A Little Too Sweet

I don’t think I’ve ever mentioned before that one of my areas of interest at work is diabetes in pregnancy.  I didn’t mean for it to happen, but I’m now the doctor who sees just about every pregnant woman in my county if she needs insulin.  A small number of these patients are women who had diabetes before pregnancy, but most of them ended up with gestational diabetes, and when diet alone wasn’t enough to control their sugars they end up being sent to see me.  Sometimes it’s their fault they’re in my office, because they just aren’t doing what they’re supposed to, but many of them really are trying, it’s just not enough.

So of course, when I saw my OB for my first visit, she asked me about my risk factors for diabetes.  My grandmother has diet controlled diabetes, but no one else in my immediate family has any problems, so we decided not to do any early screening on me, instead sticking with the usual plan for a glucose tolerance test at around 26 weeks. 

But then last week I had a horrible lunch.  Someone had brought us barbeque chicken wraps, and the chicken was disgusting, over-cooked and chewy.  I didn’t have time to go out to eat, and so I ended up eating two bites of chicken, then the wrap (with lettuce, sauce and tomatoes without the chicken), two sugar cookies with frosting and 4 snack sized Twizzlers for lunch.  I know, it was a horrible meal, and I didn’t even enjoy it, but I didn’t have anything else to eat.  Not surprisingly, I felt bad a few hours later, so I decided to check my blood sugar... it was high.  A target sugar for someone with gestational diabetes two hours after a meal is 120, but normal is about 105-110.  Mine was 126.  So I started testing – first thing in the morning, and two hours after every meal.  I’ve only had one high after a meal since then, and that was when I was eating out.  All my morning blood sugars have been just a smidgen too high, though, between 88-92.  A target fasting sugar is 90, but normal fastings are in the 60-70s.  That has me worried.  I’m worried about if I’m going to have to start following the gestational diabetic diet (right before the holidays – so unfair!).  I’m worried that getting high blood sugars this early in pregnancy might mean that I have really high blood sugars later in pregnancy.  And I’m really worried that getting high blood sugars this early in pregnancy means that I’m going to get Type 2 diabetes! 

One benefit of being a diabetes specialist is that I have access to things like continuous glucose monitors.  That picture at the top of the page is the receiver for CGM I’m wearing right now.  CMGs are cool little devices; a tiny sensor is inserted just under the skin, and attached to a transmitter.  The sensor constantly measures sugar levels in what’s called the interstitial fluid (the fluid between cells in your skin), and reflects what your blood sugar was about 10-20 minutes earlier.  By wearing one, I can see what my blood sugar is doing all the time, not just when I do a fingerstick blood sugar check.  I’m going to wear it for a week to see what happens to my sugar immediately after eating horrible meals, and what happens when I follow a gestational diabetic diet.  Based on what I’ve seen over the past few days of checking sugars, I have a feeling that I’m going to be able to do ok with just loosely following the diet during the day, and can probably get away with a least some sweets and pastries too.  But the high morning blood sugars are a concern.  I’m going to start doing a bedtime snack every night, to see if that helps (usually that does) and if it doesn’t, I’m going to start metformin.   With my OB’s blessing, of course!  I’ve already decided that if I end up with full blown GDM, I am treating myself.  I know, they say doctors shouldn’t do that, but this is just looking at sugars and dosing insulin.  People with Type 1 diabetes do that on their own all the time, so I think it’s reasonable.  I can just imagine what my chart at my OBs office will say, though.  “Patient refuses referral for GDM education because she says she could teach the class herself if she had to; can already recite diet by heart and has her own glucometer and CGM.”

Quick Primer on Gestational Diabetes aka GDM:

A normal part of pregnancy is that your body doesn't use insulin as well as it usually does, and in response to this increased insulin resistance, your pancreas makes more insulin.  If you already have an increased risk for diabetes, your pancreas might not be able to make enough insulin to cover your body's requirements, and your sugar goes up.  The consequences of high blood sugars (if untreated) are an increased risk of a big baby (with potential trauma to baby and mother during delivery), an increased risk of neonatal hypoglycemia, jaundice and breathing problems, and an increased risk of childhood obesity and type 2 diabetes.  The treatment is diet, followed by insulin of needed, or occasionally an oral agent.  For the mom, the long term concern is that it’s associated with a 50-60% increased risk of type 2 diabetes within 5 years. 

Great.