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To: OtisSam@aol.com, midwife@fensende.com
From: "Hetler-Jaffe" <cjaffe@whidbey.net>
Subject: Re: Glucose Testing -- The Evidence (LONG)
Date: Wed, 29 Oct 97 19:41:29 PST

I offer glucose testing but I follow Henci Goer's guidelines (and BTW in
her book, Obstetric Myths Versus Research Realities, she blasts glucose
testing out of the water having no basis in actual scientific fact ). I
have my clients come in after a 12 hour fast and take a FBS. The I have
then go home and eat a meal containing 100 grams of carbohydrate: A cup of
apple juice, two slices of toast with butter, a banana, a cup of milk (soy
or rice milk can be used) and a cup of non-sweetened cereal. Then I do a 2
hour post prandial blood test. I have had one GDM case in 375 women. First
baby 10# 10 ounces second after diabetic diet, 7#6 ounces. I also wonder
about so many inductions ofr LGA babies. A nice study below, shows the
folly of induction for LGA babies. I do realize they are talking about
non-diabetic but the results are clear.

Cynthia in WA
Title
Influence of spontaneous or induced labor on delivering the macrosomic
fetus.
Author
Friesen CD, Miller AM, Rayburn WF
Address
Department of Obstetrics and Gynecology, University of Nebraska,
College of Medicine,
Omaha, USA.
Source
Am J Perinatol, 12: 1, 1995 Jan, 63-6
Abstract
Fetal macrosomia is a known intrapartum risk factor for fetal injury
and maternal morbidity.
The purpose of this study was to review our experience with macrosomic
fetuses in nondiabetic pregnancies and compare perinatal outcomes between
those whose labor had been spontaneous or induced. Between January 1989 and
December 1991, the 186 pregnancies of infants with birthweights greater
than 4000 g (4001 to 5131 g) underwent labor that had been induced (46) or
spontaneous (140). Cesarean delivery was more common after induced than
spontaneous labor (11 [23.9%] vs 14 [10.0%]; P < 0.03) regardless of parity
or gestational age. Frequencies of shoulder dystocia, 1-minute Apgar scores
less than 7, and abnormal umbilical blood gas determinations were not
different between the two groups. We conclude that spontaneous rather than
induced labor is associated with a lower chance of cesarean delivery among
those fetuses with birthweights 4000 g or more.
Language of Publication
English
Unique Identifier
95225866



----------
>
> I posted last week about a presentation about GDM testing; here is a
summary
> of the presentation:
>
> Presenter: Steven Gabbe, M.D. (for those of who don't know the name, he is
> the author of a respected OB textbook and generally a well-recognized
> academic and clinical OB --- ooooops? am I veering into "discussing
> personality over substance" --or is it ok when it is an well-known OB????)
>
> Part 1: Information from the Third International Workshop COnference,
1990:
>
> Incidence of GDM: 3% = 135,000 women annually in US
>
> Why screen?
> To find those that need insulin, because they suffer the greatest
perinatal
> mortality.
>
> He presents a table from Cassady, G et al. Am J Obstet Gynecol 122:13 1979
>
> 124 Class A diabetics (diet controlled -- normal fasting and post prandial
> glucose)
>
> Perinatal Mortality: 3 = 24.2/1000
> Macrosomia: 17%
>
> 24 diabetics labeled Class A who were actually Class A2 (needed insulin
> because their fasting and/or postprandials were elevated). He doesn't
explain
> why these women were misdiagnosed and why their insulin requirement was
> overlooked.
>
> Perinatal Mortality: 4 = 190.5/1000 (this is eight times higher than the
> really truely Class A group)
> Macrosomia: 38% (more than double)
>
> This was his whole point of the presentation:
> that we should tighten up screening cutoffs, provide sound nutritional
> couseling to all GDMs, maintain strict home glucose monitoring, and
provide
> insulin for those who's fasting is > 95mg/dl and/or who's 2 hour PP is >
120
> mg/dl because this will reduce complications and lead to better outcomes
>
> ******* me again:
> I know that many midwives are angry that so many women get put into the
> category of GDM and protest putting women through an unpleasant series of
> tests, and therefore will be resistant to the notion that we should be
MORE
> vigilant in identifying glucose intolerance in pregnancy.
>
> However, IMHO we should not undertake greater survellance so as to label
more
> pregnant women as "high risk", because it is becoming clearer and clearer
> that when diet-control is sufficient (fasting and postprandials are
normal)
> women and their babies have good outcomes. But as is evidenced by the
study
> quoted above, when a woman is actually requiring insulin and for whatever
> reason her care providers don't know that she does, she and her baby are
at
> very high risk of complications and we have a responsibility to find those
> few women in our obstetric populations and PREVENT fetal disability and
> death.
>
> I understand the desire to avoid testing that has such a high false
positive
> rate (only 15% of women with abnormal GCTs will have an abnormal GTT), and
> our clients can certainly opt to not test, IF they are fully informed as
to
> the nature of the disease and it's subtle presentation and the potential
> risks. Heck, I have clients who won't do the metabolic screening of their
> kids. They know what it is for, they understand the prevalence of the
> diseases, the consequences if their child has one of them and it is not
> detected through screeing. Can't tie the kid down and draw the blood, can
> I???
> *******
>
> Part II: Management of GDM & glucose monitoring
>
> Study on home glucose monitoring: Goldberg, JD et al Am J Obstet
Gynecology
> 1986, 154:546-550
>
> 59 Class A Controls (no home monitoring. he doesn't state whether or not
the
> provider was monitoring their glucose control, but it appears from the
> results that they were, probably the reccommended weekly fasting and 2
hour
> PP)
> Rate of Macrosomia: 24% = 14 cases (does not detail definition of
macrosomia)
> Needed Insulin: 21% = 5 cases
>
> 58 Class A Treatment: unspecified number of daily glucometer readings at
home
> Rate of macrosomia: 9% = 5 cases
> Needed Insulin: 50% = 29 cases
>
> *******Comment:
>
> OK, so the group that tested their sugars at home were much much more
likely
> to be identified as requiring insulin for better glucose control, BUT
their
> outcomes show a more than 50% decrease in macrosomia, one of the major
> complications of GDM which leads to more cesareans and all the attendant
> risks of surgery, etc.
> ******
>
> Extent of home glucose monitoring:
>
> Insenstified = 7 daily home glucose reading with meter.
> Conventional = 4 times daily visual.
>
> Conventional (n=1,316 women)
> Insulin requiring = 34%
> Macrosomia (>4000 gms) = 13.6%
> Primary Cesarean = 19%
> Shoulder Dystocia = 1.4%
>
> Intensified (n=1,145 women)
> Insulin requiring = 66%
> Macrosomia = 7.1%
> Primary Cesarean = 13%
> Shoulder Dystocia = 0.4%
>
> note: all results were significant to a p<.01
>
> Langer et al Am J Obset Gynecol 1994; 170:1036-47
>
> **********
> so this large study has dramaticly better outcomes in the more intensely
> monitored GDMs, with a significant reduction in macrosomia, cesarean
> delivery, and shoulder dystocia -- and a concominantly much more frequent
use
> of insulin.
> *******
>
> Management:
>
> 1. Allow to go to term (see, no recommendation for early induction)
> 2. At 40 weeks, begin bi-weekly NSTs
> 3. Evaluate for cesarean delivery if EFW > 4250 gms
> 4. Treat Class A2 (insulin requiring GDM) as you would a pre-gestational
> diabetic) ie. NST and BPP starting at 32-34 weeks, etc.
>
> Values for home monitors compared to plasma
> Capillary result Plasma result
> Accu-check II 160 135
> Accu-check III 155 135
> One Touch II 120 140
>
> *************
> which says to me that we better be REAL careful with the results from home
> monitoring and follow up with regular fasting and 2 hours sent to a lab,
> particuarly when making the decision to use insulin therapy
> ***********
>
> Role of Exercise:
> Preliminary studies indicate that (just as in non-pregnant diabetics)
regular
> exercise may obviate the need for insulin therapy in some women with GDM.
>
> Jovanovic-Peterson L. et al Am J Obstet Gynecol 1989 161:415-419
>
>
> Screening: (this was hand-written by me on the back of the syllabus, so I
> don't know if it was his opinion or an official ACOG criteria)
>
> Women who do not need GCT screening:
> 1. < 25 years old
> 2. Normal body weight for height
> 3.No first degree relative with Type II (adult onset) diabetes
> 4.Not Hispanic, African American, or Asian (because these groups have
higher
> rates)
>
> The Rule of 15:
> A. 15% of women will have an abnormal GCT
> B. 15% of those will have an abnormal GTT
> C. 15% of those will require insulin
> D. 15%of GDM will have macrosomic baby
> E. 15% of GDM will have future impaired glucose tolerance or diabetes.
>
>
> ************
> OK, this whole thing is Steven Gabbe's interpretation of the research,
and he
> provides only thumbnail sketches of his supporting studies. But it
certainly
> made me think about the seriousness of glucose testing in pregnancy.
>
> I am very conflicted, as I am sure many of the midwives on this list are.
My
> clients mostly hate the testing. I am horrified that I have to subject a
> pregnant woman to fasting and then a huge sugar load when only 15% of
> abnormal GCTs end up diagnosed GDM.
>
> Then again, I buy the argument that some of those who truely are glucose
> intolerant are at higher obsetrical risk, but when we have to put a woman
on
> insulin she can no longer give birth at the center, which is usually very
> upsetting news (thankfully we have privledges at the backup hospital and
can
> still attend them, but the loss of the nice birth center birth dream is
> painful for many of our clients).
>
> And I realise that midwifery is not just about people having a wonderful
> birth experience, it is also appropriately using knowledge and technology
to
> wherever possible maximize the chances of a healthy outcome. So, it is too
> bad that women don't like the testing or that they get thrown out of the
> birthcenter if their sugars aren't well controlled -- it is better than a
> dead baby or an unnecessary cesarean, right? I still feel terribly
> conflicted.
>
> And I also realize that these issues bear even more weight for homebirth
> practitioners and non-legal midwives. If one of these practitioners
> identifies a woman as GDM, she may have to leave the practice all together
> and then might face all kinds of other complications at the hands of the
> mainstream OBs (ie inappropriate induction, unnecessary cesarean, etc,
etc),
> especially if the OB knows or suspects the woman started her care with a
> non-licensed practitioner or was planning a home-birth (or god-forbid
thinks
> the woman was irresponsible enough to get to 30 weeks with no prenatal
care
> if she doesn't disclose).
>
> Those of you who are still reading:
> How many OOH midwives (esp those who are extra-legal) on this list offer
> glucose testing to their clients?
> How many clients refuse?
> What do you do with identified GDM clients?
>
> sam
>
> Samantha McCormick. CNM
>
> ps. full text of conference syllabus available to those who supply me
with a
> snail mail address.
>
>