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Lady Imp

Early Delivery?

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Lady Imp

Hi there, I just wanted to get thoughts on the subject from people who aren't worried about a potential malpractice lawsuit.

 

I am currently 29 weeks pregnant, and my OB is pretty hesitant to allow me to continue to carry the pregnancy past 36 weeks, citing research that suggests that Type 1 diabetics are at an increased risk for stillbirth. I've read quite a few journal articles on the subject, and they all say the same thing, that while yes, there is an increased risk over normal or even Type 2 pregnancies, it is still only 1-2%, with the biggest increase coming when 3rd trimester A1C levels exceeding 7.0. My last pregnancy was delivered at 36 weeks via C-section, partly due to her wanting to do it early due to the fear of a stillbirth, and partly cause I was totally over being pregnant (sad but true), and my son wound up in the NICU for 8 days afterwards for reasons including (but not limited to) being born with fluid in his lungs, an inability to regulate his body temperature, and being just a hair over classified as low birthweight (still not sure how that one happened, they were anticipating him being around the 7lb mark). The pregnancy went perfectly, I had zero complications during it, blood glucose levels were good, blood pressure was good, no protein in urine, nothing went bad at all, and now I'm wondering if I had said "fugeddaboutit," would I have been able to bring my son home with me once I got released from the hospital. I want to avoid having to deal with the stress of having my daughter in the NICU this time around, and I feel like my best chance is to keep the pregnancy a little longer. So I recently cut my endocrinologist a deal that she was completely cool with and I plan on putting it forward to the OB at my appt next week: as long as all ultrasounds look good, I keep my A1C levels under 7.0, no further complications develop and I don't slip and fall on my face in the driveway (the last one being the most likely to occur), I get to keep the pregnancy to 38 weeks. But the when I first brought up the idea last month, she seemed kind of...reluctant. I know that a lot can still go wrong, and she was probably trying to keep herself from making a promise that she couldn't keep, but I am well aware of what can go wrong and I know that if the feces hit the proverbial fan, plans are gonna hafta change.

 

So now that I'm done nonsensically babbling, I was wondering if I was the only one who was having OBs express similar concerns to carrying babies to term, what your thoughts on the subject were, and if you were experiencing the same thing, how you were handling or plan on handling it.

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k_dub

Hi Lady Imp:

 

I've heard of providers in the US (and especially the UK and Australia) that insist on delivering Type 1 mamas early. I'm not convinced that it is evidence based.

I'm 33w now - I want to carry as close to full term as I can get - as long as there is no evidence of complications, etc.

 

This is my first baby, so I have nothing to compare anything to. But, so far I've had an easy pregnancy. My A1c has been averaging 5.7%. I've had some insulin resistance at various points, but not nearly as much as I was expecting.

I haven't really talked about delivery with my OB yet (crazy enough, I'm in the process of switching to a different OB at 33 weeks). I will have that conversation thisnext week, I think. Personally, I want to carry as close to 40 weeks as I possibly can. And without any hard evidence of a "problem", they will be fighting me on that.

 

In the US, ACOG just came out with guidelines that suggest that it's important to allow healthy pregnancies to carry to 39 weeks, if possible. 36 weeks (with no sign of issues) seems very early to me. So I don't think you sound crazy asking the questions you are asking...

And I agree the relative risk for stillbirth (or any other really scary bad complication) is low - even if it is higher for diabetic mamas - still very low.

 

How long have you had diabetes? Do you have any pre-existing D related complications (sounds like no from your post above, but thought I'd ask)?

 

Again, don't know where you are located - but in the US, most OBs are using the Modified White's Classification Scale for Diabetes During Pregnancy. Forcing someone with no issues to deliver at 36 weeks sounds a bit crazy to me.

 

I find that the industry is mostly driven by a need to cover their a$$es for liability.

I plan on just having a really frank conversation. I'm not going to be forced to do something based on an unfounded fear.

Get information, make an informed decision.

Don't be afraid to walk out of the clinic/hospital and come back later.

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Lady Imp

 

I find that the industry is mostly driven by a need to cover their a$$es for liability.

 

I could not have said this any better myself. And I feel like this is what's going on more than anything. I know that my OB has delivered diabetic stillbirths before, and she is less than interested in repeating the experience. Malpractice suit or no, there has got to be nothing worse than having to tell a mother that their child didn't make it. So I get where she's coming from, no one wants to have to do that. I've had diabetes for *counts fingers* 17+ years, and I will admit that in my youth I could have canned the attitude and done a **** of a lot better job taking care of myself, but I have had no real complications or hospitalizations as a result of the diabetes that weren't a result from minor idiocy and an inability to read insulin bottles. All my labs consistently come back good, and my opthamologist keeps telling me that if I didn't tell him, he wouldn't even know I was a diabetic. And I know that in the end, what I say goes, and I will go in with a section of the Amazon rainforest covered in printer ink from the Journal of Obstetrics and Gynecology, the International Journal of Diabetes Mellitus, a statistics textbook and my handy TI-83 to back myself up if I have to. I was really wondering more if my OB was just being paranoid and spending way too much time on EBSCOHost, or if it is something that other people were experiencing as well. I just feel like this is one of those situations where the benefits of keeping the pregnancy longer outweighs the risks. The decision of a repeat C-section I agreed with (admittedly for selfish reasons, I like being able to schedule things) and I feel like 38 weeks is a good, happy medium.

 

I know that things can still go wrong. I know that my body could suddenly do a 360 and I could wind up with preeclampsia. I know that there's a possibility for amniotic fluid to be too much or too little. I know that I possibly wind up being trampled by a neighbour's runaway cow and go into labour early. But for crying out loud, I would rather focus on the good than the bad. Like the fact that I don't have to drink that nasty orange sugar ****. :D

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rubidoux

Wow! 36 weeks is shocking. :( Here, I don't think they try to deliver before 38 weeks w/o something actually going wrong, unless it's changed in the last four years.

 

During my first pg, I fought like h*ll to get my perinatologist to agree to 40 weeks and he did. All labs were perfect until 39w1d when I had a plus one protein and elevated BP. My peri, who was awesome, said that the doc on call at the hosp wanted to induce me right away bc "these situations don't turn around," but that it was up to me and if I wanted to I could go into the hospital to be observed and he thought that's what I should do. Like you, I was so over being pg and I could not wait to see this baby. Lol So I was induced, 30 hours of labor w no more protein, all normal BP, 3.5 hours of pushing, c-sec. Ugh! Truthfully the whole thing was great for me somehow, like I almost wouldn't change a thing. But it was just obvious that baby wasn't ready. :(

 

Second pg, though, I felt like I didn't want any foolin' around. I felt kind of regretful for having talked peri into 40 weeks the first time. I think now that I had already had a child, I was not willing to take any chances. So, number 2 was a scheduled c-sec at 38w4d. (They say at 38 weeks here, but I think they must mean during that week, iykwim).

 

Anyhow, I am super risk averse on this particular subject, but 36 weeks does not sound right to me. Obviously there are some risks caused by birthing to early, and that just would not feel right to me.

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Lady Imp

http://care.diabetesjournals.org/content/32/11/2005.full.pdf+html

 

This is the article that I like the most on the subject, as they have a very large sample size, and they are able to control a little better for differences in medical care, as there tends to be more consistency in medical care in Sweden than there is in the US. One thing I find rather interesting is that the article does state that while diabetic mothers are more likely for intrauterine and neonatal death, there is a correlation between neonatal fatality and preterm delivery. Now, I know better than to equate correlation with causation, but what this article said to me was "****ed if you do, ****ed if you don't."

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Lizzie G

hi

 

sorry you had to go through that. every ob i have ever spoken to (and other professionals too) have always said that delivery before 38 weeks would not be recommended unless there was a specific risk to that pregnancy (ie not diabetes itself but pre eclampsia, iugr, etc) and most "standard" diabetic protocol in the uk offers induction at 38-39 weeks.

 

unfortunately i think poorly controlled diabetes is more common than maintaining "non diabetic" (ie sub 6 a1c) during pregnancy and there isnt enpugh evidence compiled that going to term is safe for some people and that risk is a continuum.

 

in my last pregnancy despite my a1c being low fives and all being perfect i was bullied into induction at just over 39 weeks (keep in mind my mothers 4 children all stayed put til 42-44 weeks) & i was extremely unhappy about the whole thing and had a dreadful experience.

 

this time i have changed to a better hospital and ob. the new ob is wonderful. whilst she obviously keeps in mind there COULD be something other than bg control at play affecting early placental degradation, she is happy to work with me providing everything continues to be straightforward and normal and il be induced at 40+6.

 

i think if my control was less tight, say my a1c was over 6, i might be a bit more worried and thimk 38-39 weeks would be reasonable.

 

the important diffference between my two experiences though, is i feel supported and that decisions will be made jointly, on the basis of my health not standard protocol.

 

my immediate thought is would you be able to see another doctor to get their thoughts, and maybe switch?

 

36 weeks, does not sound right. that is pre term and likely a full month before its ready, i would not allow this to happen and im sorry you were pushed into it, i know how that part feels x

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Lady Imp

I wish it was easier to switch doctors. Unfortunately I live in a somewhat rural area, and sadly the other local OB groups tend to send their high-risk pregnancies up to where I am, surprisingly enough. My cousin who lives about an hr from me developed pre-eclampsia during her pregnancy, and wound up being told "hey, you're gonna deliver up in TC, and I'm not gonna be there nor tell your doctors anything, sucks to be you!" She's lucky that the hospital up here also happened to be in-network, otherwise she would have been stuck with an outrageous bill all because her OB group was scared. I am currently unemployed as well as a full-time student, so travelling the two hours one way to the next nearest OB group on the regular basis required at this stage in the game is both financially and practically not doable. Apart from this one situation, I like the doctors in my group, I just wish they weren't so **** paranoid. Like I said, in the end they will allow me to call the shots, and I regret not doing more research the last time around given what I have found out. While I wouldn't go so far to say as I was "pushed," I do feel like I was given some not-too-good advice that I made the mistake of blindly following. Hubby and I are both 100% done with childbearing after this and I'm moving in August anyway, so short of another Pap smear I'm done with them regardless after this pregnancy.

 

Lizzie, you do bring up an interesting point about many cases being in uncontrolled diabetes, and I wonder if the instance of that happening has clouded the judgement of the doctors in the area. I have sadly observed a lot of bad health practices in people around here in terms of just general taking care of oneself. I've seen quite a few people who desperately needed to go to a doctor for one reason or another and just simply wouldn't go, in some cases because they didn't have health insurance or they couldn't afford it, but in others it simply wasn't a priority to them, they just didn't care (apparently, being able to whine about being in pain from a UTI was more important to them than getting it fixed). Some of the stories I heard mothers telling nurses when I would sit with my son in the NICU made me wanna beat my head against a wall. I wonder if these observations can be extrapolated to the general public in the area, and this is where a lot of the issues arise, and these complications they have witnessed in their own practice aren't so much a result of a bad statistical hand being dealt, but more due to their inability or unwillingness to take care of themselves.

 

When push goes shoving, if my endo is happy, I am happy. And she has no problems telling people to STFU, so since I've got her in my corner, I've got an ally in the medical community at least, who from my talking with others has a pretty well-respected opinion in the area. I don't plan on allowing them to deliver at 36 weeks this time around, barring any unforseen circumstances of course.

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Lady Imp

Welp, I went in for my 30-week ultrasound today and Baby Imp looks good. And I put my foot down. And found that a novel pretty much had to be written in my file indicating my knowledge on the subject, that I was making an informed decision and I have been made aware of the risks of carrying until 38 weeks. I got told it had to be done "in case of a lawsuit." I know Americans are sue-happy, but hot d@mn. I feel like I'm the only person in this country who knows and accepts responsibility for their own decisions and actions...

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k_dub
I got told it had to be done "in case of a lawsuit."

 

That is non-sense.

So basically, they are saying that evidence-based medicine plays no role - they are practicing defensive medicine. Letting their fear of liability drive their medical decisions, not clinical evidence.

I would have blown a gasket, I think.

 

I talked to new OB about delivery. He agreed that there is no reason to deliver earlier than 39 weeks unless some complication pops up that warrants it. He will let me carry to 40 weeks if all looks good. He wasn't a fan of letting me carry over 40 - he quoted the risk of stillbirth in Type 1 mothers who are overdue.

I figure I'll cross the bridge with him if we get there.

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Lady Imp
That is non-sense.

So basically, they are saying that evidence-based medicine plays no role - they are practicing defensive medicine. Letting their fear of liability drive their medical decisions, not clinical evidence.

I would have blown a gasket, I think.

 

I talked to new OB about delivery. He agreed that there is no reason to deliver earlier than 39 weeks unless some complication pops up that warrants it. He will let me carry to 40 weeks if all looks good. He wasn't a fan of letting me carry over 40 - he quoted the risk of stillbirth in Type 1 mothers who are overdue.

I figure I'll cross the bridge with him if we get there.

 

I felt like I really needed to reacquaint her with how the field of statistics works, primarily that just because the previous 98 diabetics delivered completely normal babies does NOT mean that the 99th and 100th are automatically going to stillbirth. I know that I'm only a lowly undergrad and I use more statistics than the average bear so the subject is a little fresher in my mind, but dude. If you're going to cite research (which does in fact exist), learn to do it properly and look at the meaning of the numbers, and not just the numbers themselves. *sigh*

 

More and more, Europe looks like a nice place to live...I can renew my passport and put up with checking in at the consulate every year and making sure papers are in order. I always got McDonald's after it as a kid living in Canada, I think that's a tradition I need to revisit.

 

And I don't know about you, but being overdue would make me miserable...I'm only 30 weeks and I'm ready for this to be done. I think I would be the one at 40 weeks going "GET IT OUT NOW!!!" lol

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k_dub

In my mind, I think this little boy will come when he's ready. And I think he will be at 39-40 weeks. And ohhhh, yes, I will be ready!

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Lizzie G
That is non-sense.

So basically, they are saying that evidence-based medicine plays no role - they are practicing defensive medicine. Letting their fear of liability drive their medical decisions, not clinical evidence.

I would have blown a gasket, I think.

 

I talked to new OB about delivery. He agreed that there is no reason to deliver earlier than 39 weeks unless some complication pops up that warrants it. He will let me carry to 40 weeks if all looks good. He wasn't a fan of letting me carry over 40 - he quoted the risk of stillbirth in Type 1 mothers who are overdue.

I figure I'll cross the bridge with him if we get there.

 

i would be interested to know where he got his statistics re type 1 mothers beyond 40 weeks seeing as the vast majority are forcibly ejected before either mother or baby are ready! to be bluntly honest when i see the a1cs of the populations studied in every single scientific paper relating to type 1 pregnancy, i consider the findings irrelevant to me; the best control i have seen in these studies is in the 6-6.5 range. i am not trying to be arrogant or dismissive of anyone that achieves this, but to me that is still clearly in the range of diabetic physiology, whereas a sub 6, throughout pregnancy, to me makes my physiology (and the fact my controls always been in this range) more comparable to someone without diabetes. i was told i was insane forbelieving this inmy last pregnancg but one day tbere will be an evidence based outcome study supporting my common sense assertion.

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Lady Imp
i would be interested to know where he got his statistics re type 1 mothers beyond 40 weeks seeing as the vast majority are forcibly ejected before either mother or baby are ready! to be bluntly honest when i see the a1cs of the populations studied in every single scientific paper relating to type 1 pregnancy, i consider the findings irrelevant to me; the best control i have seen in these studies is in the 6-6.5 range. i am not trying to be arrogant or dismissive of anyone that achieves this, but to me that is still clearly in the range of diabetic physiology, whereas a sub 6, throughout pregnancy, to me makes my physiology (and the fact my controls always been in this range) more comparable to someone without diabetes. i was told i was insane forbelieving this inmy last pregnancg but one day tbere will be an evidence based outcome study supporting my common sense assertion.

 

From the research I've seen, of those miscarriages that did occur, between 40-50% (depending on the study) of them occurred in people with A1cs over 7.0. So it seems to me like if you're going to miscarry (which you have a pretty low chance of even happening in the first place), it will be more likely due to having meh control. I don't see why someone who keeps A1c's in the high 5-low 6 range should worry nearly as much as they do here in the States.

 

But then again, Americans are quick to blame...we're seemingly incapable of admitting when something that happened might be a result of our own actions, and instead we look to blame someone else. Thus the reason for doctors fears. *sigh*

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Tanikit

I was induced with both my girls at 38 weeks (37 +6 and 38+2 if I remember correctly) - my gynae would NOT let me go before 37 weeks as then a baby's lungs are less mature and diabetics babies lungs according to research take even longer to develop. I had had higher hba1cs that pregnancy (they ran around 6.9-7.2 all pregnancy). If I were you I would fight to delay the birth - by 38 weeks I wanted my children out and I felt it was a compromise between too early (38 weeks is full term) and the risk of stillbirth if waiting later. Neither of my children had breathing problems - they did take xrays of my eldest's lungs at birth as she had had a difficult prolonged birth after an induction with vacuum extraction and they were being careful. Both were in ICU and the youngest was there for 4 days - I was allowed to stay in hospital for 3 days following the birth and paid for an extra night as I didn't want to upset the breastfeeding by not being there and having to express and give bottles (this related to troubles I had with my first). The eldest was kept an extra night as she had jaundice, but they needed me there with her to keep the feeding going. So both children went home with me from the hospital.

 

I would push for a 38 week delivery - it should be a good compromise with your doctor as its not as though you are asking for 40 weeks. You could bring up the studies for lung development as a comparison - also ask the gynae to speak to a pediatrician - the gynae's main problem is you and bringing a live baby into the world, but what happens afterwards to the baby goes to the pede and hopefully the pediatrician can tell the gynae that it is better for the baby to stay in a bit longer.

 

My first baby was coming by herself when they induced me - I had lost my plug the evening before induction and the induction was very fast and relatively uncomplicated for a first induction - often they struggle if the baby is not ready and too early. While my second would have stayed in longer, the induction also worked well, but this time probably because she was a second - it ended in a C-section as her heart rate kept diving and would not come back up fast enough before the next dive.

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Lizzie G

i still think 38 weeks is very early for someone with decent control and bizarre that its considered a compromise. here in the uk "standard" diabetic protocol is 38-39 weeks and earlier would be if a problem arose. 36 weeks is considered pre term and hence not appropriate unless there are specific concerns in that particular case (eg severe pre eclampsia, ruptured membranes that havent resulted in labour).

 

re the risk of still birth i remember the (really ****) ob i saw in my last pregnancy trying to manipulate me with fear of a "doubled risk of stillbirth". never mind that the risk was doubled from 1 in 10,000 to 1 in 5000 (again for an average diabetic).

 

unfortunately medical practice appears to be dictated by a fear of litigation, outdated and over generalised ideas about diabetes and pregnancy, and a lack of empirical evidence relating to subgroups of people with much better than average control.

 

i hope that over time excellent diabetes control will become the norm, there will be studies to back this up, and medical practice will change to reflect this. in the mean time the best we can do is present our cases eloquently, demonstrate that our efforts are paying off, and hope we can chip away enough in order to make it easier for the next pregnant type 1s that show up at our hospitals hoping for a less over medicalised approach.

 

its wonderful that we are all here to talk and support each other, have a bit of a moan but also hopefully give us the confidence to pick the battles important to each of us.

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Lizzie G

ps lady imp agree re the stats point. i also work in a fairly statistical field (im a CA) & studied chemistry as my major in uni, so see straight through all the presentation tricks (double risk to me hugely depends on initial level of risk!)

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Tanikit

Yes, those risk things are a bit crazy. I remember arguing with my gynae about having an amniocentesis - I asked her why she would even offer one when the risk based on the blood tests was 1:18000 of my baby having Downs and the risk of miscarriage with the amnio was 1:100 (she told me it was 1:200 when I said this) - I said statistically it made no sense for me to put my baby in that danger when the risk of Downs and other problems was 1:18000. She did agree I was right, but said she still had to offer it. Needless to say when she offered it she did not give me the risk of miscarriage with an amnio until I pressed her.

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Lizzie G

wow, are you saying you were offered an amnio due to diabetes despite being "screen negative"; im quite shocked by that. having had a termination for a fairly common trisomy i know theres no link between genetic abnormalities and type 1 (other than general bad luck!!!)

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Lizzie G

ps when i was offered cvs as result of a screen positive result, risk of procedure was made very clear (in my case a 1 in 5 risk of T21 versus 1 in 300 risk of m/c was a no brainer, but no way would i have taken that chance with such a monumentally low screen rwsult!)

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