GD induction

[A-mac]

I rarely post here, but I've come up against a sticky situation that I could use some thoughts on.

This is my first pregnancy and I'm 37 weeks. At 18 weeks I was diagnosed with gestational Diabetes. We tested early because I have every risk factor. Because I was diagnosed with GD my care was transferred from a midwife group to an OB. Since that time I've taken my blood sugars regularly and had to work VERY hard to keep them perfect, but they are perfect. I had an ultrasound at 33 weeks that showed that the baby was exactly the size she is supposed to be. All of the measurements of my belly have been exactly on schedule as well. I have absolutely no other pregnancy related problems, my blood pressure is great, my weight gain is great, I still walk 3 miles every day, and I generally feel fabulous.

The problem is that the doctor wants to induce no later than 40 weeks because I have, as he calls it, 'phantom gd'. I know that the risks of stillbirth and other complications go up with GD, but I'm just not sure that those risks really apply to me. I have no problem with declining the induction, but I want to do it with full knowledge of the risks and benefits of either course of action. I'm having trouble finding any research with reguards to inducing for GD when it is well controlled.

I do think that at some point the risks of waiting will outweigh the risks of induction for me personally, and that point isn't 40 weeks, but how do I figure out where it is?

For anyone who has read all of this, I really appreciate it. I'm still holding out hope that I'll go into labor spontaneously, but I know that it's not really very likely.

[msmiranda]

I just did a little internet research, and from what I can tell, the risk of stillbirth is related to poorly controlled GD, and women who had preexisting diabetes before pregnancy.  (A Merck manual on pregnancy complications states, "Good control of plasma glucose during pregnancy almost eliminates the risk of adverse outcomes attributable to diabetes. ")  The Dartmouth-Hitchcock Medical Center website indicates that increased risk for stillbirth is for poorly controlled GD.  This article indicates that stillbirth rates for women with GD who are not on insulin were comparable to rates for the nondiabetic population.  (It talks about a lot of other interesting stuff as well).

So, I would feel absolutely justified declining an induction at 40 weeks.  Any additional risk that you may have over the average non-GD pregnant woman is likely miniscule, but can be controlled for by additional monitoring (BPPs, in particular, to check the condition of the placenta).  I'm sure you know that, as a first-time mom, an induction is highly likely to end in a c-section, which would then complicate every future pregnancy you have and introduce additional risks to both this baby and any future children you may want to have.  (not to mention that it could hinder the breastfeeding relationship, if you are planning to breastfeed). 

I would NEVER agree to a 40-week induction in the circumstances you describe.  Probably not a 41-week induction either.  I would accept biweekly BPPs and NSTs because that kind of monitoring would help put my mind at ease (and might help your doctor feel better about your decision to decline the induction as well). 

I think that OBs conceptualize risk in a way that differs from how most of us here at MDC see it.  They discount the risks of c-sections, but overemphasize very small increases in the risk of stillbirth ... which makes sense for them, because a stillbirth can get them sued and a c-section won't.  But it doesn't necessarily make sense to the patient.  For example, this ACOG bulletin on managing stillbirth says that the baseline risk for the general population of all races except African American women is 6 per 1000.  They go on to state that women with a BMI of 30 to 39.9 are at "increased risk" -- 8 in 1000.  That's not a huge increase, but that's the kind of scale on which OBs measure "increased" risk for a particular outcome. 

[A-mac]

Thank you SO much, this is exactly what I've been searching for but unable to find. The links you provided are very helpful and professional. I can't thank you enough.

[mncowmom]

I'm in the same situation you are.  I'm seeing a family doctor and a midwife and as long as I keep my numbers in line, then it's no different that a "regular" pregnancy.

[msmiranda]

Glad I could be of some help.  The other thing I was going to mention is that I kept finding the abstract to this study.  As best I can tell without being able to access the whole thing, they did a retrospective study on women who both had diabetes during their pregnancy and then went on to develop diabetes after their pregnancy (hence why it was retrospective), and women who were going to develop diabetes later on had an increased risk of stillbirth, although they admit that this may be related to uncontrolled GD.  Not sure why this particular abstract kept pooping up -- guess it was my search terms.

{I wanted to put this below the quote but I can't get the cursor to go there so I'll put it up here}  I followed links to several other articles cited in the below review and from what I can tell, there has been very little research done into how GD affects stillbirth, mostly because stillbirth is a rare enough outcome that the studies would have to be HUGE to show any effects. 

A more recent review of studies about factors affecting stillbirth has a good section on GD and preexisting diabetes.  Their conclusion is:

While data from RCTs is scarce, the limited evidence, largely from clinical management of diabetic patients (Grade C evidence), suggests that pregnant women who do not have vascular complications and with good glycaemic control do not as a group have an increased risk of stillbirth above the general population [85].

[lifeguard]

I would not accept a blanket "you have gd so you can't go past 40 weeks". But I would be ok with increased monitoring at the end of the pregnancy (weekly nst's is what we did) with the possibility of induction if the baby was showing signs of distress.  There are risks besides stillbirth although most seem to be if the gd is uncontrolled.