“Pregnancy in Women with Pre-Existing Diabetes” – with Dr. Jennifer Lam-Rachlin
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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OBGYN and Maternal Fetal Medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.
Okay. We’re here with Dr. Jen Lam-Rachlin, one of my partners at Maternal Fetal Medicine Associates and Carnegie Imaging. Welcome back to “Healthful Woman.” So glad you’re here.
Dr. Lam-Rachlin: Thank you for having me, Nathan:
Dr. Fox: Unfortunately, we’re not face-to-face, we’re doing this over the phone, but not because of COVID, only because we’re in different offices today. But I did get to see you earlier, which was lovely.
Dr. Lam-Rachlin: Thank you.
Dr. Fox: Today we’re gonna be talking about pregestational diabetes, which is a little bit different from gestational diabetes. And I think just to sort of jump right into it, you know, how would you explain to someone, what is the difference between gestational diabetes and pregestational diabetes? Just in terms, like, the definition.
Dr. Lam-Rachlin: I guess the easiest way to differentiate or define both of them would be pregestational diabetes is diabetes that was diagnosed before you got pregnant and classically, we think of gestational diabetes as diabetes being diagnosed at really any point in the pregnancy. Obviously, there are some nuances, but with patients that are diagnosed early in the first trimester or second trimester, but that’s generally kind of the defining line, right? That diagnosis before pregnancy or diagnosis during pregnancy.
Dr. Fox: Right. And then someone is diagnosed during pregnancy, right? As you were saying, the nuances, it’s possible to have pregestational diabetes and we just didn’t know about it, but sort of conceptually, if someone has true gestational diabetes, they’re perfectly fine when they’re not pregnant, and this is just sort of their body responding to the hormones of the placenta, right? Meaning they’re fine before pregnancy, they’re fine after pregnancy, but their response to the placentas is greater than someone else’s would be, whereas pregestational diabetes is someone actually has a condition called diabetes when they walk into pregnancy. Why is that significant? Like, why would it make a difference, right? If you have it before pregnancy or in pregnancy?
Dr. Lam-Rachlin: In general, there’s obviously different risks that we talk about with both the mom and the baby with regards to whether someone has pregestational diabetes versus just what we call “regular gestational diabetes.” But the way that we monitor is differently, the way that we somewhat treat is differently and the adverse outcomes that we look for are a little bit different between the two.
Dr. Fox: If someone were to see you, and let’s say, she’s not pregnant, she’s thinking of getting pregnant and you find out she has diabetes, right? So what is it you would tell her that, you know, at pregnancy, she would be at risk for potentially compared to someone who’s not diabetic?
Dr. Lam-Rachlin: For someone who knows that they have diabetes and they’re not pregnant and they’re thinking of pregnancy, I usually kind of think of it in a few terms. One would be, you know, how does diabetes affect her during the pregnancy, how does diabetes affect the baby during the pregnancy, and then just in general, how does pregnancy itself affect the long-term outcomes of diabetes on her overall health. There’s kind of those factors that we would look for and talk about.
Dr. Fox: Right. And so if someone walks in, the first thing that I sort of think about with women is, which is really important and why it’s important to know before you get pregnant is that actually, if you walk into pregnancy with diabetes that’s not treated, you have an increased risk of having a baby with birth defects. And that’s generally related to what?
Dr. Lam-Rachlin: It’s related to how well your sugar control, your glucose control is, right? The general testing that most primary care doctor or most endocrinologists would test for in someone with known diabetes would be something called a hemoglobin A1C. And there are certain cutoffs that we use for what is normal, what is prediabetic, what is diabetic, and then the worse your A1C levels are, the worse in terms of pregnancy outcome, and the higher the association of these birth defects that we talk about. So ideally, before pregnancy, you want it as well-controlled as possible to lower all those risks.
Dr. Fox: Right. And I think that that’s something that’s, it’s so important because there are conditions that women can have that can affect pregnancy outcomes. But diabetes is one of the unique ones where it really needs to be done before she gets pregnant or right when she gets pregnant in order to reduce one of those outcomes, and namely birth defects, because the baby, the organs are formed very early in pregnancy. So someone has diabetes and it’s not well controlled and her A1C is high and her sugars are high, and she gets pregnant, even if we quickly sort of recognize that and try to correct it, it may take several weeks and by then the organs may be formed, or in this case, malformed, there may be a malformation or a birth defect. So it’s really important for women, if they have diabetes, to make sure their sugars are under control before they get pregnant.
And most women with diabetes know this, because, you know, their endocrinologists tell them, their internists tell them, they know, and for those who are able to do it and their A1Cs are normal, they really shouldn’t have a greater risk than anybody else would. And there’s also…I mean, there is a nuance with this in terms of controlling sugar and we probably should have said this when we defined diabetes is that we sort of categorize women with either type one or type two diabetes. And so how do you explain the difference between type one and type two? Like, what is it and why do we differentiate those two?
Dr. Lam-Rachlin: Usually the differentiating factor would be, you know, someone who has type one diabetes would be someone who doesn’t produce their own natural insulin, so they’re not able to have the appropriate response to the glucose load that someone without diabetes would have. And someone with type two diabetes, they actually do produce insulin, but they are either not producing it to the same amount that they’re supposed to, or at the receiving end, they have what we call insulin resistance where the cells are just not reacting the same way it’s supposed to and it’s not as efficient in terms of that signaling to the insulin. The reason to kind of differentiate between the two, for me, for my purposes would be someone with type one diabetes, they do well with a very small amount of insulin and they are very insulin-sensitive. So that’s not someone that I would, you know, put them on a huge dose of insulin and titrate them very aggressively. And they could do well with just small titration versus someone with type two diabetes, they are a lot more insulin-resistant, their bodies can handle a lot more of the insulin dosage changes. And so I’m less concerned about changing doses among those patients.
Dr. Fox: Yeah. It’s also on the patient and, you know, women who have type one diabetes have…most of them have had it since childhood. And not always, but most and they sort of…they get it. They know, many of them are meticulous and understand their blood sugars. Type two diabetes, something frequently develops slowly over the course of one’s lifetime. And so they may not be as much on top of it or it’s sort of a relatively new thing for them and it’s also not as acutely dangerous, right? Type one diabetes, if someone doesn’t take their insulin, they’re in the hospital, right? They get really sick really fast and so they sort of know. But type two, you could go months or years without, you know, being properly treated, and especially if you’re in your 20s, or 30s, or early 40s, you may not have a lot of consequences in your own health from that, it’s more of a long term. Sometimes they’ll come in and it’s not so hard to convince the type one diabetics to be on top of their sugars because they’re already doing that. For type two, sometimes it’s a real big lifestyle change for them because you have to diet, exercise, and take insulin, or oral medicines, and that’s new for many of them.
Dr. Lam-Rachlin: Yeah. I agree. I mean, in general, I tell patients with diabetes or gestational diabetes that you really don’t feel your blood sugars, right? Like you don’t feel when it’s high. For most people, most people are type two diabetic, so you’re talking about really longer-term issues where if it starts affecting you to the point where you’re feeling something like, you know, your vision going, your kidneys are being affected, your heart’s being affected, then it becomes irreversible, you know, you could treat the glucose, but you’re not reversing the damage that’s created. It’s a little different than, say, type one where you really, your body is going to react really poorly to just a very small period of non-treatment and you wind up in the hospital. That’s true.
Dr. Fox: Right. And, again, just to review, women with gestational diabetes don’t have any of this, right? There, it’s a much different, because they’re not at risk for birth defects because the sugar isn’t high early in pregnancy, the sugar is, like, never high enough to sort of harm the mother, and anyone who really does get that probably has real diabetes. And we’re really just, we’re worried about things like, you know, the baby’s size, and preeclampsia, and sort of in this grand scheme of things, less critical than the stuff with type one diabetes. And type one diabetes, type two diabetes, you know, they’re at risk for, you know, the baby not growing well and preterm birth and, you know, they can have birth defects and the mother’s health. It’s a really big difference from gestational diabetes, which is why even though we sort of, they’re all followed as diabetics in pregnancy, at least we as the doctors really categorize them between pregestational and gestational. It’s a huge difference between how we think about them, like you said earlier, how we test them, you know, what they’re at risk for. And so someone, you know, they come into pregnancy, what would you say would be the ideal strategy for someone who is a diabetic pre-pregnancy? Like what are the things she should really do before she gets pregnant, in addition to, as we said before, making sure her sugars are under control?
Dr. Lam-Rachlin: Assuming that she’s already had a recent hemoglobin A1C, and that is in the “normal range,” that’s a good reflection of how well her glucose control is. Then we really look to assess to see really if the diabetes has had any sort of effect on their end organs, right? So they’re, you know, they wanna have an up-to-date eye exam, an up-to-date EKG to evaluate their heart, some form of evaluation of their kidneys, whether it’s a urine test or a blood test. And then some patients with longstanding diabetes, they might have what we call neuropathies where they’re kind of losing sensation to their nerve endings, and they classically will present in, like, the extremities, behind the fingers or in the foot, so they wanna make sure that they have, you know, a recent, like, podiatry exam and stuff like that. Additionally, a lot of patients with diabetes also have other comorbidities like high blood pressure, probably one of the most common comorbidities. And you wanna make sure that their blood pressure’s well-controlled because, you know, ideally, with patients who have diabetes or high blood pressure, obviously they can get pregnant, but the better controlled they are going through the pregnancy, the better the pregnancy outcome, the more, like, normal pregnancy they’re going to be.
Dr. Fox: That all makes a lot of sense. You want their overall health to be as optimized as possible. Are there any women with diabetes who you would, if you saw her pre-pregnancy, you would recommend, A, not getting pregnant for the time being, or B, not getting pregnant ever? Does that ever come up?
Dr. Lam-Rachlin: Once in a while, yeah. Those are gonna be the rare cases, but the most common scenario where I would tell them not to get pregnant yet would be really, you know, that their glucose control isn’t great. You know, their A1C’s extraordinarily high, you’re looking at a very high chance of first trimester miscarriages and congenital birth defects. So those patients, I would recommend holding off on pregnancy, starting on medication, get them in a better range before they can start to conceive. Patients that we would recommend not getting pregnant, it’s rare that we would say that but, for instance, if someone’s had longstanding diabetes that is starting to really have an effect on their heart or they have, like, major cardiomyopathy from that or they have end-stage renal disease where they’re on dialysis, it’s not that they cannot get pregnant, but they have a very high risk to their own health and even, you know, high risk of potential mortality related to that. So those are probably the rarest of conditions, and I would say for the most part, I’ve never really told someone that they can’t get pregnant because of it, but those are the potential scenarios where they might really seriously think about whether they wanna pursue a pregnancy or not.
Dr. Fox: Yeah. I agree. And again, it’s not the diabetes, the high blood sugar, because, you know, we could always recommend someone delay pregnancy and really aggressively treat her sugar and get it under control over the course of weeks or months and find it’s more so if her general health has deteriorated so much because of the diabetes, like you said, now, now, in addition to diabetes, she has heart disease. Again, it’s from the diabetes, but once you fix the sugar, the heart disease remains or kidneys, and that’s [Inaudible 00:12:57] but those, fortunately, are pretty rare, particularly in the population of women who are gonna be getting pregnant, so in their 20s, and 30s, and maybe 40s. So, those types of things are more common in women in their 50s, and 60s, and 70s who have diabetes, not so much.
So I agree. It’s pretty unusual to tell someone because of diabetes, you can never get pregnant, which is good because, you know, when I see, you know, either patients of ours who aren’t pregnant who have diabetes, or maybe patients of ours, their children developed diabetes, and one of the things they always think about is are they gonna be able to have children? And the answer is, well, yeah. You know, as long as they’re on top of their diabetes and they’re meticulous, and which, again, most of them can be and are, then they should, yeah, as many children as they want and their pregnancies generally go very well if they walk into pregnancy in pretty good status with their other organs and their sugar. Again, there are some risks and we have to watch them closely, but basically, they’re gonna do okay. And we’re usually pretty optimistic that things should go well. Now, someone, let’s say they walk into pregnancy and you say, you know, “You haven’t been getting treated, but it’s time to start getting treated because your sugars are a little bit high,” and it’s early in pregnancy, how do you decide whether to give them insulin or pills? Because there are oral medications people take for diabetes. How do you make that decision?
Dr. Lam-Rachlin: I guess the easy answer is, my first recommendation is almost always insulin.
Dr. Fox: And why is that?
Dr. Lam-Rachlin: You know, the issue, for the most part, is insulin resistance or for someone who is type one, is they’re already usually on insulin. So mainly we’re talking about type two diabetics. Their main issue is insulin resistance, so it’s effective. You give more insulin, you’re gonna see the appropriate response. It’s also safe. It doesn’t cross the placenta. So from a fetal risk standpoint, it’s no risk, right? A minimal risk to the baby and it’s effective. For the pills, you know, generally, the two pills that people come in on are either glyburide or metformin. The main reason why I don’t usually start with the pills is there’s just an extraordinarily high failure rate, especially amongst patients that are pregestational or have a very early diagnosis in the first trimester. At least half, if not more of patients fail oral therapy, whether because it doesn’t work or more commonly, they just have a lot of GI upsets and side effects from the medication itself and then have to be switched to insulin anyway. And there are some support for some placental passage of these medications, even though as far as we know, there is an adverse fetal effect from it, meaning it doesn’t cause birth defects, but again, you know, if I have such an effective and safe alternative such as insulin, I would rather start someone on insulin and then the pills.
Dr. Fox: Yeah. I mean, insulin’s been around a really long time and, you know, the one downside to insulin, okay, is it has to be injected, which, you know, sort of freaks people out a little bit. The thing about insulin people don’t realize, the needle that people use for insulin is so fine, it’s so small. It actually, it hurts less than checking your blood on your fingerstick. It’s less painful than checking your blood glucose to give the insulin. So, it’s more of an issue generally of, like, inconvenience than it is of pain, but the nice thing is it’s so much more precise. I mean, you can change the dose of insulin by 5%, by 10%, you know, someone’s on 10 units, you can make it 10, you know, 11, or 12, a very small change to have very small or fine effects or not overdo it. Whereas the pill, it’s hard to do that. So, if it’s not working and you increase their dose, they may end up having very low blood sugar the next morning. You know, it could not work at all to do that. And so I think that from a medical perspective, if someone wants to have really good, tight, precise control, almost always it’s gonna happen with insulin and people just sort of have to, you know, accept that they’re gonna be doing injections in order to have that done. It’s a state of mind. People have to really get on board with that.
Dr. Lam-Rachlin: Yeah. It’s true. I would say of almost 100% of the patients that we start on insulin, no one’s very excited to start it, truthfully. But really after surgery, I usually have them follow up with me the day after, and almost a hundred percent of the time, they would say, “It’s really not as bad as I thought it would be. Like, I hardly even felt it. It’s a nonissue.” So it’s really kind of getting over the hump of doing that first injection and then the rest is pretty smooth sailing.
Dr. Fox: And it’s also, there’s so much, like, immediate positive reinforcement because there’s someone, you know, every day they wake up and their fingerstick, which is supposed to be under 95, let’s say it’s 105 every day. So it’s high. It’s not crazy. It’s high every morning. You know, like, they take insulin and the next morning they wake up and it’s 82. It’s just like, boom, they’re cured. And they do it every night. And okay, if they woke up and it was 62, we could lower the dose. And if they woke up, it was 92, we could keep it the same or decrease it a little bit, but it works so quickly. And there really aren’t side effects from it unless you overdose and your sugar gets too low. That’s the only side effect from insulin, is if your blood sugar gets too low, you took too much, which is not typical because we don’t really give people too much.
Dr. Lam-Rachlin: Right. And with the newer generations of long-acting insulin, you don’t really get those hypoglycemic episodes of really low blood sugar. Obviously, it depends on, you know, which insulin. There’s so many different types of insulin.
Dr. Fox: I mean, I would say other than our type one diabetics, the majority of type two diabetics are taking an injection just once or twice a day, total, right?
Dr. Lam-Rachlin: Mostly once a day, maybe twice a day. For the most part, just once a day.
Dr. Fox: Yeah. I mean, the people who have to take the insulin sort of with every meal based on what they’re eating or go on a pump or do these things, those are the type one diabetics who, they’re just sort of trying to replace what their body, what their pancreas would normally be doing, which is sort of adjust your insulin based on what you’re eating. But that’s really only the type one diabetics. And they’ve been doing this before pregnancy. So they’re used to this. They know this.
Dr. Lam-Rachlin: Yeah. They’re used to it. They carb-count and they know how much to give themselves per meal, stuff like that.
Dr. Fox: Right. Right. And it’s quite predictable. They say, “Okay. If I’m having this meal, I need this many unit of insulin. It’s gonna do this to my sugar.” And they’re on top of it. The type two, again, if it’s new to them, it’s not quite as intense and they don’t have to be as meticulous about, you know, “If I eat this, I have to do this.” It’s really more of a general coverage. And almost, you know, once, you know, a type two diabetic, sort of once she gets to the middle of pregnancy, they’re sort of not really different from a logistic standpoint than a gestational diabetic who needs insulin. They sort of behave the same, right?
Dr. Lam-Rachlin: Yeah. Correct. Treatment-wise, they’re very similar. I can have them [Inaudible 00:19:31]. Yeah.
Dr. Fox: And then, you know, we do follow diabetics closer because there are some risks to the baby aside from birth defects, you know, so there is an increased risk, ironically, of the babies being both too big and too small, which is an interesting feature, the too-big is because there’s too much blood sugar and the too-small is really a factor of either you’re over-treating them or that they have, like, a disease of their blood vessels from longstanding diabetes. So they’re an increased risk for both, ironically. And so we follow them with ultrasound for that.
Dr. Lam-Rachlin: Yeah. We follow them with generally, depending on, you know, how the growth has been, but usually at least once a month, check on how well the baby’s growing and making sure the baby’s in that normal range that we define. The not too big and not too small, we’re happy about that.
Dr. Fox: A unique thing we do for women who come into pregnancy with diabetes is we do an extra ultrasound, looking at the baby’s heart, called an echocardiogram.
Dr. Lam-Rachlin: And that’s usually done, you know, around the time of their 20-week anatomy scan, and it’s just an extra look at all the structures within the heart and making sure that there is no major or minor heart defect. Because the heart is such a complex organ, it’s so sensitive to external changes. As we said, you know, your blood sugar is high. It’s almost like a teratogen. It can make the baby more prone to birth defects and if we’re gonna find a birth defect, it could commonly be in the heart of the baby. So doing a fetal echo can assess for heart function and hopefully will not have all those major and minor heart defects.
Dr. Fox: Right. And then one of the things with women with diabetes and pregnancy which is hard to sort of talk about because it’s so devastating is there is an increased risk of stillbirth for these women to have babies who are born stillborn to sort of die during pregnancy. How do you sort of talk about that with women? Or what do you do about that from a strategy standpoint?
Dr. Lam-Rachlin: Hopefully we’re talking about it before that event occurs.
Dr. Fox: Right.
Dr. Lam-Rachlin: I usually tell patients during my consultation with them that we do have to talk about stillbirth because the general risk of stillbirth is higher than the general population among patients with diabetes, and especially in the pregestational diabetic population, it is correlated with how well-controlled your blood sugar is and for how long, right? So chronic hyperglycemia and chronic stress to the baby is one of those risk factors. So that’s one reason to aim to treat even if the baby is “normal size,” right? Like what happens a lot of times, patients will say, “Oh, my baby is normal size, but my blood sugar is high. Why do we need to treat?” And really, that’s really my ultimate goal, right, is to make sure that you have a healthy baby going home with you and that there is no adverse outcome such as a stillbirth. And then that’s really the main goal of treatment for me, and especially in the first trimester. Assuming the blood sugar is well-controlled, then, you know, at some point in the pregnancy, we do monitor for, you know, overall wellbeing of the baby to make sure the baby’s “happy,” right, like in the intrauterine environment. And we can do that by ultrasound and those are [Inaudible 00:22:33] scans and they’re called biophysical profiles. And generally, for someone with pregestational diabetes, well, we would start them around 32 weeks of pregnancy all the way until delivery.
Dr. Fox: Yeah. So that’s the last two months.
Dr. Lam-Rachlin: But I also give the patients some reassurance, right, that everything’s going okay.
Dr. Fox: Yeah. I mean, so in our practice, we do the ultrasound test, the biophysical profile. In some places, women undergo a test called the non-stress test, which is the same concept, we’re sort of testing the baby’s health and the health of the placenta. It’s done a different modality, but it’s the same idea, but, you know, women are coming once a week or twice a week for the last two months. It gets to be pretty intense because we take this risk very seriously. Now, obviously someone who has a much milder form of type two diabetes, you know, close to borderline, probably her risk is lower than someone who’s had type one diabetes for 10 years. But we don’t really differentiate that much because it’s hard to say for sure, like you’re safe and you’re not. So we follow everyone closely. If there are changes or concerns, sometimes we deliver early, but generally, if everything’s going well, how long would you sort of “let them stay pregnant”? Or when will you say, you know, time to induce the labor, time to, you know, have the baby born, even if everything’s going well?
Dr. Lam-Rachlin: If everything’s going well, I would say for the most part… I mean, we’re assuming these patients are on medication, but everything’s going well in the full-sized baby, then, you know, not a huge change to timing of delivery. We usually just say don’t go past your due date. So if someone hasn’t gone into labor by them, we might be scheduling an induction in and around the due date time period, which is not so bad.
Dr. Fox: Right. And the thought is that, you know, one of the other risk factors for stillbirth is as you go past your due date and beyond, the risk starts going up because the function of the placenta goes down. So the thought is, you know, why compound it? You’re already at increased risk. Why add another risk? So let’s just, you know, you got to 39, 40 weeks, time to deliver. Now, we don’t recommend a C-section because someone has diabetes unless potentially the baby’s very large and we’re worried about a birth injury, but diabetes itself is not a reason someone has to have a C-section. Correct?
Dr. Lam-Rachlin: Correct. Yeah. You know, and assuming that the baby’s normal size, there’s no other reason to do a C-section. Ideally, I would like, you know, all the patients to have a vaginal delivery, but also specifically for someone with diabetes, they’re more prone to infections and when you do a C-section, it’s a surgery and there’s always that chance of an infection. Even if you do everything under sterile conditions, it would make the most sense to hopefully have a vaginal delivery. Like the only time period from a diabetes standpoint to have a C-section would usually wind up being the baby’s very big and we don’t wanna run the risk of a birth injury to the baby by trying a vaginal delivery.
Dr. Fox: Right. Because babies who are large, the larger the baby, the higher the risk of a birth injury. And also specifically in diabetics, that risk seems to be worse because when babies are large, related diabetes, it tends to be more in sort of like their chest and their body, their trunk. It’s not so much their head or their legs, and so that’s the part that typically would get “stuck.” And so that’s, you know, it’s a higher risk, you know, if you have two babies who both weigh nine pounds, one of them, the mom is a diabetic and one of them, mom was not a diabetic, the 9-pound baby whose mom is a diabetic will have a higher risk of a birth injury than the 9-pound baby whose mom’s not a diabetic just because where the weight is placed are sort of thresholds for getting nervous about a vaginal delivery are different for them.
For women who are in labor and have pregestational diabetes, they’re being treated during pregnancy, there is, you know, we do have to consider, go back to that type one versus type two because they’re treated much differently in labor, right?
Dr. Lam-Rachlin: Yeah. We still monitor their blood sugar levels, whether you’re type one or type two, you’ll be monitored very closely in the course of labor. And some people who might, you know, type ones probably will generally need insulin coverage during labor. Type twos may or may not need it or they might just need it for just a short period of time during labor, not the entire labor. So, there’s a slight difference, but not a huge, I would say, not a huge difference between the two. There’s still [Inaudible 00:26:32] monitoring it.
Dr. Fox: A lot of us, it depends. I mean, a woman who has type two diabetes, what typically happens with her is, you know, in labor, if she’s not really eating or drinking a lot of sugary fluids, her sugars will, it’s easier for them to be normal. Whereas a type one diabetic, they tend to be a little higher. And the other thing is type one diabetics ultimately can’t be without insulin for too long of a time because then they get other issues. Then sometimes women even go on insulin drips in labor, which is sort of intravenous insulin instead of getting injected under the skin periodically, it’s just given into their IV, into their intravenous line because it’s just easier to change it. You could quickly go up or go down. Yeah. And what about women who have insulin pumps? Right? So they’re a type one diabetic, so they get their insulin delivered into their skin sort of continuously with a pump. What happens with them in pregnancy, and at delivery, and after delivery?
Dr. Lam-Rachlin: For patients and pumps, during their pregnancy, there’s going to be an increased need for their insulin usage. So there’s gonna be a increase in their rate for their pumps. But in labor, it’s a tricky one because I think if you poll different endocrinologists, poll different MFMs, they will do different things. They would either keep them on the pump and adjust it based off of what their fingersticks are and then they have this adjustment for labor or turn off the pump completely and then switch them to what we call an insulin drip protocol, where the insulin will go through the IV. The benefits of the drip is that it’s a quicker acting. So, you know, generally, we’re checking blood sugar levels of these on an hourly basis for someone who’s in active labor. And if it’s high, then you give a dose by the IV and you expect a response almost immediate. With the pumps, are giving the insulin subcutaneously like we traditionally do outside of labor. It depends on how quickly that insulin is absorbed in the fat, right? So the rate of response is not as predictable. And so when we check the fingerstick, like, an hour later, it might still be high, but it’s just, you know, it just hasn’t fully metabolized through the fat yet and if you increase the dosage, you might wind up with a hypoglycemic episode hours later. There’s nuances with the pump that I think people do it differently depending on, you know, how well they deal with the patient, how well they know their response, but you can either stay on the pump or turn it off completely and switch to the drip while in labor.
Dr. Fox: Right. There’s also some logistical issues because what happens frequently, again, the women who are on the pump, it’s not like just for pregnancy, they’ve been on it for a long time. And so these women tend to know their pumps, they know how to work it, they know what their doses are, and they’re very, they’re on top of it. But the problem is in labor, so you’re sort of putting that responsibility on the woman in labor to take care of her own blood sugar. And so not only is she dealing with, “I’m in labor,” “I do or I don’t have an epidural,” “I’m pushing,” “I’m this,” “I’m that.” You know, all these things are going on. “I got to be on top of my fingersticks.” And so that’s just a, sometimes not the best idea, but even if she wants to do it, there are times in labor where women, they get lightheaded, they get dizzy, they’re nauseous, they’re not with it, so to speak, at certain times. They could be groggy. And so we’re concerned that maybe she won’t be able to do it, or if there’s an emergency and no one knows how to use her pump, the nurse doesn’t know how to work it, the doctor doesn’t know how to work it. Everyone’s sort of like, “What do I do with this thing?” It could potentially be, like, complicated in that sense. So I think some people are squeamish about it for that reason. I think the endocrinologists, a lot of them are okay with it because they sort of are very adept at using the pumps and adjusting the pumps. Like, “Oh, I’ll just change it.” Whereas, you know, like, you know, I wouldn’t know how to work someone’s pump, I’d have to ask her. And so it’s one of these things that a lot of people are like, “Well, I know how to do it this way, so let’s just do it this way.” And so sometimes it’s even just logistical, not so much as medical. After delivery, so someone has pregestational diabetes, they deliver, they still have diabetes but they’re not pregnant, what happens to them at that point?
Dr. Lam-Rachlin: So, I mean, the moment the placenta is delivered, the insulin resistance dramatically drops off. So your medication requirement will drop by at least a third, if not 50% for the moment after delivery. So, for the most part, most patients, if they were coming into the pregnancy on insulin and we had to increase their dosage during the pregnancy, we’re going to reduce that insulin requirement by about a half. If someone came into the pregnancy on just oral hypoglycemic medication but we switched them to insulin because, in your previous talk about the benefits of that, then a lot of the times they just get switched back to their oral post-delivery.
Dr. Fox: Right. All right. That makes sense. I mean, most of them, either they go back to what they were on before or we just sort of reduce it and go from there, which is different from gestational diabetes where we usually tell them they could just stop and just, you know, don’t even check their fingersticks, you could stop everything and we’ll just recheck you in a month or two to make sure that it’s out of your system. So you have the pregestational diabetics still have diabetes when they deliver, gestational diabetics don’t, they’re sort of cured, so to speak. Excellent. Wow. Jen, this was great. What a great review of pregestational diabetes in pregnancy. And I know that, you know, for our listeners, Jen actually runs our own, our practice’s diabetic program for women who are pregnant either with pregestational diabetes or gestational diabetes, which is a daunting task. And Jen, thank God for Jen, because that is not easy to run both from an intellectual standpoint and just from a workload standpoint, so God bless you and thank you for doing that.
Dr. Lam-Rachlin: Happy to do it. It’s been definitely of interest to me since residency, really, and kind of stimulates my brain. Because not every patient’s the same. I think, as doctors, we like to see a problem, fix it, and see it work, and that, like, diabetes is one of those things that you see a problem, you fix it, and you actually see something work effectively, right? During this very, like, short time period that you’d have a patient. So it’s very rewarding for me. I like it a lot.
Dr. Fox: Yeah. I totally agree. I think one of the most satisfying things about diabetes in pregnancies, and it’s something you could talk with patients, it’s really something that they can take control over, right? So many things that happen in pregnancy and in life, you just have to sort of, you know, accept it and try to move through it and, you know, deal with it and all that. But for diabetes, it’s one of those things where you say, “Listen, if you can get your sugars under control, and we have medicines and it’s a lot of work and it takes a lot of effort and it’s hard, but if you can achieve it, you’re gonna have better outcomes and it’s doable.” Right? So whether it’s pre-pregnancy, “Let’s get your A1C down, let’s really do this,” or during pregnancy, “Let’s be really meticulous about your food, your finger tracking, you know, your medications,” it’s gonna help. I mean, you can’t take away every risk of diabetes, but you could take away a lot of the really major ones, and that’s so rewarding because it’s unusual in medicine that we can do that. And it’s, you know, both as doctors and as patients, I always tell people it’s very annoying, but it is something that can be accomplished, which is hard, but it’s doable. Well, Jen, thank you again, and I’m sure we’re gonna have you on another time, but until then, I’ll see you soon.
Dr. Lam-Rachlin: Okay. Take care.
Dr. Fox: Thank you for listening to the “Healthful Woman Podcast.” To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at email@example.com. Have a great day.
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