Gestational Diabetes By Douglas Penta MD

There is a distinct difference between adult onset diabetes and juvenile diabetes.

Pregnancy-related diabetes, better known as gestational diabetes, is also important to understand should this condition arise during your pregnancy. I hope this article will clear up any questions regarding the distinction between these various types of diabetes mellitus. Unlike many medical conditions that are not fully understood, diabetes is well understood and regardless of what type you are dealing with, the goal is the same: to maintain an overall normal range of blood sugar levels to prevent organ damage associated with uncontrolled diabetes, including heart disease, renal disease etc..

Juvenile diabetes is perhaps the easiest to understand as it relates to a lack of insulin production by cells in the pancreas and is thought to be a result of genetically predisposing factors and viral-mediated in certain cases.

Adult onset (AODM), is very different in terms of its cause as it is not related to a lack of insulin production, but instead, to the ability of insulin receptors to respond to the insulin. AODM is controlled well with life style changes and in many instances such changes alone can resolve the problem ( changes include weight loss and changes in diet and exercise). I have actually seen many overweight patients with AODM, lose weight such that the condition no longer required treatment with medication.

Finally, as an OB/GYN physician I must mention the diabetic condition I have dealt with most often during my career and that is gestational diabetes (diabetes relating to pregnancy). It is routinely screened for during pregnancy and is most like AODM as it is a lack of response of receptors to the insulin that is present and not a deficiency of insulin.

I have had many patients on very large doses of insulin for gestational diabetes to maintain normal ranges of blood sugar. The insulin receptors are not sensitive enough to normal levels of insulin and thus the need for additional insulin supplementation. Women with gestational diabetes are thoroughly educated about how to maintain normal blood sugar levels and it is a task that takes a great deal of education/instruction.

Gestational diabetes can be indicative of a predisposition to diabetes later in life and thus it is important to follow-up one’s blood sugar after delivery and be conscious of this possibility later in life. In the majority of cases the diabetic condition associated with pregnancy resolves immediately after delivery of the placenta.

I hope this information is helpful. It is not intended to diagnose, treat, cure or prevent any condition; however, the more one understands the cause of a particular condition the more proactive one can be about the management.

Douglas Penta MD

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Is This Normal?

There are so many aches and pain during pregnancy.  At times it is hard to tell what it is concerning and what is not.  A huge question I have been asked lately is, “When should I  call my doctor? Is this normal?”  The thing about pregnancy is, so much is going on with your body and everyone is different.  You can not pinpoint a “norm” because what may be completely normal for one woman, could be concerning for another.

It is very rare that women fly through pregnancy with ease and never have a situation where calling the doctor is necessary.  If you are one of those women, I am jealous!  I managed to have kidney stones, pyelonephritis (kidney infection), hyperemesis, fluid leak at 27 weeks, the list goes on.  Like you, I questioned, when do I need to all the doctor?  I was always so worried about being an alarmist because so many things feel uncomfortable and are changing during pregnancy.

A rule of thumb is when in doubt, call your doctor or midwife.  You want to be safe than sorry.  I just want to educate you further so when you do call your doctor or midwife you have a bit more knowledge on what you may be calling about.  So many times I went in a nervous wreck when it was nothing or I would go in completely calm and end up at the hospital.  Here are some questionable times for women, normal or not, and when to call your doctor or midwife.

Bleeding:

Bleeding can happen in the first trimester and this is because of implantation of the fertilized egg in the lining of the uterus.  No matter what the circumstance, if you have bleeding always call your doctor or midwife.  Especially if it is associated by cramping.

Fluid Leak:

Any fluid leak is tricky because some women can experience some incontinence throughout the pregnancy.  Yup, you could pee yourself.  This can often be confused with thinking your water has broken.  In my own experience, I had some fluid and at first I didn’t really say anything, then I showed my mom and we called the doctor.  When I called the doctor, she said it was probably urine and not to be too concerned.  I called back and they were closed so I got the on-call doctor who brought me right in to the hospital.  I kept having nurses and doctors explain that sometimes you can pee during pregnancy but I knew this wasn’t pee.  They did 3 tests to see what was going on and test the fluid, turns out it was NOT pee...it was amniotic fluid.  The story goes on, but back to my point, it is difficult to tell so don’t hesitate to call your doctor or midwife.  If you feel you aren’t getting answers you must be your own advocate!

Frequent Urination:

It is totally normal to be running to the bathroom more than ever before.  The baby can be pressing on the bladder causing this.  It becomes a problem when you are urinating frequently and have pain, burning or any discomfort during urination.  Also, beware of a constant urge to go.  This could be from the baby’s position but could also be signs of a Urinary Tract Infection.  

Changes In Discharge:

You will find changes to vaginal discharge throughout your pregnancy.  Discharge is totally normal but watch out for any itching, burning or unusual odor that may be associated with the discharge.  Be sure to mention any changes to your doctor or midwife.

Depression:

Prenatal Depression is something that is sometimes over looked.  How blue is too blue?  Being uncomfortable and miserable during pregnancy is normal depending on your situation.  If you find you are lethargic, having excessive mood swings, uncontrollable crying, and constantly feeling hopeless, you need to make sure you address this with your doctor or midwife immediately.

Nausea/Vomiting:

Be sure to monitor your nausea/vomiting.  If you are finding there is no relief and it is getting worse, it most likely is not just morning sickness.  The predictable spurts of nausea and vomiting that can be relieved would be classified as morning sickness.  If you are finding nothing will help and it is all day and all night with no let up, it could be hyperemesis.  Talk to you doctor immediately to see what you can do to help stay hydrated and as healthy as possible through your pregnancy.

Swelling:

Having swelling during your pregnancy can be normal, but it can also be a sign of some serious complications.  During pregnancy, all the hormonal changes will cause some water retention and minor swelling.  If you find any sudden swelling in your hands, feet, and/or face accompanied by headaches and/or blurred vision call your doctor or midwife immediately!  These are signs of a serious complication called preeclampsia.  You may also hear the terms, gestational hypertension, pregnancy induced hypertension or toxemia.

Contractions:

A huge sign of labor, contractions.  How do you know when they are real or not?  I kept asking my mom throughout my pregnancy, how will I know?  Her response was always..”you’ll know.”  It could not be more true.  I was in what is call inactive labor for 2 weeks prior to delivery.  Inactive labor is when you are have true contractions but not dilating.  Some women experience Braxton Hicks contractions, which are practice contractions, prior to real labor.  The Braxton Hicks can be uncomfortable but definitely are not the real deal!  I had Braxton Hicks which were tightening and slightly uncomfortable.  When the real thing hit, I couldn’t even speak when I was in a contraction.  It is a tough call of knowing when to go and when to stay.  Timing your contractions is important.  Contractions in early labor last from 30 to 60 seconds and will be 5 to 10 minutes apart.  Let you doctor or midwife know and they will guide you.

These are some just instances where it is hard to tell what is normal or not.  I hope this gives you some more information.  As I said before, when in doubt do not hesitate to call your doctor or midwife.  You can never be too safe when it comes to pregnancy.  So much is unknown so it is normal to question things going on with your body.

Inducing Labor

What is inducing labor? One of the many questions I had during my pregnancy and delivery.  I never thought my delivery would go as it did, but then, that is the point about “What To Expect When It Isn’t Expected”.  I can not tell you exactly how your experience will go with an induction, but I can answer some questions that I have been asked about my own.  If nothing else it gives you a bit more knowledge.

What is an induced labor?

An induced labor is when your labor doesn’t start or progress on it’s own and you need the help of outside medications or methods to give birth.  

Is induced labor a guarantee?

No, in some cases inducing labor does not work.  If the baby is not ready to grace you with his or her presence, then an induction most likely won’t work.  When I was going through my induction I was very fortunate that each step went beautifully and the total process took 12 hours.  The girl in the room next to mine, unfortunately, had been going through her induction for a week and it was not progressing.  They were inducing her because of gestational diabetes but it was not terribly urgent for her to deliver as it was in my situation.  The poor thing was walking the halls and doing whatever she could to help the process.  It is important to know that know matter what, if the baby is not ready, the baby will not come naturally.

When is your labor induced?

There are a number of reasons and pregnancy complications that would lead you to an induced labor.

• Having a pregnancy complication, such as, preeclampsia, gestational hypertension, gestational diabetes, or kidney disease.
• Broken water with no contractions.  If you water has broken and labor does not follow you and your baby could be at risk of infection.  If there is a suspicion of infection, further testing will be done and your doctor or midwife will decide what is best for you and your baby.
• Your baby has stopped growing at a proper weight or is very overgrown.  Any feeling that your baby is at risk will lead to an induction or c-section.
• A lack of amniotic fluid around the baby.
• A placenta abruption, deterioration to the placenta or an insufficient placenta.
• Hitting the 42 week mark and no baby will usually lead to an induction.  You will be offered the option but some women do not opt for an induction which is totally fine as long as you and your baby are safe.  Waiting longer than 42 weeks can increase the risk of stillbirth or other medical problems so it is best to listen to your doctor or midwife and trust them.

How will my labor be induced?

There are a few different methods and medicines used for a labor induction.  I won’t lie to you, it can cause a bit of discomfort, but if it is what is best for you and your baby, you do what needs to be done.  The goal in an induction is to ripen the cervix, which means to get your cervix softened, thinned out, and beginning to dilate, and to begin labor.  Some methods and medication used to induce are: 

Prostaglandins -- If you are being induced but your cervix is not ripe, you'll begin the induction by having medication containing prostaglandins inserted into the vagina by the doctor or midwife at the hospital. This medication helps to dilate you and thin out the cervix.

Foley catheter -- You may have a catheter placed in the cervix.  The catheter has a small balloon that is not yet inflated at the end of it and is placed into your cervix. The balloon is inflated with water to puts pressure on the cervix helping the release of prostaglandins, this will cause the cervix to dilate and thin. When the cervix has dilated to about 5 cm it will fall out and be removed.

Rupturing the membranes (Breaking your water)-- If you're at least 4 to 5 cm dilated, but not showing much sign of progression, your doctor or midwife can insert an instrument that looks like a crochet needle through the cervix to break your amniotic sac. This looks like it will hurt and be uncomfortable, but it really isn’t.  It is no worse than having a vaginal exam.

Pitocin -- This is given through an IV drip to get contractions going.  In an induction once you have reached the point where you go down to the delivery room an epidural will be given if you decide you want one and Pitocin will be given through your IV.  For women who’s water does break but there is no progression, Pitocin is also given.  When your water breaks, most doctors or midwifes will want to deliver within 12 to 24 hours because the risk of infection for you and your baby increases the longer you go with a ruptured membrane.  The amount of Pitocin is adjusted as you start progressing.  I don’t want to deceive you, Pitocin will make the contractions come on very strong and they are painful.  In labor that start on it’s own there is a build, with Pitocin and it is WHAM! you are in labor.

In my own experience, all of these methods and medications were used together.  I was admitted and had the foley catheter done and medication also inserted to help in ripening the cervix.  Within a few hours the catheter fell out and I was having very strong contractions.  I was given some morphine for the pain to ease the contractions.  By this time I was in “inactive labor” for a week now.  This means contractions but no progression, going in I was about 3 cm dilated.  After the dose of morphine wore off I was brought down to delivery, given an epidural and the Pitocin started.  Shortly after, my water was broken, and a few hours later it was time to push.  I was vey fortunate and had a very successful induction.  It is so important to relax to help your body do what it needs to and help your baby relax.

Under what circumstances should my labor NOT be induced?

• If there is an indication that the contractions would be too much for your baby then you will most likely be brought in for a c-section.  It depends on the test results.
• Placenta previa, which is when the placenta blocks the exit for the baby.
• Your baby is breech (head up, feet down).
• You previously had a c-section. 
• You have genital herpes.
• You are having multiples.

I hope this helps inform you a bit about what inducing labor is and the procedure.  It can be scary, but I have to say, don’t be.  Most things about pregnancy and childbirth are unknown.  Whatever you endure is for your baby.  If you have any stories of your experience, questions or comments feel free to contact me at helpingmommytone@gmail.com!

Gestational Diabetes

A few days ago a girlfriend of mine went to the doctors to take a dreaded test... the glucose tolerance test.  The glucose tolerance test is done around the 26th to 28th week of pregnancy.  If your doctor has reason, such as history of diabetes or pre pregnancy weight being very high, the test will be done prior to the 13th week and repeated at 28 weeks.  A glucose tolerance test is done to see if you have gestational diabetes.  Some people think that if you have diabetes you are overweight.  That is not necessarily the case.  She only weighs 138 pounds at almost 30 weeks gestation.  She was asking me a slew of questions because it wasn’t clearly explained to her through her doctor and her first test came back a bit high.  She wanted to know: What exactly is gestational diabetes? Will this hurt the baby? Am I going to have diabetes after pregnancy? Do I need insulin? How did I get this? Do I need to lose weight? Am I going to be able to deliver the baby naturally? Could the test have been wrong!  With all these questions being asked by her, I figured many other women would have the same questions.  I know I did when I was pregnant and I learned from extensive research through my studies and doctors.  

Gestational diabetes is high blood sugar levels during pregnancy.  It is tested by getting a blood draw, drinking a sugary, syrupy substance, then waiting an hour and getting more blood drawn.  The body absorbs the glucose very quickly which causes the blood glucose levels to raise within the hour you are waiting.  The blood is taken to measure how well the body has processed this overdose of glucose.  Every state has a different “norm” for the blood glucose level.  Some state say if your number comes back less than 140mg/dL form the 1 hour glucose screening you are in the clear.  Where we are, the blood glucose level is supposed to be less than 130mg/dL.  If in the event your number comes back high, chances are your doctor or midwife will order to have a 3 hour glucose screening done.  The 3 hour test is a bit more intolerable than the 1 hour.  You must fast from midnight to when the test is done, you get blood drawn at the fasting point to see what the levels are, then drink, wait an hour and blood gets drawn again, then do this 2 more times.  Your office will give you the exact instructions if you need to do this screening.

There is no EXACT cause for gestational diabetes, but it is known that the placenta, which is a source of your baby’s growth, does alter the way your body uses insulin when you have gestational diabetes.  If your body can not properly use and create insulin then it can lead to greater issues like hyperglycemia.  

Gestational diabetes can cause harm to your baby IF it is not properly monitored with intense cases. With gestational diabetes, any extra glucose will go through the placenta.  This will give the baby high blood glucose levels causing the baby to have extra insulin, more than necessary for their little bodies to grow, it will store as fat, leading to an overweight baby.

For most women, you will be put on a strict diet to keep your numbers down and all is good.  You may or may not end up going in for an induction do keep the baby from getting too big.  It depends on your doctor or midwife and what they feel is best.  More than not, all is fine and you will have your gorgeous healthy baby at the proper gestation.  So many women mistake induction for a c-section, they are different, and just because you may be induced does not mean you need to have a section.

I hope this answered some of your questions and helps to keep you informed!  Stay healthy, eat right, exercise and enjoy being pregnant! From this point on, it is over before you know it.