Gestational Diabetes

A massively fascinating and equally maddening topic. Including info on race, class, and my own family history would just set me off, so I'll save that for a later post.

Here are the basics (as basic as I can get) about gestational diabetes:

When we eat food, we take in three main things - fat, protein, and carbohydrates. After eating, our body takes carbohydrates, breaks them down into glucose, and then uses the glucose for energy so we can do things like move and think. The pancreas makes insulin, which takes glucose out of the blood and helps it get into the cells of the body so it can be used for energy.

In Type 1 diabetes, the pancreas doesn't actually make insulin, so people with Type 1 diabetes must take insulin every day in order to survive. Since the body can't use carbohydrates for energy, it uses fat and protein instead, which can cause huge health problems and even death.

In Type 2 diabetes, the pancreas makes insulin but for reasons no one knows, the body can't use the insulin correctly. After years of this, the pancreas sort of gives up and stops making insulin and the result is the same as Type 1 diabetes, where glucose builds up in the blood and the body can't use it for energy.

In pregnant women, hormones affect the whole glucose - insulin dance. In early pregnancy, there is a lot of insulin and so glucose levels are low. This might by why some women have nausea and vomiting when they don't eat every couple hours or so. All pregnant women have higher glucose levels than normal, but they also have higher insulin levels than normal, which usually balances out and doesn't cause a problem. However, as the placenta grows, it makes a hormone (human placental lactogen) that actually keeps insulin from working right, which causes higher glucose levels. The peak time when this happens is around 26-28 weeks. If there is too much glucose in the blood, the body is not able to use it for energy. As the level of glucose in the mom's blood rises, it crosses over to the baby. The baby then has to make insulin to keep the glucose level down. This process affects the baby's metabolism in a weird way (which leads to the baby having a higher risk of obesity and diabetes later) and the extra insulin is stored as fat on the baby.

Gestational diabetes can cause some major issues. Some of issues include a higher rate of stillbirth and miscarriage, birth defects to the baby's brain and heart, respiratory distress for the baby, and a baby that is larger than normal. The large baby can get stuck coming out and is at a higher risk of being hurt by forceps or a vacuum or needing to be born by cesarean.

In order to prevent the large baby caused by gestational diabetes, pregnant women are screened for gestational diabetes. Here's where the controversy sets in.

The medical model of screening is done early in the third trimester (which doesn't help those at risk for miscarriage) and consists of drinking 50 grams of glucose. One hour later, the patient's blood is tested. If the level of glucose in her blood is higher than 140 mg/dl (some doctors use 130 mg/dl), she has to have a second test. The second test consists of an 8-12 hour fast (always healthy for pregnant women), then a blood draw, then a drink of 100 grams of glucose (nasty!), then blood tests one hour, two hours, and three hours later. Two or more high levels lead to a diagnosis of gestational diabetes. Even though only 2-5% of women will actually have gestational diabetes, as many as 30% of women will be diagnosed with it from the tests used by OBs. They are then labeled "high-risk," with all that entails.

By contrast, the midwifery model of screening is more comprehensive. At the very first visit (1 1/2 to 2 hours long), the midwife and client have an actual conversation about diet, exercise, ethnic background, health history, and potential risk. Clients are offered a blood glucose test as soon as they know they're pregnant to determine whether diabetes existed before the pregnancy. At every visit thereafter, clients talk with the midwife about nutrition, exercise, changes they're noticing in their body, how they're dealing with stress, etc. We used to give out recipes and bottled water all the time.

Clients are given a glucometer to take home and test their blood sugar first thing in the morning, after eating, and at certain points during the day. This exercise actually makes clients self-motivated to be as healthy as possible (not just to avoid a diagnosis). Some people realize for the first time that they are extra sensitive to white rice, potatoes, etc. and they change their diet for positive long-term benefits. If they get high levels from testing, they know they can make a change immediately. Midwifery clients have the option of choosing or refusing care all along the way and are actively involved in all decisions made. They receive education and counseling that just isn't possible in the 15 minute OB visit. Instead of drinking straight glucose, which normal people don't normally do, midwives screen for high blood sugar by asking women to eat the food they normally would and make adjustments from there. This way, the small percentage of women who actually have gestational diabetes can be referred for proper medical care, and the vast majority who don't have it can continue to receive quality, comprehensive, holistic prenatal care.

Makes sense to me.