Questions about early screening for diabetes/GDM, history of "borderline" PCOS

[haurelia]

Hi all. 

I'm 8 weeks pregnant with my second baby, and had a low risk PG and home birth with DS.  Long story, but I've been planning concurrent care with a homebirth midwife as well as an OB practice as my backup plan.  I wanted to do some care with the OB practice because I wanted to get an anatomy scan and be somewhat known to them in case I need to transfer care.  Complicating factor is that I work as a contingent RN with the OB group in L&D.  

Background: I had trouble conceiving, and had an ultrasound that revealed a polycystic-appearing ovary in October. I had no PCOS-specific labs tested, but have markers such as obesity and hirsutism; the OB said I was "borderline" PCOS.  I switched to a low-glycemic diet and lost 15 lbs. I started taking myo-insoitol to decrease insulin resistance that can come with PCOS (and has been shown to help PCOSers conceive).  I've been a regular exerciser for some time now, so nothing has much changed with that.  I conceived in January.  With feeling queasy/fatigued in early PG, I've been consuming a lot of carbs over the last month or so. It's all that appeals/stays down. I stopped the myo-inositol when I learned I was pregnant. 

Ok, so my BMI is 30, and the NP I saw at this OB intake visit ordered a Hgb A1C drawn with the usual first visit labs. She also ordered a 1 hour glucose challenge, which I didn't have time to complete at that visit, and planned to do surrounding my next appointment in 2 weeks.  I got a call from the office nurse today that my A1C was 6.4 which is "borderline."  She stressed doing the glucose challenge and that then the "plan" would be determined.  

I'm freaking out a bit...if I fail the glucose challenge at 10 weeks PG, is that a diagnosis of pre-pregnancy diabetes rather than GDM?  If I'm diabetic, that risks me out of midwifery care, and I'll be subject to hospital birthing and all it's attendant interventions, including recommended induction, which totally differ from the home birth I've had before and am planning again. Very anxious about this!

Any thoughts? Thanks in advance to anyone who weighs in. 

[phathui5]

You don't have to agree to do the one hour glucose test in early pregnancy. What I might do if I were in your situation is talk to your midwife and work out a plan with her.

You could also consider just going ahead and following a (healthy, not restricting calories) gestational diabetes type diet and declining further GD testing.

[Vaske]

IIRC, the one-hour glucose challenge is mainly a screening test to see who should take the 3-hour GTT.  Personally, if I wanted to quantify my blood sugar levels, I'd rather do it with my actual diet and my actual exercise (and not during the first trimester).  You already know better than to eat a crapload of plain sugar and then follow it up with a few hours of just sitting around.

I too had a hard time eating anything but carbs in early pregnancy, but gradually I am getting back to lower-carb and healthier eating.  I am comfortable with skipping the testing in my case, and concentrating on diet and exercise.  I can see a lot of good effects from those alone--my wedding ring actually fits on my ring finger this time around.

Gentlebirth.org has midwife archives that might be of some help, and also Plus Size Pregnancy has a lot about gestational diabetes; at least you can see the homebirth/midwifery community perspective, vs. the standard medical approach.

I can't answer the question about a diagnosis of diabetes vs. gestational diabetes if you fail the glucose challenges.  If you were diabetic before pregnancy, wouldn't the A1C test have been more definitive?  (Asking--I don't know.)  Will a gestational diabetes diagnosis also risk you out?  Do you yourself think you're diabetic?  What does your midwife think about all this?  How far are you willing to resist pressure from the OB group?

[haurelia]

Thank you, both, for replying.  

I've settled down a bit since posting.  I've got a call in to my midwife, and will discuss it with her.  I've also sought opinions from my family doc (very holistic practice), and some midwife (and non-midwife) friends.  In my mind, now, the A1C is a screening test, the same as a one hour GCT.  Why would I do two screenings? Neither of these tests are diagnostic.  I am not too worried about gestational diabetes, as I don't really "believe" in it, but I am concerned about the warning sign for type 2 DM to be found in the A1C.  It's been a good wakeup call for me to address my food and exercise, for the rest of my life.  After I give birth, I may consult an endocrinologist regarding the "borderline" PCOS diagnosis, as the OB who made that pronouncement was vague and didn't test all the lab values to make that diagnosis. 

Vaske- I have reviewed the PSP info, as well as some of the stuff at gentlebirth.  Thanks.  Your question about the A1C prompted me to think more about it...you're right.  If I were diabetic pre-pregnancy, my A1C likely would have been more definitive.  Thanks for pointing that out. I don't think that I'm diabetic, but I do think that the PCOS spectrum makes me more resistant to insulin, thus the higher A1C.  Unfortunately, that's the only A1C I've ever had done, so I can't compare it to anything. But I do know that, until I got my positive pregnancy test,  taking the inositol and doing a low carb diet were the only things that helped me to kickstart weight loss (I'd been exercising like a fool without much movement on the scale). I felt better and had fewer cravings on the inositol and low carb/low GI diet. 

Anyway, I think my course is to discuss it with my midwife (hopefully today), and then attend the follow up appointment with the OB on the 25th. I won't take the test, and will ask her to discuss it with me fully. I'd like to ask for a glucometer and track my fasting and post-meal numbers for a while to make sure I'm on track, and go from there if my blood sugars are abnormal from day to day.  I am not shy about being that patient who refuses things, and if she refuses to keep me for care, I'll just use my family doc as a backup (the only reason I didn't start out that way is because his privileges are at a more distant hospital than the one I work in, and I've had some bad experiences there...for a home birth transfer, I felt more comfortable with the place I work, 5 minutes away).  

Thanks again for your thoughts. :)

[Vaske]

Weird--there's a link on "Plus Size Pregnancy" above that I didn't put there, and that doesn't show up for me when I'm logged in--so don't click on that one, it's from some marketing slimeball or other.  The other two are from me, and are ok.

[phathui5]

The A1C can be used as a diagnostic test. I've seen one that was super high and she was definitely diabetic. The test confirmed what we already knew.

[glassesgirlnj]

I have many of the symptoms of PCOS, though I've never been "officially" diagnosed. I was asked by my health plan (not my midwives) to take an A1C in early pregnancy, because of my age and BMI.

I did fine on it, and fine on the one-hour glucose test as well (though my midwives let me use ginger ale instead of the nasty orange stuff). But my point is, I don't think it's so unusual to be asked to do a first-trimester A1C... but I've never heard of a GTT that early.