Friday, March 28, 2008

Consequences

Midwife with a Knife wrote an interesting and thoughtful post on one of the consequences of noncompliance in pregnant diabetics. Sometimes their babies die. Sometimes that happens very close to their due date. She writes about the challenge of speaking with these women about how their behavior contributed to the stillbirth of their baby. Not an easy conversation to be sure but they need to know that following the doctor's advice in future pregnancies will significantly improve the next baby's chances of survival.

Stillbirth (fetal death) isn't the only negative outcome when a pregnant diabetic fails to follow her OB's advice in regard to diet, blood sugar testing, medication (often insulin) and monitoring. The surviving infants are very likely to end up in the neonatal ICU. When someone tells you that their baby weighed more than 9 pounds and was born more than a month early, think non-compliant diabetic. That's usually the case.

It isn't fun or easy to check your blood sugar 4-6 times/day, follow a fairly rigorous meal plan, and maybe even give yourself multiple doses of insulin. I know how hard it can be - I was diagnosed with diabetes just prior to my last pregnancy. I was spared the insulin, but my fingers certainly were sore and I met with a dietitian monthly to make sure I stayed on track. I might not have done so well, but that was the year we admitted one after another 9+ pound 34-36 week gestation infants of diabetics. They nearly all were so sick that they required ventilators and ALL of them needed huge amounts of IV glucose solutions to manage their blood sugar issues. The experience made me obsessive about doing everything necessary to keep MY baby out of the NICU. It also made me much more sympathetic to the moms who weren't able to stick with the program. It's hard. Really hard. The results are worth the effort.

Babies whose mothers aren't able to keep their blood sugar under control during pregnancy are very likely to be larger than normal for their gestational age. This often leads to pre-term delivery with resulting respiratory distress. They are also at significantly higher risk for birth defects - particularly cardiac anomalies.

Another problem for infants of poorly controlled diabetics is hypoglycemia. When mom's blood sugar is high, the baby produces large amounts of insulin in response. When the baby is born, the insulin production continues - resulting in dangerously low blood sugars. It isn't uncommon to need a 15 or even 20% sugar solution to stabilize the blood sugar in these babies. Once we get the blood sugar stabilized, we can slowly decrease the amount of glucose we give and wean the baby off IV fluids. This can take several days.

Discussing the cause of their baby's admission to the NICU can be almost as challenging as MWWAK's discussions with the moms of stillborn infants. It isn't uncommon for the women to lie to their OB's.

One woman had told her OB that her blood sugars were essentially normal -- all 6 times the was testing each and every day. She had even managed normal fasting blood sugars when those were tested by the lab. I don't have a clue how she managed that last, because each and every urine specimen tested at her office visits had been 2-3+ positive for glucose. That's pretty significant.

I didn't bother pretending that I believed she'd stuck to her diet and checked her blood sugars. I simply told her that many women found it hard to follow a diabetic meal plan and unpleasant to test their blood sugar. She burst into tears and confessed that she'd given up testing her blood sugar and found it too easy to hit the drive-through when she was hungry. I'm sure her OB had given her what MWWAK calls the "dead baby talk" - and that she'd likely left the office and had a hot fudge sundae on the way home to console herself. We had a chat about how things could turn out differently next time if she followed her OB's advice. I also recommended that she see a dietitian - preferably beginning PRIOR to her next pregnancy so she would have a better chance of following that advice. I don't know if any of that had a long-term impact on her. I do know that we never saw another baby of hers in our NICU.

3 comments:

chartreuse said...

I think you need to be careful about assuming that all diabetic moms who have larger or sick babies just haven't tried hard enough. Particularly for the Type I moms out there (or for Type II's with more severe disease) it can be very hard. I'm thinking of a new mom I know who was very compliant, checked her blood sugar something like ten times a day, met with the diabetic team weekly, and still had a large baby and lots of hyperglycemia through the pregnancy. Pregnancy affects your sugars and can make management hard to impossible sometimes. It is a difficult disease.

Judy said...

You're right that some women do their very best to keep things under control and don't succeed. In my experience, though, they are in the minority -- and will generally TELL you how hard they tried. Also, their blood work matches their urine tests. IOW, you won't find normal fasting blood sugars in those women when their urine tests show evidence of significantly elevated blood sugars - as in the case I described.

I wasn't mean to her. I didn't accuse her. I simply stated that it can be very hard to manage diabetes during pregnancy. She agreed with me. Despite all the "dead baby talks" she really did not think this would happen to HER baby -- until it did. My point was that she could have a different experience the next time around.

anna said...

Nice post