Gestational diabetes as a reason to induce?

[foreignerforlife]

I have very mild gestational diabetes (I failed the 2-hour test twice, but my daily blood sugar is normal; I am taking low doses of insulin), and my OB says it is likely I will be encouraged to have an induction on my due date at the latest to reduce the risks involved in carrying longer. She didn't say what these risks are, but I have an appointment with the clinic at 37.5 weeks to discuss all this.

Do any of you know of any research supporting or refuting induction in mothers with gestational diabetes? I'd like to be armed with info before the appointment. Thanks!

[lifeguard]

I would ask to do non-stress tests if they are having concerns as you approach/pass your edd. As long as the nst's are ok then I would NOT consent to an induction.

[clutterbug]

This is a few years old...I didn't peruse the Cochrane site really closely but you might find some other reviews on there related to GD and interventions :)

http://www2.cochrane.org/reviews/en/ab001997.html

[msmiranda]

I did a little research when someone else posted a similar question a few months back and posted some links on this thread:

http://www.mothering.com/community/forum/thread/1294280/gd-induction#post_16220125

Well-controlled GD is not a good reason to induce at 40 weeks, IMO.  You are right to push back.  Unfortunately I think that many women with GD do not control it well, and then because we share the label, women who do are lumped in with them. 

BTW, why are you on insulin if your GD is mild?  I thought insulin was only for GD cases that cannot be controlled with diet or diet + oral medication (e.g. glyburide or metformin).

[foreignerforlife]

Thanks ladies! 

@msmiranda: thanks for the great links. I'm on insulin because Germany has a new regulation that recommends insulin if you fail the 2-hour test and your baby measures large. I also have too much amniotic fluid, another indication for insulin here. The idea is to keep the baby from making too much insulin on its own, so it doesn't develop metabolic problems. They do not give oral medication for gestational diabetes here because it can be harmful to the baby.

[lifeguard]

Many care providers will not do oral medication for pregnancy. My last doctor told me that the main recommendation is still to go straight to insulin even though many don't follow this recommendation.

[kriket]

I would be honestly concerned with a large baby. Usually when you hear the horror of "The baby was too large for my pelvis" it's not entirely accurate. However, GD is one of those things that CAN cause a baby to grow too large.

I am concerned about GD for this reason. (among others) DS1 measured 3 an 4 weeks ahead from the 20w U/S on, but was born at 37w. DS2 is also measuring 3w ahead so far. So I can only imagine if I get GD, and have large babies (DH is 6'3", I'm 5'8" we're just larger people :)) AND go to 40w. Whew!

But if things look good at 40w, I would wait as long as I could.

[msmiranda]

Originally Posted by kriket 

I would be honestly concerned with a large baby. Usually when you hear the horror of "The baby was too large for my pelvis" it's not entirely accurate. However, GD is one of those things that CAN cause a baby to grow too large.

I am concerned about GD for this reason. (among others) DS1 measured 3 an 4 weeks ahead from the 20w U/S on, but was born at 37w. DS2 is also measuring 3w ahead so far. So I can only imagine if I get GD, and have large babies (DH is 6'3", I'm 5'8" we're just larger people :)) AND go to 40w. Whew!

But if things look good at 40w, I would wait as long as I could.

My understanding is that the risk of a too-large baby only applies to UNCONTROLLED gestational diabetes.  OP says hers is well controlled, even that her blood sugar was normal before she started insulin. 

Oops, just noticed she said that her baby was measuring large.  Presumably that is from the period before she was diagnosed.  If her GD remains controlled from now on then the baby probably won't be too big for her to birth.

[msmiranda]

Originally Posted by lifeguard 

Many care providers will not do oral medication for pregnancy. My last doctor told me that the main recommendation is still to go straight to insulin even though many don't follow this recommendation.

From the research I have done, I think that this just reflects differing comfort levels with how much evidence of a drug's safety needs to be amassed before prescribing it to pregnant women.  There have been several recent studies (past 5 years) indicating that both glyburide and metformin are safe for pregnant women and their babies.  However, a more conservative doctor would want to wait until these studies have been replicated many times before prescribing those medications.  I am comfortable with the available evidence on the safety of metformin and am currently taking it to help control GD, but patients should definitely do their own research and decide what their comfort level is with respect to any prescription medication taken during pregnancy. 

That's interesting that they don't use oral meds in Germany.  From what I had read, many other countries have been using metformin for years while the U.S. lagged behind on offering it.  I think there are a couple of reasons why people might want to use oral meds before going to insulin: (1) ease of use; (2) less difficulty determining dosage; (3) potentially, better compliance bc of 1 & 2; (4) seems less invasive; (5) many midwives (and the OBs who back them) draw the risking-out line between oral meds and insulin, e.g. if you can manage your GD with diet or diet +meds, you can have midwifery care, but if you need insulin, you must see an OB.  That last one would be pretty powerful for me.
 

[lifeguard]

msmiranda - you said it much better than I did. Thank you.

[foreignerforlife]

I guess I should have been more specific and said that my diabetes center doesn't give oral meds--whether other practices in Germany do or not, I don't know. I'm not worried about being risked out of anything because I am planning a hospital birth and they are overseen by midwives unless there are complications during the birth that require a doctor's intervention.

[msmiranda]

Originally Posted by foreignerforlife 

I guess I should have been more specific and said that my diabetes center doesn't give oral meds--whether other practices in Germany do or not, I don't know. I'm not worried about being risked out of anything because I am planning a hospital birth and they are overseen by midwives unless there are complications during the birth that require a doctor's intervention.

I hope I didn't come across as though I was questioning your care providers or anything -- totally didn't intend that!  I was just responding to some of the other posters.  It's great that in Germany most births are overseen by midwives -- I wish it was that way here too.  A lot of midwifery practices in the U.S. who attend hospital births do risk out GD mamas who are on insulin ... I guess they consider that outside their scope of practice.

[NicaG]

I have had gd with 2 pregnancies, and it's my understanding that there's an increased risk of stillbirth if you go past 40 weeks, even if nsts have been good.

[Bird Girl]

The main risk from GD is shoulder dystocia. Babies that get very large due to high glucose levels sometimes tend to grow barrel-chests that lend to them getting stuck after their heads are born. The fear is that you won't discover that the baby is too big because his/her head is too big, but you'll discover it after you birth the head. So that's why they don't like GD babies to go much past term--some care providers want them induced even before term.

[mncowmom]

Those are all riskes with uncontrolled gestation diabetes.  There have been no studies done that I can find that only include diet and exersice controlled GD.  All of the studies lump in insulin control GD and most studies include women who have Type I or II diabetes also.

I have GD that is diet controlled and my numbers are very good.  I will not be treated any differently than any other pregnant woman as long as my numbers stay consistant.  Currently I'm 37 weeks and they think that baby is ~5.5 - 6 lbs, so not big at all!

Last pregnancy was with an OB and I had great diet controlled numbers. I was also clueless about the current labor model in the US.  They tried to tell me my DS was 8.5lbs at 36 weeks and they pushed for an induction at 39 weeks.  Doctor stripped my membranes @ 39 weeks when I was only fingertip dialated and DS was not engaged in the least, my water broke the next morning and then I had no contractions and was started on Pit.  After 12 hours on Pit I was only at 5, labeled FTP and headed off for a c-sec.  DS was 7lb 3oz. 

Everyday that I fight for my upcoming VBAC I regret my lack of knowledge about what I was consenting too!

[msmiranda]

Originally Posted by NicaG 

I have had gd with 2 pregnancies, and it's my understanding that there's an increased risk of stillbirth if you go past 40 weeks, even if nsts have been good.

I did some research on this recently (links in the thread I linked to above) and have not been able to find any studies suggesting that a woman with well-controlled GD has a higher risk of stillbirth.  I am not sure whether or how the studies that have been done have broken out data on women who are on insulin versus those who control with diet or oral meds.  Also, I think a confounding factor in studying GD is that at least some GD mamas may have had preexisting Type 2 and not been aware of it ... so they are actually Type 2 diabetic and not GD.  Women with full-blown Type 2 do have a higher risk of stillbirth.

[NicaG]

It's so hard to find good, consistent information about any aspect of gd. I have just assumed that my doctors were right, that stillbirth was a risk (both my labors were induced). It would be helpful to have more up-to-date info/studies on this. For me, I get sort of demoralized by the whole gd experience, and I have a hard time pushing back when it comes to extra interventions. My gd has required insulin, though.

[lifeguard]

NicaG - I definitely found gd totally demoralized. I read everything I could find while pregnant with ds & ever since & quite frankly there is very little available.

[MarineWife]

I haven't read all the responses but I'll share my experience. I was diagnosed with "borderling" GD when I was pg with ds2. I had been taking metformin (an insulin regulating oral med) to prevent miscarriage associated with PCOS before I got pg, failed the 1 hour test and just barely past the 3 hour test (1st level was high, 2nd level was right at the top # and 3rd level was fine). The clinic I was getting my care from decided to treat me as if I had GD jic. Very annoying but because of the rules of military insurance at the time I couldn't switch providers. Even though my supposed GD was very well controlled, they still wanted to induce me at 39w. I refused. I think they scheduled the induction at least once but I didn't show up. That's one of the nice things about military care. They can't drop you as a patient for not going along with what they want. Anyway, we eventually compromised and I agreed to weekly NSTs. Baby was born big and healthy at 40w1d.

I think the concern was placental deterioration. But, I also think that's associated with uncontrolled diabetes. If the diabetes is controlled, that shouldn't be a problem.

[subuyoung]

There is a risk that the baby could be too big (http://egestationaldiabetes.com/complications-at-labor-with-big-baby/). 

I had my son induced for other reasons, but at 39.5 weeks.  Everything went well and he is a healthy and active little boy.  I would trust what your doctor says!