Type 2 diabetes and childbirth (long)

[fillefantome]

I was just diagnosed as having Type 2 diabetes a few weeks ago, and I must admit I'm freaking out a little bit about what this means for my future baby-having plans.

Quick (or not-so-quick) background: I'm just shy of 32, no kids yet, hoping to start trying to conceive in 2-3 years (probably through IUI, as I'm both single and bisexual). Waiting a couple of years, while necessary to get my life in order, means I'll likely be of "advanced maternal age" if/when I get pregnant. I've been pre-diabetic for a couple of years, since gaining quite a bit of weight after starting grad school and going from exercising daily to being a completely sedentary academic type. I've always been heavier, even when doing all that exercise, but have definitely felt the effects of the added weight in many ways and have every intention of getting back into shape (any second now). My A1C was 6.6% (6.5% and over = diabetic), but my BG has been in the high-normal range since I started testing it right after being diagnosed. I've been working on diet (lower carb and portion control) and exercise, and my doctor also prescribed 500 mg of Metformin ER/day. He gave me the option of whether or not to start medication right away or just to work on diet/exercise for the moment, and we decided that the Met would help while I'm working on losing weight and getting into an exercise routine. I'm actually fairly happy to stay on it--I'm not having any of the GI side effects many have, and the diabetes educator who taught the class I just finished says Metformin can help preserve long-term pancreas function by lowering your body’s demands for insulin production. I know I need to get into much better shape before I have a baby anyway, so none of this is horrible. It's probably a really good wake-up call for me to get my house in order, physically speaking.

The real reason I'm freaking is because the diabetes educator told me that if I have type 2 diabetes I will definitely have to be on insulin during pregnancy . In fact, she was so insistent on this notion that when I was trying to say to her "if I am on insulin, then I will not be able to see a midwife...." she kept interrupting me to say "you'll definitely have to be on insulin," not seeming to understand that I wasn’t questioning her professional opinion (she made it sound like I was being insanely naïve), but trying to explain to her that people on insulin are usually risked out of midwivery care. And that's my fear, that I will not be able to have the natural childbirth I desire because of this diagnosis. Even being controlled with just Metformin (which some MDs think is okay and some don't during pregnancy) would probably mean being considered high risk and forced to go the highly-medicalized route, and though I’m fairly certain I can get to a diet and exercise controlled place with my diabetes now, I know that insulin resistance is intense in pregnancy because the placenta puts out some hormone or other. I don’t necessarily have an idealized vision of the beautiful natural birth experience, so much as a deep fear of snowballing interventions—according to my reading diabetic pregnancies are usually induced on or before the due date because the placenta decays faster in diabetic women (as well as for the much less medically relevant “big baby” issue, which isn’t actually an issue at all if your BS is controlled during pregnancy, even by insulin), there is significantly more monitoring going on in a high risk birth, as well as possible insulin/glucose IVs during birth, which means much less mobility during the process, if your baby’s BS is low after birth, they try to feed formula/sugar water to raise it, rather than encouraging BF. All-in-all, I feel like I’ll be fighting the system, more than having a baby. I'm convinced that they're going to want to induce, that I'm going to end up having a c-section. If that's truly what's best for my baby, then so be it, but everything I've heard indicates that a lot of the "medically necessary" interventions are caused by the very medicalized mentality of the high risk OB, and I don’t want that.

I'm not sure what I'm hoping anyone will say in response to all this. I'd like to know if anyone is/knows a type 2 diabetic who was able to control her BS through diet during pregnancy (avoiding insulin). Or, a diabetic of any stripe, GD, Type 1 or 2, who was able to have a midwife or natural childbirth (beyond simply not having an epidural), and how they were able to negotiate that. Or, maybe suggestions on how to be empowered to make decisions that will help me avoid interventions if I have to be treated by high risk doctors and do the constant NSTs and ultrasounds and… stuff… that “high risk” requires—to walk the line between being sure my baby is safe and that I’m not being needless stubborn and just caving to their “expertise?”

I know I'm putting the cart three years ahead of the horse, and I shouldn't be fretting about all this when who knows what the future holds, but it's all I can think about since I got slapped with the diabetes label. I really just want this diagnosis not to be something that crushes my dreams as well as my ability to heedlessly eat ice cream....

[Wittyone]

Hmm, lots going on for you here! First, you've just been diagnosed and there is A LOT to process right now. Take your time, get comfortable with the dietary recommendations, etc. As you pointed out, there is no rush to conceive, and this is a good heads up prior to pregnancy to start working on your health. Second, I am far more familiar with gestational diabetes management than non-pregnant type 2, but I do know that there are people who are able to reverse their DM diagnosis with wt loss/lifestyle changes. It seems you probably have underlying insulin resistance issues that have led to the pre-diabetic state, which your Met will be treating. The conversion to DM happened after your lifestyle changed and you put on a lot of wt - no reason to assume that's irreversible!

For pregnancy - yes, you are more likely to have gestational diabetes even if you reverse your DM prior to conception d/t the underlying insulin resistance in you body. This is not the end of the world, and many of our patients are able to maintain their sugars tightly in pg with diet and exercise. Others are started on glyburide (oral med) or metformin - our practice follows the Sweet Success program guidelines, I'm sure you could find their info online. Some women do need insulin to maintain their sugars in pg.

Our practice is comprised of 4 CNMs and 5 OBs - women on diet control who are well controlled are eligible for CNM care, require no extra testing, are not induced prior to 42 weeks (unless there is a separate medical indication), and are eligible for a CNM for birth. Sugars are checked every 2 hours in active labor, women are offered GDM diet to eat in labor, regular diet postpartum, no further fingersticks once baby is born.

Women on meds, whether they are on oral meds or insulin are asked to start antenatal testing at 35 weeks (NST twice a week, AFI weekly) and are recommended to be induced at 40 weeks for the risks associated with diabetes requiring meds in pg (higher rate of stillbirth after 40 weeks mainly).

Someone on oral meds in good control is still eligible for CNM care in pregnancy and birth, with consultation with the MDs as needed. Usually their oral meds are not given in labor as food intake is generally decreased, but they are still free to eat in labor. BG's every 2 hours, meds or insulin as needed (often is not needed). They return to a regular diet postpartum and BGs are checked post-meals for a day.

Women on insulin are not eligible for CNM care in labor b/c their sugars are more likely to be difficult to control and with the amount of consultation that would require it's just easier for the docs to manage their labors. Postpartum care/management is similar to women on oral meds.

All women with GDM are asked to go for a 2 hour glucose tolerance test 6-8 weeks postpartum to make sure their GDM has resolved and their pancreas is again functioning normally.

Women in poor control of their sugars in pregnancy are not eligible for CNM care in pregnancy or birth as the pregnancy is definitely high risk at that point.

For the babies - our hospital is pretty relaxed and it also Baby Friendly so breastfeeding is highly valued. They have a glucose check within a 1/2 hour of birth, they may already be nursing but if not they are encouraged to do so ASAP. They have a couple more checks in the first 4 hours and if stable I think that's it. If there is a borderline low value the nurses will get them to breastfeed and recheck. If it's very low (under 30 I believe) it's automatic formula, but in very small amts so as not to overfeed.

I work in a very ideal setting. I know a lot of hospitals do not allow oral intake in labor so sugars are managed by glucose/insulin IVs (crazy!!). I know a lot of places do way more sugar checks on babies (like every 4 hours for 24 hours, even if the babes are stable) and are way less likely to encourage breastfeeding as the answer to stabilization. In addition to working on your own health, you have time in the next couple of years to research your local facilities and decide where your desires for your birth are most likely to be supported. Even our women on insulin who are not able to have a CNM are still birthing in a hospital and with MDs who are supportive of women's choices and know how to support natural birth.

Good luck - time is on you side and you already have a lot of insight into how to get where you want to be!

[fillefantome]

Wow, Wittyone, thanks so much for taking the time to explain all this. It's reassuring to know that there are places out there where I'm likely to at least be able to come at it from a natural childbirth perspective. Unfortunately, I'm living in the town where I went to grad school and jobhunting elsewhere (internationally as well as U.S.), so I have no idea what my local options are going to be in future. *sigh*

Anyway, you have no idea how much I appreciate the input. I feel a whole lot less nuts about the whole thing, so thanks!

[Wittyone]

You're welcome! Good luck with the job hunt