Monday, February 8, 2016

MiM Mail: A hard pregnancy during residency


I've been a lurker on the Mothers in Medicine blog for awhile, and let me just say, the stories and posts have been so comforting to me, especially on my tough days. I'm a third year resident, currently in my third trimester of my first pregnancy in a two-resident household. I wanted to share my pregnancy experience to see if I could gather some advice from fellow mothers in medicine. I feel quite isolated as the only resident in my male-dominated program to be a new mother/pregnant in a long time, and at a hospital system where few female residents are mothers/get pregnant during residency, in general.

My pregnancy has been hard, to say the least. I envy all of those mothers who have the pregnancy glow, who have boundless nesting energy, and who just "love being pregnant!!!" My pregnancy has not been like that. First, it was unplanned, and happened about a month after my husband and I got married. I found out the day after my 24 hour call; I was so nauseous and I was late. I took the pregnancy test two times before I could truly believe that the two lines were actually there. After I confirmed the positivity and announced the news, it seemed like everyone was happy about it, but me. I had unknowingly performed multiple fluoroscopy procedures, and I was so worried about what the effects would be on the baby. I consulted my OB, a radiation physicist, and multiple radiologists, who assured me that this early, the effects should be all or nothing, and if the baby had made it through to this point, everything should be fine. My husband and I made the decision to proceed with the pregnancy. We felt that women go through pregnancies in worse situations and conditions, and we should be so lucky to get pregnant this easily with a supportive environment there to welcome the baby when he/she arrives.

Anyway, fast forward through first trimester, which was fraught with all- day morning sickness that even lasted through my night shifts and into my second trimester, to third trimester, where I now find myself having failed the 1 hour and 3- hour glucose tolerance tests. Just barely. I'm now diagnosed with gestational diabetes, and I feel like a failure. Prior to being pregnant, I was skinny, fit, and perfectly healthy. The only risk factor I had was being Asian. The news was terrible; I had been feeling like I couldn't excel as a resident, and now, I felt like I couldn't handle my duties to be a healthy pregnant mother. As someone who has been usually been able to balance multiple plates somewhat successfully, these two losses felt like huge blows.

I've been dealing with gestational diabetes the way that I deal with most challenges in my life; through hard work. I've been increasing protein intake, decreasing carbohydrates, logging my food religiously in a diary, pricking my finger 4 times a day, and walking at least 5 miles a day. My post-prandial sugars have been great. They're super tight, and well below the cut-off of 140. In fact, I haven't had an abnormal number. On the other hand, my fasting sugars in the morning are a touch high. The cut-off is 95 at my physician's office, and mine ranges from mid eighties to mid-to-upper 90's. Actually, there have only been 3 values from 95-100. My physician has given me until Monday to get the values down, before I have to go on insulin. I've tried everything to no avail. I still have 2-3 values hovering at 96. I feel like considering these numbers high is like splitting hairs. But I think my physician disagrees.

It's not that I'm against using insulin. I'm all for using insulin... that is, if I'm truly and outrageously hyperglycemic. I've done my research (on primary literature resources) and read that physicians will use cutoffs of less than 90, 95, 100, even 105. My range is in a gray area. There's also been a paper published showing that if the pregnant woman has no risk factors (the baby is not measuring large, there's no polyhydramnios, etc.), then the physician will let the fasting glucose ride to 105 before initiating insulin. The paper showed that aggressively treating lower risk gestational diabetes women (below 105, and with normal to smaller fetuses) with insulin may be associated with restricted fetal growth. I would be considered a "lower risk" mother, as my latest ultrasound this past week showed the baby was measuring below average, and everything else was normal. I also don't want to run the risk of being hypoglycemic, which I think is a valid concern, given that I'm about to enter a much busier rotation in which it will be harder to eat, and in which, if i become hypoglycemic, would be disruptive to patient care.

Do you guys think that my hesitancy about insulin in my situation is unreasonable? How should I approach the conversation with her? Of course, if more of my numbers are abnormal, then I'll definitely initiate insulin. I already superficially brought up this concern to my OB, which is why she has let me wait until Monday. But it seems like she is pretty set on starting me on insulin that day no matter what I tell her. She dropped the cutoff, saying that normal pregnant patients' fasting blood sugars run from 70-90's, and that tight control is necessary to prevent macrosomia and to improve the baby's transition (and to lessen NICU admission). I don't want to be "that patient." But at the same time, even though this is not my field of expertise, I do have health literacy, and I don't want to act too aggressively to make an already stressful situation more stressful. I don't feel like I'm as high risk as she's making this out to be.

I really appreciate your thoughts and opinions.

By the way, I have been and will continue to work 24 hour shifts and nights into my 9 month. But that's another dilemma for another day.

Thank you!


  1. This post actually really got me upset, partially because of my own experience with borderline high blood sugars and  when I expressed my concerns to an OB/GYN, she basically screamed at me that I was being unreasonable without making me feel like she was taking my concerns seriously.  

    I may not be an OB/GYN, but I am a physician, and taking insulin is not without risk.  If you get hypoglycemic and pass out while at work, that could be tragic, depending on the situation. If you feel like your own doctor isn't addressing your concerns, I don't think it's a terrible thing to get a second opinion.

  2. A) I hear you feel that you're not excelling at being pregnant. That's true, and it's the hardest part of parenting -- we're all used to excelling and there's no excelling at parenting. There's simply surviving, being good enough and enjoying the ride. I'm really serious: save excelling for work, and get used to good enough at home.

    B) It sounds like you have a rational, scientific argument against the use of insulin. I would simply state it to your doctor and if she can't refute it calmly and scientifically, I'd find someone else. Take the advice we always hand patients: serious decisions deserve second opinions; it's not personal and it doesn't make you "bad."

  3. Ah, how well I know the struggle! I had GD, IUGR, and preeclampsia during my intern year. The struggle to feel adequate as a resident was real. Add the crushing blow to my soul when I found out about GD and the subsequent complications, and I had very little fight left. When I found out about GD, I was aware of NO risk factors. Later I learned one obese aunt had GD with her last baby. My fasting sugars were upper 60s - low 70s. I had to watch what I ate or I could go high postprandial. That first week I probably checked sugars 8-10 times a day, just trying to grasp what my body was doing. I hit 60 before lunch, with a snack. Looking back, I really do wonder how much the food restrictions of my work environment contributed to the whole situation, how much it sped along the placental dysfunction. There are lots of what-ifs. But that's my story, not yours. It took a long time for me to heal emotionally from the compounded challenges of residency, pregnancy complications, and a bumpy postpartum course.

    Have you adjusted your evening snacks? I've heard many moms report better fasting numbers with a bigger evening snack, heavy on protein.

    I certainly understand your hesitations about insulin. Many OBs are also willing to use glyburide or other meds, if needed. Meds can help decrease the dietary carb restriction, if that is an issue. One thing I wish they would have emphasized was the need for sufficient carb intake (rec is min 175g/day in 3rd trimester). I'm sure I was burning ketones.

    One thing to keep in mind is the inherent inaccuracy of the glucose meters. My new meter with new strips (yes, I'm either brave or foolish and pregnant again) at my last glucola read 17 points higher than the formal lab result, about 15% off.

    As a word of hope for the future, it is possible to have an easier pregnancy the next time around. Many of my symptoms with my first are less this time around. I've passed 3 glucolas. Baby is average size. There is still time for complications to develop, but so far I'm tracking right along and doing well. Plus I'd like to think I'm a little older and a little wiser. My schedule is less grueling. I've done this before. And I'm seeing an OB who's both very knowledgeable and reassuring, so the burden of worrying and watching for trouble is lessened.

    The last thing I'll leave you with is that from what I read, sugars leading up to delivery are the most important for limiting baby's risks. So even if you're toeing the line on your fasting sugars now, maybe you can add a little extra help via meds the last week or two before you expect to deliver. After delivery, feed that baby frequently. I was told not to go more than 3 hours from starting one nursing session to starting the next. Baby dipped close to the cutoff once, but passed every sugar check and we didn't look back. My IUGR 36 weeker peanut came home with me 2 days later.

    I look forward to an update when your munchkin arrives!


  4. wow! your adherence to diet and exercise really sounds like it's beyond the call of duty for any patient, let alone a resident! on the opposite end of the spectrum, one of my co residents would check her blood sugars at the wrong time purposely to get lower numbers. ;) kudos to you! imagine how different your sugars might be if you weren't doing all you are doing! definitely the beginnings of a great mom :) fasting blood glucose is often least likely to be amenable to lifestyle modification. sometimes it has nothing to do with what you are doing. as with many things in parenting, sometimes you just need a little help. where i train our fasting cut off is 90 so 95 seems generous as it is. if insulin seems a bit severe, what about an oral? perhaps just a question to broach with your OB. in any case, remember that this is not a reflection of you or anything you're're working so hard and doing the best you can! hang in there...the end is closer than you think! and you'll get the cutest little prize at the end :)

  5. I would honestly switch doctors, or at least get a second opinion. I had something similar happen, only I think my samples might have been mixed up with someone else. I had a high fasting glucose and one more abnormal value, so my doctor diagnosed me with gestational diabetes. I had planned an unmedicated natural childbirth, so I was devastated. Plus, I was healthy, active, and ate a whole foods vegan diet. I began to monitor my blood glucose, and I noticed that all of my values, including fasting glucose were within normal range. After a month of daily monitoring, I was pretty convinced that my samples were either mixed up with someone else or improperly processed. When I brought this up with my doctor, she didn't seem to believe me and said that she would treat me as a high risk patient just to be sure...and referred me for an ultrasound to get measurements (this is highly inaccurate and can lead to unnecessary inductions/c-sections!). So I knew it was time to switch providers. My new doctor agreed that this may have been some kind of lab error, sent me for a HbA1C test (which came back normal), and encouraged me to monitor once or twice each day at random times. I had an all natural birth in a birthing center! My baby was born at 39w5d and was a healthy weight (7 lb 11oz). I'm so glad that I switched doctors because this would have never happened with my first doctor....she would likely have induced me "just to be safe." Anyway, I'm just a med student, so I don't really know anything, BUT I think that you should have a provider who you can be on the same page with. You've done your research, and it seems like this person is going to stick by the guidelines she was trained by, regardless of how many research articles you show her. So I would really look into getting a second opinion and even switching altogether to a doctor who you feel you can trust.

  6. Hi, I hope I can help you with your decision.
    I had glucose values around 93 - 102 during my pregnancy.
    Although I am not a doctor, I have access to medical literature. So, I read everything about this. My first diabetologist wanted that I start with insulin. I decided to ask for a second and third opinion. So, I contacted a diabetologist specialised in GD and a OB/GYN specialised in GD.
    They agreed that with this values NO INSULIN was needed.
    The OB/GYN monitored the growth of the baby to be sure that she was growing normally. My OB/GYN told me that the reason I was originally advised to start with insulin was to follow strictly the guidelines and avoid liability.
    My daughter was born with a normal weight and no consequences due to those slightly high fasting values. The nurses measured her glucose values 3 times per day the first 3 days of her life. Hope it helps. Wish you all the best !!

  7. I had gestational diabetes twice. First pregnancy was just diagnosed then had a preemie.For second pregnancy had glucose testing much earlier. I was able to control the post prandial values with diet but my fasting was higher 90s. I was put on glyburide, small dose. It is off label use but worked to bring down those morning sugars. I was with an excellent high risk ob/gyn group at a major academic center. I think insulin may be tricky for you especially if you have vomiting and erratic ability to eat etc. If you do end up on insulin "start low and go slow" Hang in there! I wish you the best.

  8. I am a nurse on a high-risk OB unit - We see a lot of diabetics. Fastings under 100 are usually fine, especially if your post-parandials are under 140s. Our MFMs won't start insulin as a first line for gestational diabetes - usually they start with metformin if diet/exercise is not enough, which usually works very well. It can lead to some GI upset, but doesn't carry the risk of hypoglycemia.

  9. Thank you for sharing your experience with all of us. I cannot offer you the medical advice as our colleagues above - they have done a great job and we'll let that stand:-) But, I have read lines of your third paragraph over and over, and they are breaking my heart for you:

    "I feel like a failure"
    "I had been feeling like I couldn't excel as a resident, and now, I felt like I couldn't handle my duties to be a healthy pregnant mother"
    "As someone who has been usually been able to balance multiple plates somewhat successfully, these two losses felt like huge blows"

    My friend, rest assured, you are amazing. You cannot fully control your pregnant body - despite your admirable and Herculean efforts. If you need to start insulin (clearly a debatable point!), it does NOT represent a failure or something that you did or didn't do. It represents your medical condition. And similar to what Larval Doctor was saying, this experience will be the first of many on your parenting adventure, where you must yield to forces greater than yourself. I am not saying this in a hard or patronizing or paternalistic way AT ALL, I hope you don't hear it that way. I am empathizing with you as you discover this. It is HARD, but pregnancy and parenting are not situations where you have ultimate control. Ever. No matter what. And beating yourself up, as you have done above, serves only one purpose - it beats you up.

    I am concerned for you. In not the same situation exactly, I hear myself saying your words. The sense of disappointment, of failure when you can't achieve something (even something that you can't control) that you work so hard for - it's a huge blow. The satisfaction you get from balancing multiple plates at once, and the agony when you can no longer do so (to your own satisfaction) - another blow. But here is the thing: Who, other than you, says you are not meeting your duties as a resident and pregnant woman?

    Again - this is not at all a criticism of you. I think you are incredible. I see myself in you, and I see us both in a culture (both medical culture and North American culture) where we are conditioned to "buy in" to exactly these unreasonable and unobtainable ideals of success. And I don't have an answer as to how we can fix this. I just ask that you let yourself be "imperfect", somehow, and that you love what you do and how hard you work in both your home and career life - and give yourself much credit where credit is due. Good luck to you.

  10. I would definitely meet with another OB … ASAP. Also - seems like you are doing exactly what you need for your (borderline) gestational diabetes. If your fasting glucose is a little high I'd guess it has more to do with your stress/cortisol than your diet or your insulin sensitivity. So if I were you I'd do what I can to relax (soooo much easier said than done, but definitely the best move for you and baby) rather than stay with a doc who is going to cause you more stress. And the cost benefit for your going on insulin has to be more toward risk than reward (though I am NOT an OB by any means). A less uptight Gyno would be a good start to your relaxing. Also your level of stress over the fluoro reminds me of friend who had exposure to some unknown chemical dye at a big costume party before she knew she was pregnant, my own concern about having spent a day with a dying (heavy) smoker just before I found out I was pregnant my sister-in-law's realization she had been out drinking right before she found out, etc. … I know two female docs who knowingly and willingly were exposed to fluoro (wearing lead, of course) through multiple totally healthy pregnancies of kids. I think we perseverate on these exposures more as an outlet for general angst over the big responsibility and the many unknowns ahead of us rather than for the risk in any of these examples. So do yourself a favor and forgive yourself this one ASAP and realize that almost every first-time mom has a similar story! … You are doing GREAT! … As you said, you've always juggled a lot. Pregnancy and motherhood will be no different. So trust that, trust that well-informed voice that tells you your doc is leading you in the wrong direction. Trust yourself. A lot of early motherhood is learning to have confidence. You have it professionally, don't lose that now! You've got this! And you will have lots of resources (friends, family, (good) physicians, this forum) to help you along the way.


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