Gestational Diabetes and Stillbirth?? - Mothering Forums

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#1 of 23 Old 10-16-2007, 04:14 PM - Thread Starter
 
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Okay, please help me out here. I just had my 39 week visit with my doc and told her that I would like to wait at least until week 41 before considering induction (she has wanted to induce me at 40 wks due to GD) So I talk to her about it and she says of course I can't force you to do it, but I will need to 'put a note in your file that you know the risks and refused induction" and I need to let you know that the risk of stillbirth goes up 50% after 40 weeks with GD.

Is this true or is it a typical scare tactic? My GD has been well under control for the past 2 or 3 months although I am on insulin at night.

Is there some arbitrary day that all of a sudden the risk of stillbirth just goes up? It doesn't make much sense to me - how can one week make such a difference?
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#2 of 23 Old 10-16-2007, 04:35 PM
 
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I can't find any hard data or specific #s for stillbirth in GD pregnancies and where they come from (i.e. studies etc.). But the risk increasing by 50% may actually be a reasonably small increase in risk, depending on what the actual numbers are. It doesn't mean it's going up TO 50% risk of stillbirth, which is sort of what it sounds like.

If, let's say, the risk of stillbirth is 1 in 200 or 0.5% at 38 weeks (making all these numbers up!), and slightly higher, say 0.6% at 39 weeks, and then 1.0% at 40 weeks, that would be a roughly 50% increase from 39 weeks 0.6% to 1.0%. I think my math is right there. That risk may be overall acceptable to you, although it is twice the risk of stillbirth that you had at 38 weeks. Does that make sense?

So an OB may be trained to see that increase in risk as unacceptable, but an individual patient may feel that the increase in risk is acceptable, taking the entire situation into consideration.

There's no arbitrary date, but often those statistics will come from studies that, for example, evaluate the risk of stillbirth at 38, 39, 40, and 41 weeks, for example, for the purpose of comparison and risk evaluation so that a treatment protocol/standard of care can be developed. I'd assume the risk goes up daily, but that it starts to get more measurable/statistically significant at 40 weeks and later, based on what your doctor said.

I'm sorry I couldn't give you more accurate/specific information. Hopefully someone else will know for certain.
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#3 of 23 Old 10-16-2007, 05:01 PM
 
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Ugh, you do not need that kind of stress. Hugs!

Did you ask this in the "Birth Professional" forum? They might be able to provide some more stats.

Kimberly
(Mama to West (11/07) Mabel Kelly 10/02/09)
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#4 of 23 Old 10-16-2007, 05:12 PM
 
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Originally Posted by Romana9+2 View Post
But the risk increasing by 50% may actually be a reasonably small increase in risk, depending on what the actual numbers are. It doesn't mean it's going up TO 50% risk of stillbirth, which is sort of what it sounds like.

If, let's say, the risk of stillbirth is 1 in 200 or 0.5% at 38 weeks (making all these numbers up!), and slightly higher, say 0.6% at 39 weeks, and then 1.0% at 40 weeks, that would be a roughly 50% increase from 39 weeks 0.6% to 1.0%. I think my math is right there. That risk may be overall acceptable to you, although it is twice the risk of stillbirth that you had at 38 weeks. Does that make sense?
: It depends on whether your OB is talking in terms of relative risk as Romana9+2 points out above.

I tried to do a search to see what I could come up with, but I don't think I quite have the right search terms. IMO, I'd ask the OB for her proof of that risk (studies, etc). Me thinks it's bad form to note in your records that you "know" the risks without actually providing your proof of her standpoint. It may help put your mind at ease...especially if she can't ante up on anything specific.

mama!
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#5 of 23 Old 10-16-2007, 06:07 PM - Thread Starter
 
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FYI, I found one canadian study here: http://www.aafp.org/afp/20050515/1935.html that seems to (if I am reading the jargon correctly!) indicate that the standard is to begin much monitoring after 40 weeks and induce at the beginning of week 43. Of course this all seems to be related to normal, low risk pregnancies and I am still not sure about the whole GD factor.

I agree with Romana9+2 as well - I think your math is right on. If the risk is 1%, after 40 weeks it goes up to 1.5% - still doesn't sound like a huge leap to me, although saying "50%" makes it sound huge!

What would you do? Is that amount of increase in risk worth not having an earlier induction?
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#6 of 23 Old 10-16-2007, 09:14 PM
 
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I would like to see more on this, too. I believe there is basically hardly any more chance of stillbirth up to 40 weeks any more than a regular pregnant mom would have IF THE SUGARS ARE KEPT NORMAL. The whole thing with the placenta shutting down earlier is when the sugars are not kept in control. If you keep your sugars in perfect control with TIGHT diet and lots of exercise, the risk of stillbirth ect should be no more than a normal pregnant mom, Right?
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#7 of 23 Old 10-16-2007, 09:29 PM
 
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I thought the stillbirth issue was placental deterioration. I don't think anyone has any clue when the magic # is. My question for the OB is how fast does it occur. I mean, would a daily NST eliminate the risk, or would a 2-3 a week? I can't believe I can't remember 3 yrs ago but I *think* I was having an NST a week starting at...35w? 36w? Gah, so sad what sleep deprivation will do to you!

Not trying to encourage flames or dissent, but I think a lot depends on personal attitudes towards risk. I don't think a 1% chance of stillbirth is acceptable to DH, yet if I hear someone else talk about it, it does sound so miniscule. I mean, is the issue 1% stillbirth vs. 50% c/s?

I wonder what the stillbirth rate actually is. I did a trial of Med Consult and found a study that had a pretty high (IMO) %, but it was uncontrolled GD, which of course makes a huge difference. But then I think, does "well controlled" also mean the mom was induced early, because that's the standard protocol, it seems. The study I read didn't mention interventions used.

Sorry for the rambling, I see this as such a complex issue.

ETA When I say high sb rate it was nothing truly alarming; just more than 1%. But as far as that goes, since I have no risk factors, am otherwise healthy, followed the diet and exercised, blah blah blah and still had to take insulin overnight, I fall in the 2% of gdiabetics so it's hard for me to feel comfortable playing the odds, but of course everyone's mmv.
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#8 of 23 Old 10-17-2007, 02:00 AM
 
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You asked what I would do. I would have to have more information. I have a couple friends in med school with access to the latest research, and one of them is applying to OB/gyn residency programs. I would ask her for help getting data/studies and FAST. I would also ask my doctor for the studies/research that she's basing her opinion on. I'd read them all ASAP. I'd talk to my med student friend again to get her perspective (very intervention-happy so a good "other" perspective) and I'd post in the Birth Professionals forum here if there were specific things I still didn't understand. Bottom line, I would need a lot more information to make a decision.

My "gut" based on what little I know about GD is that provided the GD was under control with treatment, and I was getting regular NSTs, I would wait for either a very favorable Bishop's score or 42 weeks to induce. But that's a shot in the dark because I don't have enough information to really make a decision. Personally, I am a researcher by nature and need all available information to make a decision that I'll feel comfortable with.

I think a pp hit the nail on the head when saying that your doctor is making a note that you're informed and deciding not to induce anyway, when in fact you doctor has done very little to ensure that you ARE informed. : Good luck - I hope you can find some answers and come to a decision you're comfortable with.
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#9 of 23 Old 10-17-2007, 02:42 AM
 
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Ok, agreeing here that your doctor has to inform you what the risk actually is before she can note that you're "informed." People are talking about the math with 1% vs. 1.5%, which is a tiny difference... but it could just as easily be going from 0.1% to 0.15%. Or add another decimal place. The relative risk she's given you is a totally useless statistic.

Here's the kicker... I bet when you ask "Ok, what's the overall stillbirth rate at 41 weeks, then?" she *won't know*. I'm guessing this based on the fact that I'm pretty darned good at turning up statistics, and I couldn't find it. Not on cdc.gov, not on google scholar, nowhere. In fact, while I found several oblique references to increased risk of stillbirth with gestational diabetes, I found NOTHING in terms of hard data about such a correlation. The CDC has a long FAQ about diabetes in pregnancy that mentions stillbirth as a risk in the *intro*, and then NONE of the rest of the FAQ mentions it.

One tidbit I did turn up is that previous stillbirth is considered a risk factor for GD. Heh, I wonder if your risk of GD in a subsequent pregnancy goes up 50% (from 2% to 3%, that would be) if you've had a stillbirth delivery?

Tell her you're happy to have her make that note, but you will need to be completely informed first. And, hey, maybe she'll give you info that changes your mind... just make sure you get the cites on it ;-).
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#10 of 23 Old 10-17-2007, 05:07 AM
 
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To put this in perspective, overall stillbirth rate at 39, 40 and 41 weeks in the UK is 1:1000- it's slightly higher in the US, but not much. You're looking at a stillbirth rate of 1.5:1000, if her figures are accurate. Did she quote her sources?

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#11 of 23 Old 10-17-2007, 05:13 AM
 
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I think any info you can find on this, is going to be biased, simply because the natural protocal of obs these days with GD patients is to induce and intervene, so theres not many numbers out there of mothers who have actually been controlled and gone over their due dates.
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#12 of 23 Old 10-17-2007, 12:15 PM - Thread Starter
 
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Thanks for all your input. I feel like I have a lot to think about in a very short time. It's funny, I never even realized when I was talking to her that she didn't give me any actual stats or sources! When She just told me that the risk of stillbirth goes up, I asked 'what is the risk' and before I could even get the rest of the words out (I was looking for numbers - from what percentage to what percentage) she misunderstood what I was asking and said 'I mean stillborn, dead, death!' A bit dramatic I thought. Maybe my body will take pity on me and start labour quickly on it's own
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#13 of 23 Old 10-17-2007, 12:59 PM
 
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This is not true for what is called "gestational diabetes". There is solid research to show that the diagnosis of GD is subjective and not accurate - and the treatment does not reduce risk (which is basically big babies).

The risk of stillbirth comes with uncontrolled pre-pregnancy Type I or Type II diabetes, mainly Type I. If you are on insulin prior to getting pregnant this could be an issue if you're not good at monitoring your blood sugars or taking your insulin or medication.

The reason for this is that uncontrolled, dangerous swings in blood sugar affects placental (and of course umbilical cord) formation, adherance and growth.

This is not an issue with what is called "GD".

I think the stillbirth card is drawn out so women will comply with induction at or before term. The biggest risk that docs worry about with "GD" is big babies. They talk about low blood sugar in the baby, but that's a whole 'nother rant.

I'd ask for some research and studies. Especially when you're talking about women that are not insulin dependent.

Based on the research, the whole testing process, diagnosis and treatment of GD is inaccurate and not helpful.
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#14 of 23 Old 10-17-2007, 01:31 PM
 
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This is not true for what is called "gestational diabetes". There is solid research to show that the diagnosis of GD is subjective and not accurate - and the treatment does not reduce risk (which is basically big babies).

The risk of stillbirth comes with uncontrolled pre-pregnancy Type I or Type II diabetes, mainly Type I. If you are on insulin prior to getting pregnant this could be an issue if you're not good at monitoring your blood sugars or taking your insulin or medication.

The reason for this is that uncontrolled, dangerous swings in blood sugar affects placental (and of course umbilical cord) formation, adherance and growth.

This is not an issue with what is called "GD".

I think the stillbirth card is drawn out so women will comply with induction at or before term. The biggest risk that docs worry about with "GD" is big babies. They talk about low blood sugar in the baby, but that's a whole 'nother rant.

I'd ask for some research and studies. Especially when you're talking about women that are not insulin dependent.

Based on the research, the whole testing process, diagnosis and treatment of GD is inaccurate and not helpful.
With all respect, gestational diabetes is an existing, provable condition. Type I is completely different from Type II. With Type I, your body does not produce enough insulin, therefore making you insulin dependent. With Type II your body produces too much insulin--more than the body can handle, which is why it stays in the bloodstream. This is how it's diagnosed. I can guarantee you that my post-prandial blood will have more glucose in it than yours or a non-GD, whether we both eat a donut or a steak. With gestational diabetes, hormonal fluctuations cause processing issues that mimic type II (too much insulin vs too little, unable to effectively utilize insulin) but this hopefully goes away after pregnancy. People w/ gd are at a greater risk for developing Type II in the future.

I think the issue many people have is in what the magic # is for a GD diagnosis. 130..140..higher..In my opinion it's a moot point, since you (I"m assuming you are not gd) will test no where near those levels. It's splitting hairs to say "But ACOG says 140 and ADA says 130, therefore it's unknown..." because, again, if your body is working the way it should, you're not going to get that high in the first place.

I especially take issue w/ your closing statement. I am very glad I was diagnosed. I wasn't type II before, but I am now considered pre-diabetic. Well, actually, now I'm gd but I was pre-d before getting pregnant w/ #2. Prior to to my first pregnancy my levels were fine. Anyway, what that meant for me is that after my pregancy I had to stay on a low carb diet. (Going into unintended scare tactics here...) If I had not been diagnosed, or if I had continued to eat a "normal" American diet, I would have been walking around w/ 200+ sugars. That WILL lead to neuropathic damage and heart disease. Really, if you or anyone can find any study that says that's not true, I would like to see it to bring to my endo.

I don't disagree for a moment that OBs may use a little bit of info--uncontrolled diabetes can have life threatening consequences--and twist it for their purposes, be it intervention or just a power trip. But based on the many articles I've read and certified diabetic educators and endocrinologists I've talked to, for *some* people the following statement is not true.

[B]The reason for this is that uncontrolled, dangerous swings in blood sugar affects placental (and of course umbilical cord) formation, adherance and growth.

This is not an issue with what is called "GD".


It IS an issue for a very small percent like myself, which is why I need to carefully monitor my sugars. Again, I've been seeing an endo group for the last 3 years and I am still not considered Type II, yet the complications you describe apply to me.

I just disagree with your attitude towards treatment and the risk of GD on both mother and child, I don't disagree that interventions may be useless and even counterproductive.
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#15 of 23 Old 10-17-2007, 01:40 PM
 
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Have you read much of the research on GD? Critically? There is good information in Anne Frye's Understanding Diagnostic Tests, her Holistic Midwifery Vol I text and Henci Goer has solid information in her book Obstetric Myths vs Research Realities - here are some of her articles on the topic: http://www.parentsplace.com/expert/b...269209,00.html and http://www.parentsplace.com/expert/b...253331,00.html.

What we do know to be true above all is that women who are borderline Type II diabetes prior to pregnancy (like yourself) can easily be thrown into true II diabetes because of the increased blood sugar that is present in all pregnant women. A hormone called human placental lactogen keeps blood sugar levels higher for the growing baby. This could tip borderline women into true diabetes.

However, the screening methods are inaccurate and the treatment for those diagnosed from these screening methods is not helpful. The only way to accurately determine blood sugar issues in pregnant women, IMO, is to do glucometer checks of fasting and two hour postparandial times. These offer a true reading of what the blood sugars are - the Glucose Tolerance Test is fine for non-pregnant women, but NOT accurate for pregnant women simply because of the physiological changes.

I guess we can agree to disagree on many parts of this 'diagnosis', but I do agree that your situation reflects women who are borderline Type II diabetic before pregnancy that become true Type II when pregnant. This is vastly different than the "gestational diabetes" diagnosis that is thrown around right and left because of the inaccurate GTT.

However, based on the topic at hand, unless you have wild uncontrolled blood sugars at the time of conception (which is someone who is Type I or Type II diabetic) you're not in the stillbirth risk categroy.
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#16 of 23 Old 10-17-2007, 02:14 PM
 
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Please, Pamamidwife, not Henci Goer again! Yes, I'm familar with what you've posted but thank you. I'm sorry if I was not clear in my previous long-winded novel, but I was NOT borderline Type II prior to pregnancy. NOW I'm borderline. Repeat for clarity: before DS #1, not borderline. DS#1=GD. Post DS#1=borderline.

However, the screening methods are inaccurate and the treatment for those diagnosed from these screening methods is not helpful. The only way to accurately determine blood sugar issues in pregnant women, IMO, is to do glucometer checks of fasting and two hour postparandial times. These offer a true reading of what the blood sugars are - the Glucose Tolerance Test is fine for non-pregnant women, but NOT accurate for pregnant women simply because of the physiological changes.

This intrigues me. Why do you think it's less helpful than fingersticks? You're given a boatload of sugar and a limited time to process it. Either you can do it or you can't. I'm assuming you're a midwife--you've had clients who tested in the upper ranges but who had no further trouble w/ levels? How can that be? I think the GTT is useful in today's hurried society because docs don't want to take the time to pore over a food diary and corresponding numbers, but even if they did, I think they'd still want a GTT to prove it. Again, either your body can do it or it can't, and while pregnancy does increase insulin resistance, I thought that's why the GTT diagnostic #s are higher during pregancy than if you test before/afterward. I had a GTT 6 months post-partum and the diagnostic numbers, if I recall, were lower, and they told me it was because they skew them up during pregnancy since our bodies naturally become more insulin resistant.

So sorry to hijack this thread, All, but like everyone else, I want as much info as possible!

I do have another question for Pamamidwife and other GD nay-sayers. I keep encountering well-meaning women who, upon hearing my GD diagnosis, ask me if I've read the lit (no more Goer!!! ), have I educated myself, etc. When I go into the details--high readings despite diet and exercise, insulin required 3rd tri, etc.--it shuts them up. What did they expect to hear? Has anyone encountered a pregnant woman who was diagnosed GD but didn't have high levels? Everyone on this board who's been diagnosed seems to be pretty sure they have it.
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#17 of 23 Old 10-17-2007, 02:18 PM
 
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If you cannot hear anything that Henci Goer has to say and have an implication that somehow I'm silly for thinking her reviews of the research (not to mention the normal physiology of pregnancy) is trustworthy, then I just have nothing to add. I'm not sure what you're looking for.

Your experience is different than the vast majority of women. When we talk about using insulin, it's very different.

Anyway, I trust that you have educated yourself and didn't mean to imply that you hadn't. Reading over my post, I can see how that first paragraph could come off condescending.

I just don't agree, but that's ok. It's good you've stated your views for those who want an opposing point.

regarding the GTT, I think that the physiology (and the numbers) of pregnant women is completely different from non-pregnant people! there are a variety of thresholds and numbers for diagnosis...and most of these are based on non-pregnant values. We cannot keep those numbers for pregnant women simply because of the decreased insulin production in pregnancy and the increased blood volume and subsequent kidney function.

http://www.preciouspassage.com/Gesta...%20Clothes.htm

Of course this article is from Goer, so it may not mean much to you but the discussion of physiology makes sense, no matter what the diagnosis is.
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#18 of 23 Old 10-17-2007, 02:23 PM
 
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This intrigues me. Why do you think it's less helpful than fingersticks? You're given a boatload of sugar and a limited time to process it. Either you can do it or you can't
I'm not a professional, and have done limited research, but common sense tells me that giving a person who does not normally eat alot of sugary foods or drinks, a LARGE amount of sugar at one time, is not a smart thing to do. I suffered the side effects of the GTT, and I will never ever do one again.
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#19 of 23 Old 10-17-2007, 02:41 PM
 
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Thanks you, Panamidwife, good points and info. I'm sorry if I came across snotty re: Goer, it's just that her name comes up here like the ADA does on a mainstream site--w/ good reason, I'm sure--so my response was not doubting her worth but rather : at the number of referrals, if that makes any sense. If I understand correctly, she is not a diabetic educator bit has reviewed select research as opposed to conducting her own, right? Again, not that lessens her knowledge or expertise regarding overall health, pregnancy and birth, I just feel that she's perhaps not as qualified in diabetes management as say, a researcher who specializes in endocrinolgoy. But I certainly don't think you (or anyone) is silly or wrong to use her as a valuable resource and I apologize if my attempt at humor came out that way!
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#20 of 23 Old 10-17-2007, 02:41 PM
 
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I think the GTT is useful in today's hurried society because docs don't want to take the time to pore over a food diary and corresponding numbers, but even if they did, I think they'd still want a GTT to prove it.
Just because their "too busy" doesn't mean that they should be excused from doing it. Providing proper care shouldn't be excused by their unwillingness to let up on their monopoly on pregnancy and birth. And the only reason I think they'd want a GTT to "prove" it is because they want something in th chart to CYA...not because it's neccessarily helpful, prudent, or wise to do so.

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Originally Posted by newbymom05 View Post
I do have another question for Pamamidwife and other GD nay-sayers. I keep encountering well-meaning women who, upon hearing my GD diagnosis, ask me if I've read the lit (no more Goer!!! ), have I educated myself, etc. When I go into the details--high readings despite diet and exercise, insulin required 3rd tri, etc.--it shuts them up. What did they expect to hear? Has anyone encountered a pregnant woman who was diagnosed GD but didn't have high levels? Everyone on this board who's been diagnosed seems to be pretty sure they have it.
And I've seen you do the same thing with those of us who have chosen not to do the GTT. It's fine that you trust your doctor and believe that the GTT was most the most prudent and appropriate action in YOUR case. I just don't agree with you that it's wise to blanket test EVERY pregnant woman for this - for the exact same reason that I don't think that the practice of late term u/s to determine if a baby is a "big" baby. There is a genuine (and valid) concern for the cascade of interventions and the gradual limiting of birth choices for women. This for me is a serious concern.

(Oh..and I really would suggest actually reading the links that pamamidwife has posted instead of just assuming that because it's Henci Goer you won't listen or don't care. Most specifically the second article which states: "All of this presents you with a series of decisions, the first of which is whether to agree to be screened for GD. If you decide to go ahead with GD testing, you will want to try to ensure that any abnormal results are real and not due to the vagaries of the testing process. Finally, if you are diagnosed as a gestational diabetic, you will want to minimize your chances of experiencing the drawbacks of GD treatment. The rest of this article will help you make those choices and achieve those goals.")

Which is why I'll try to bring this back to the focus of the OP. Her experience is why I find the blanket use of GTT so problematic. Now she's got an OB who wants to limit her choices by using the "dead baby" card to coerce her into submitting to the induction WITHOUT providing the data to back it up!

halo8 - As for what I'd do...ask her for the data to back it up. If she can't provide the evidence then IMO her opinion is quite subject. Ask for the citations, the studies. Ask her to provide you the full-text copies. Then read what they have to say. One of the things I appreciate the most from Henci Goer is that she is a champion for regular people just like you and me reading the data out there. She's helped to show that we can be every bit as capable as the "properly trained professionals" in interpreting the data (and seeing the bias found in many a researcher). *If* you actually get the hard data and you have a hard time understanding it, post back as I'm sure many heads put together can help interpret.

Regardless...sending lots of your way. Try not to let her get you too worried or worked up. Your baby will come when he or she is ready. Trying to rush things is not always the wisest course of action.
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#21 of 23 Old 10-17-2007, 03:57 PM
 
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Panamamidwife-
Thanks for your information. I believe that the main risk for stillbirth insulin-dependant and high blood sugar swings. If your blood sugar is perfectly controlled with strict dietary guidlines and lots of exercise, I think your risk for stillbirth is minimal at least up to 40 weeks. I have been induced twice at 38 weeks and once at 38 1/2 weeks and I really dont want to be induced by doctor before 40 weeks ever again unless something is medically wrong.
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#22 of 23 Old 10-17-2007, 05:03 PM
 
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Only on the topic of insulin resistance or prediabetes -- Syndrome X or Metabolic Syndrome. Endocrine problems are all related and 1 imbalance means other things are also out of balance. There might be a natural cure after pregnancy to corrrect the imbalances if you can determine what the main culprit is -- for me it's my thyroid, technically blood levels of a border line hypothyroidism, but symptoms of full hypothyroidism and now some signs of blood sugar problems.

On the topic of stillborn... Ask a midwife was my suggestion, I did note Pam responded. I do know my first mw lost a 43 week baby just before my dd arrived. The mother did have GD.

Research it as best you can and make an informed decision. Natural herbal induction with the assistance of a midwife trained in the use of herbs might be a better alternative to artifical induction with synthetic drugs. Stay clear of off label drugs used for induction (Baby Story started out with one of those the other day, I changed the channell ASAP).
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Quote:
Originally Posted by newbymom05 View Post
I'm sorry if I was not clear in my previous long-winded novel, but I was NOT borderline Type II prior to pregnancy. NOW I'm borderline. Repeat for clarity: before DS #1, not borderline. DS#1=GD. Post DS#1=borderline.
What kind of test ruled out borderline Type II prepregnancy for you? Was it a fasting check, a GTT, or regular fasting and postprandial checks?
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