Thursday, August 30, 2012

Testing, Testing

So I failed my goddamned 1-hr glucose test. They want me to go sit in the fucking hospital for over 3 hrs to do the 3-hr test there and go on a preemptive diabetic diet. I think I am not going to. Here's why.
  1. My failing score was 165 mg/dL. The American Diabetic Association cutoff is 180 mg/dL* to diagnose gestational diabetes. Therefore, the national authority on diabetes says I passed.
  2. A baseline glucose was not drawn, only after 1 hr post-orange drink. So we don't know if the oatmeal I had for lunch prior to my 1PM appointment might have already spiked my glucose level. It might be a baseline issue more than a metabolism issue. (I was told to eat normally.)
  3. Even if blood sugars are lowered -- through testing, diet, exercise, even with insulin or oral antidiabetic medications -- the risk of having a larger birth weight baby remains if I do, in fact, have gestational diabetes. So the intervention is useless for the biggest concern to the baby.
  4. The major risk factors for me are poorly supported by research: increased risk of preeclampsia (conflicting data) and increased 5-year incidence of type 2 diabetes (even experts concede that the gestational diabetes diagnosed for this subset of women likely just uncovered latent undiagnosed type 2 diabetes, and pre- and post-pregnancy obesity is a strong correlate).
  5. Some experts think that gestational diabetes, considering it's estimated to occur in up to 10% of pregnant women depending on the source, may actually be a normal condition of pregnancy that simply bears routine monitoring as with blood pressure (for preeclampsia), fundal measurements (for intrauterine growth restriction), etc. 
  6. My blood pressure remains perfect, my urine shows no spilled protein or glucose or ketones, and my weight gain and fundal measurements are on track (exactly the same as with Jackson).
So as far as I can tell, the lower threshold (set by many OB clinics) is really a catch-all for false-positives and probably leads to lots of pointless intervention. I can agree to proactively reduce carbs in my diet and add more exercise, which is pretty much the entry level approach to management, anyway. The difference is I do not want to do finger sticks four times a day and obsessively record the blood glucose values which will undoubtedly be scrutinized by defensively conservative clinical standards and then end up fending off further intervention. I also don't want to be labeled as high risk come delivery, since I have a fighting shot at an intervention-free labor this time (as my doctor thinks it will go pretty fast and smooth given my first labor). (I opted pretty early on for an epidural with Jackson because I presented to L&D with high blood pressure -- although only around 150/90, which is not that high, and it resolved during labor -- and the work-up protocol for preeclampsia that this triggered made me concerned about emergent inventions. Having the epidural gave me peace of mind that an emergency C-section would not require general anesthesia and that frequent internal exams wouldn't keep making me want to crane-kick the nearest nurse.)

Fuckity-fuck-fuck. Just when I thought I was in the home stretch (3rd trimester!) with single-digit weeks until full-term, and then this bullshit. They are mailing the info to me with the diet (which I'll do my best to follow) and a lab order to schedule the 3-hr test. I might just not do it and then talk it over at my next monthly appointment in 3.5 weeks. And if they call in the mean time, I'll explain my reasons and see what they have to say. I'm not psyched about the prospect of being flagged as noncompliant, so I want to be sure to lay out a clear case for them. I also don't want for the compromise to come down to frequent non-stress tests or whatever, because that's just more intervention of another kind. I feel like the level and nature of monitoring already built in to the OB practice is sufficient to look out for me and the baby. I hope they agree. They are generally a low-intervention practice (which is partly why I chose them) so perhaps I will prevail. Dare to dream.

Of course, none of this can stop the paranoia that I should just give in to the testing and intervention for the sake of safety. I might pass the 3-hr test anyway. I just don't know. I'm not inherently high risk, so I want to proceed like a normal pregnant person. Anyone here know how the hell that even works?

*So I looked into it more and the test should have been done fasting per ADA recommendations, and the 180 mg/dL cutoff is for a fasting test. So maybe I will suggest we simply repeat following the ADA guidelines and then go from there.**

**Okay, after looking into it even further, the routine OB test is non-ADA and is a "challenge" versus a tolerance test, and I roundly failed. So I appear to be screwed and should probably take the 3-hr test and cross my fingers. Fuck me.

 

7 comments:

Lauren said...

All the reasons that you listed, plus some more, are why I opted to not even do the glucose screening this time around. I've discovered that one of the major benefits of having a midwife is that the testing that appears mandatory when you have an OB is discussed with you and then you make your own decision. And you're not labelled as "non-compliant."

Good luck, whatever you decide to do!

Steph said...

Hi Jen.

I failed the first test due to something I ate. Take the 3 hr test. Yes it's a pain in the ass, but there are a lot of false positives on the first and you may pass the 3 hr with flying colors. Also, you can have them give you the numbers as each hour passes so you'll know where you're at. The sooner the better too, that way you won't have to worry about any of that GD stuff.

Cheri said...

Oh, I'm sorry you have to mess with and worry about this. Sometimes ignorance is bliss, like back in the day. We had no clue and few problems. I never had an ultrasound, and I don't recall a glucose test. BUT get this. After my first was born, they routinely screened EVERYONE in the hospital for TB - including nursing mothers (!) via chest x-ray. Yikes.
Anyway, fingers crossed that you pass the next test.

bunny said...

UGGH! It does seem like these lower thresholds are causing huge pains in the ass, with people then going on to pass the 3 hour. I betcha that will be you, too. Sorry you have to deal with this, but I'm confident it ain't no real thing.

Rhianna said...

Awww, shit. :( I'm with everyone else--betting my bottom dollar that you'll ace the 3hr with no issue. I'm trying to remember if I was told to fast for my glucose screening, but I remember having it done in the middle of the day, and I know there was no way I fasted for that long.

I have some lab orders just languishing on my countertop as we speak (quad screen and the like), and I just can't bring myself to go take care of them. I feel a bit pissed that I was just told to go do them like I *have* to, when, you know, I could seriously give two shits about the quad screen. Wouldn't any issue be identifiable during the anatomy scan? Anyway, just nodding my head to the notion that some of this stuff feels...not helpful and not necessary.

Good luck, dude!

Mina said...

Whatta freck? Why are these tests gives midday in the US and only in the morning, first thing, in Germany? And they take your fasting level too. And there is no 3hs test here. And the values are lower than in US (although it depends where you look, apparently). Whatever...
I had it, you know. Diet worked just fine, both times. babies were both long, but not fat. I did need extra monitoring because of the low fluid, which I found out was the reason for both inductions. Otherwise I felt just fine, I was not overweight so that was not the reason I got GD. I don't know how you monitor fluid level other than by u/s, but maybe you should have this in mind?!
Good luck! It is not the end of the world if you have it, but I would bet you don't.

kdactyl said...

While reading through this I was inwardly screaming ...Noooooooo....just get the retesting done. I had GD in my 2nd pregnancy. I presented like you...I didn't actually fail the test...I was one point shy of failing so my Dr. told me to cut out sugar and white food and we would check again in a month. I did that and 3ish weeks later I redid the 1 hour test (fasting) and failed it completely...so things can change soooo quickly and you may become full blown GD and not know it....and it isn't just big babies that is a problem...it can lead to proglems later in life and can also have complications at birth if the baby's blood sugars are out of whack. I was able to control mine through diet for awhile..but it does tend to get worse near the end of pregnancy and I had to go on an oral medication for the last two weeks. I know it is a hassle to re-do the testing... but it is sooo worth it to know everything is okay. Hang in there. GD is totally temporary and resolves itself in you and baby right after birth...but only if you manage it well during pregnancy.
kd