Gestational Diabetes: A Common-Sense Approach

Should you agree to a reduced calorie diet or to routine or aggressive use of insulin?
Pros: Some studies have shown that this can reduce the incidence of big babies, although reducing this incidence often doesn’t reduce high cesarean rates (16).

Cons: Restricting calories or limiting glucose availability by injecting insulin manipulates the growth mechanism of the seventy to eighty percent of babies who would not weigh in the upper range even if GD were left untreated, not to mention the ten percent or so who genetically were supposed to be big. Aggressive diets and insulin use can cause starvation metabolism (ketosis), which produces byproducts known to be toxic to the baby (27). These diets can also result in underweight babies, and symptomatic episodes of low blood sugar (hypoglycemia) (5,30,32). Limiting food intake can also lead to malnutrition (26).

Should you agree to fetal surveillance tests (nonstress test, stress test, biophysical profile, amniotic fluid volume measurement) before your due date or ultrasound scans to estimate birth weight?
Pros: None.

Cons: GD babies are not at any greater risk than non-GD babies with the possible exception of those whose mothers have sugar values in the range of true diabetes. On the other hand, all fetal surveillance tests have high false-positive rates, meaning the test indicates a problem that isn’t really there. This can lead to an unnecessary induction or cesarean. Ultrasound scans predict high birth weight poorly and the obstetrician’s belief that the baby is big increases the chances of cesarean independent of the baby’s actual weight (9-10,12,25,34,38,47).

Should you agree to routine induction or induction for suspected big baby?
Pros: None (16). Some doctors believe that inducing labor at or before 40 weeks or for suspected large baby will reduce the risk of cesarean for poor progress or having the shoulders hang up during the birth (shoulder dystocia). Studies show this isn’t so (10,12,18,22,33,47). A few doctors believe that routine induction at or before the due date prevents stillbirth, but in the absence of other risk factors, GD babies are not at increased risk (7).

Cons: Inducing labor increases the incidence of fetal distress and cesarean section (19).

Should you agree to planned cesarean?
Pros: None (16,41).

Cons: A cesarean section is major surgery with all that entails in pain, debility, and potential complications, including life-threatening and chronic complications. In addition, the presence of scar tissue and the uterine scar threaten the life and health of mother and baby in future pregnancies.

Should you agree to routine testing for newborn low blood sugar?
Pros: Babies of mothers with GD sometimes develop low blood sugar.

Cons: Babies not displaying symptoms of low blood sugar such as tremor are unlikely to have a problem requiring treatment. Testing involves one or more heel pricks. The baby may be separated from you for observation in the nursery or given bottles of sugar water or formula, which interferes with establishing breastfeeding.

Suggestion: Refuse routine testing. Medical staff usually tests large babies, small babies, babies born after a difficult labor -- all situations increasing the odds of low blood sugar -- and babies with symptoms of low blood sugar in any case.

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