the patient ended up with a beautiful, normal-sized baby. Yes, there was a pretty big laceration, but these are relatively common irrespective of the size of the baby. But in general, our management was within the standard of care, although there is room to debate whether or not we should have been more aggressive. True, the doctors lost hair and years from their lives (or, my life, anyway), and experienced the wonderful emotion called FRGIS, but hey, this is medicine, right?
secretwave101 
Good call. I would have done the same thing. Though man, I know what FRGIS feels like.
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Thank You!! it’s nice to know there are doctors out there that still use commone sense.
I have 5 & 1/2 children & I have always been “borderline” gestational diabetes. (my numbers are 1 or 2 below the guideline Or like your patient here I had one number on the 3 hour test above recommendations.)
I was told that I would need to take insulin & be induced early, both of which I refused. I did comprmise & agree to test my sugar 4 times a day & after eating my normal diet(BTW- I normally don’t eat much for sugars & during the rest of my pregnancy I had 3 numbers over the 120 recommendation.) Even with these numbers the doctor still insisted I be induced or take insulin or I would have a huge baby (again I refused. I was amazed at the change in estimated baby weights after the diabete diagnosis suddenly my baby had gained 5 lbs.)
Anyway my largest baby was 7 1/2 lbs at 40 weeks, & I’m extremely happy that I suck up for myself & my child.
I was thrilled to find your blog & that there are some doctors out there still that don’t “panic” & use common sense with pregnancy & childbirth.
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I was happy to find this post even though it was from awhile ago. I failed my first 1 hour glucose test by 5 points and then the 3 hour test on the fourth draw but the doc didn’t tell me by how much I failed. So I am considered borderline and am 31 weeks. Now I’ve got myself into a panic b/c I am overweight and have a big sweet tooth. I have done some research on GD and I am kinda freaking myself out. I have been exercising most of my pregnancy and watching my portion size just for myself. How concerned do I need to be? This is my third child and so far he has been active, but a lot less active than I remember my other two being. I don’t know if that’s just “mommy brain” not remembering things right but I was already feeling a little more worried than normal with this pregnancy although I don’t know why b/c other than this everything has been fine. Just a general worried feeling that I can’t seem to shake followed by nightmares. I don’t want to add this to my need to worry about list unless I really need to. I just need a second opinion. Thanks.
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Pleeease do NOT take this as an actual second opinion. BAD idea. I’m basically functioning as a low-paid Dr. Phil or Dr. Oz or whatever, ok?
BUT, I will tell you that you are worried about the right things…and then a bunch of things that don’t matter also. We docs work hard to try to get people to worry about the right things…and then totally forget about everything that doesn’t matter. If you worry about too much stuff, you will fail at the stuff you need to get right.
Fundamentally, you need to be VERY concerned about your weight gain, which is most closely tied to what you eat. Further, what you eat needs to be low in carbs for the sake of your baby along with your weight. Exercise is crucial, but you need to jog from Seattle to Portland and back to burn off a couple of Carl’s Jr. burgers (the good ones, anyway), so be smart and just don’t put the food in there in the first place.
Trying to keep track of fetal activity is not worth your effort, unless you want to do actual “kick counts,” which have specific directions so that you actually do a reasonably good analysis of them (your doc can help you with that if you ask him/her).
Seeking to ascertain a general “activity level” of your baby isn’t helpful, because its always going to be totally subjective (ZERO activity is another matter), and because every kid is different. Some kids just bounce off the walls, some are nearly dead most of the day. One of my kids is in “lazy lizard” mode for about 14 of her waking hours. It’s almost creepy. She sits there and reads while her siblings warp all around her trying to unearth the magma buried 4 miles under our house, and she just placidly reads her book, oblivious to everything.
So, my advice, is to worry about the boring stuff: 60 SOLID minutes of mild to moderate (read: challenging) aerobic exercise a day, sensible caloric intake and minimal simple carbs. Let your doc worry about fetal growth and glucose metabolism.
Try to ignore the nightmares. They’re so unsettling, I know, but try not to give them much thought. It’s part of pregnancy and for many women, they subside at some point, much like morning sickness does in most pregnancies.
Just remember: This ain’t your first rodeo, girl. You can do this…just like you’ve done before.
SW101
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I am very curious about false positives in gestational diabetes. During my last pregnancy, I had gestational diabetes. I failed the first test at 143, and bounced all over the place during the second with the peak being around 165. I monitored my glucose levels religiously and didn’t have any high numbers for the entire duration of testing–which I later discovered was irregardless of the amount of exercise. That pregnancy I had 0 % over their limit of 130 mg/dL. My daughter was born (via cesarean for breech presentation) at 39 weeks weighing in at 7 lbs. 6 oz.
This current pregnancy, I was required to take the 1 hour test at 10 weeks. I completely failed that one with a 236. Yikes! None of my tests last time were that high (seriously, if I had a number near 200 I would have sent myself to the ER or something). Anyhow, I started testing diligently. My numbers this time around are even better than last time ranging from about 80-100 1 hour post-prandial. My fasting numbers are always consistently in the 73-83 ish. This time, I do sometimes have really whacked numbers that seem to come out of the blue–I’ve had a 163 and maybe a 140 something, but the meals were really tame (I didn’t eat a doughnut or anything completely off the charts). The problem is I’m at 23 weeks and totally tired of testing. My weight gain is a little on the high end (15 lbs so far) and that stresses me out a bit since I’d like to try for a VBAC–no one wants to do a VBAC with a GDM 9 lb baby. My success at managing “GDM” has nothing to do with the third grade nutritional counseling I receive from the dieticians. I seriously am not trying very hard at all. I just eat what I want, when I want and my ranges seem to be generally normal. Sigh. Their good news is that if we decide to have another baby, I don’t even need to take the test again–I just get the diagnosis. I am very curious if I’ll be as wiling to accept that the third time around if this baby weighs in at 7-8 lbs and is delivered vaginally without much of a to-do. We can only hope.
On top of that, the doctors and dieticians have me stressed that some wicked form of GDM might just jump out of the closet at 25-28 weeks once the placenta gets bigger and insulin resistance kicks in. Joy of joys.
I know this is a late comment to this post, but not many doctors write about the grey areas in testing for GDM.
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