The Story of Sarah, My Prototype Gestational Diabetes Patient
Today we are talking about diabetes, no surprise. I talk about this a lot, but if you have diabetes and you're pregnant, there are so many questions that I can't do enough videos about this!
The story of Sarah, my most common patient
We are going to create a typical patient, we'll call her Sarah. She is a composite of a lot of pregnant patients that I've seen in pregnancy.
We're going to throw everything at her and talk about how we manage her pregnancy. Sarah has been a Type 1 diabetic since she was eight years old and she is now 23. Although she saw a dietician and an endocrinologist in childhood, she has not been seen at the children's hospital since she turned 18.
Sarah has kind of just been winging it for a few years.
She has an adult endocrinologist, but she hasn't seen him in more than a year. She checks her glucoses every now and then, and she takes the same dose of insulin that she has taken for years, when she remembers to take it.
Unfortunately, Sarah’s situation is one that I see all the time.
Can you relate to Sarah? If so, then keep reading.
Stuck in the past with your insulin
If you have had diabetes for years, you might've been really motivated when you were first diagnosed, but sticking with it gets old. And your body gets used to having high blood glucoses over time. So your glucose could be 250 or 400 even, and you might not feel bad. You're thinking you feel fine. But you have to be careful, "Sarah," because there's a lot going on behind the scenes.
Sarah came to me when she was in the very early stages of pregnancy. That's a good thing.
Ideally we like to see you before you are pregnant, but this doesn't always happen. Sarah is about eight weeks pregnant.
What are we going to do for her first?
The first thing we will do for Sarah
There's a routine that we follow when someone with diabetes becomes pregnant. The first thing is to gather as much information as we can about where they are with their diabetes. Is it well-controlled or not so well controlled? Do they have any co-morbidities (high blood pressure, visual problems, kidney problems)? We collect some baseline information. The next thing we're going to do is start a routine of checking glucoses regularly.
Sarah fell out of the habit of checking glucoses multiple times every day. Currently she takes the same amount of insulin no matter what she's eating or how high her blood sugar is.
During our first visit, we spend a lot of time on dietary counseling and sharing the research about nutrition in pregnancy.
Nutrition for diabetes has evolved a lot since Sarah became diabetic. So what she was taught when she was 8 years old is not what she needs to follow now that she's 23. In our first visit with Sarah, it's really important to get her diet basics down because food is medicine, for better or worse. What you eat will help or hurt you during pregnancy. It's not just the insulin that matters. It's how you eat that makes everything else possible.
In pregnancy, a low-carb diet is something that, most of the time, will make you successful with diabetes, or just controlling weight gain. If you're not diabetic, it's going to help reduce the risk of becoming diabetic. If you are diabetic, a low-carb diet means that fewer starchy foods, which make your glucose go up.
Fewer starchy foods, more healthy fats, and a moderate amount of protein are what you want. Check out my post from last week. And this post here talking about diets that help with gestational diabetes.
What happens after the first appointment?
Sarah is going to start eating three meals a day, with snacks as needed. She is going to check glucoses first thing in the morning and two hours after she takes her first bite of each meal. Sarah is going to stay on her current insulin dose for now, but we're going to bring her back in a week and review her glucoses. She's going to bring her glucose log and her food journal.
Keep in mind that the journal and log are not a report card that you're going to be graded on. It's something that's going to help us work as a team to see what works for you and what doesn't.
We are looking for foods that might be making your glucose go up. We're looking at combinations of foods, or foods at the wrong time. We want to work with you. We don't want to be critical. We want to help make you successful. And you are the most important member of this team!
Long-term gestational diabetes risks
If you have long-term diabetes there are some long-term risks you need to be aware of. We have talked about some of these in another video about Type 1 diabetes, but below are some things to know. A key risk to know about is microvascular changes. These will make you more at risk for heart disease, neuropathy, and chronic digestive problems.
We will send Sarah for an EKG. Diabetes also places you at increased risk for having blood vessel changes in your eyes, which can lead to blindness. So will also send Sarah to see the ophthalmologist.
All of these things are important to evaluate in early pregnancy if you have diabetes, whether you've had it for a year or more than 10 years, like Sarah.
We will give Sarah a 3-liter jug to collect a 24-hour urine sample. She is going to collect every drop of urine for a 24 hour period and bring it back to us. We will see how much protein is spilling into her urine in a 24 hour period.
A 24-hour urine collection may seem bizarre, but it gives us an idea of how well her kidneys are functioning. Again, diabetes does a number on your small blood vessels over a period of time. So organs like your eyes, heart, kidneys, liver can be affected by diabetes.
If you are like Sarah and have an endocrinologist, get in to see them ASAP - they can do a great job of partnering with you to keep your blood glucoses in the normal range.
But you have to stay motivated and responsible.
If you're not pregnant and you have diabetes, our expectations are a little different. But if you're pregnant with diabetes, tight control is very important because your baby's glucose is pretty close to your glucose level.
And high blood glucoses are not good for developing babies.
Hemoglobin A1c test
One of the first labs that we will get on Sarah, along with her 24-hour urine, is a hemoglobin A1c test. An A1c test looks at glucose on your red blood cells. The life of a red blood cell is about 12 weeks. So when we look at glucose on the red blood cell, it tells us what your average blood sugar has been over the last three months.
In Sarah's case, this was high. We're going to say it's about 10%. That's a lot higher than it should be. So before you get pregnant, or as soon as you find that you are pregnant, you need to see your primary care provider, endocrinologist, OB or MFM provider.
The higher the A1c in early pregnancy, the higher the risk of major birth defects for the baby. Obviously in Sarah's pregnancy, we're going to do ultrasounds early and frequently. At eight weeks of pregnancy, we look at Sarah's baby with a transvaginal ultrasound.
Who will help Sarah manage her blood sugars
One of the early decisions we will make is whether Sara's blood sugars will be managed by us in the maternal-fetal medicine office. She may continue to see her endocrinologist. Either way is fine. If you have an endocrinologist that you work with, then by all means continue. We will manage all the other aspects of your pregnancy that are high risk. We will watch your blood pressure and your baby's growth and anatomy.
Sometimes primary care doctors or endocrinologists are not comfortable managing glucoses in pregnant women. We will manage blood glucoses in pregnancy, then patients can go back to their primary care provider or their endocrinologist after they have the baby.
What we've covered so far with Sarah
To sum up, Sarah has been diabetic for 15 years, and she's gotten a little lax about taking care of herself. On her first visit, we talked to her extensively about how to eat for diabetes, how to take her insulin, how frequently to check her blood sugars, and we've collected a lot of lab work and data from her, including her 24-hour urine protein and her initial A1C. We have referred her to the ophthalmologist and we have gotten an EKG.
This is just the beginning! In the next video, we're going to talk about how Sarah's pregnancy progresses, what kind of ultrasounds we do, what kind of fetal testing we're planning for her, and very importantly, when and how we will deliver her baby.
For now, subscribe to the channel and join my email list so you can see how Sarah's pregnancy progresses.