I want to skip the GTT this pregnancy...

medussamedussa Posts: 12,993Registered Users
Is that a really stupid decision?

I'm just not in the mood to sit in that nasty lab for 1 hour with Lilly. I hate going there for just routine bloodwork.

I see the midwife tomorrow and this is the point in the pregnancy when I'm given a script for the test.

Can I opt out of this one?

Comments

  • RedCatWavesRedCatWaves Posts: 31,259Registered Users Curl Connoisseur
    Here's a famous article by a world-renowned birth author and midwife, Henci Goer, on gestational diabetes. The first link below the article is to the the article quoted here complete with bibliography. The second link is to an article Henci wrote to update her original article: (Broken into 3 posts due to size)
    Article by Henci Goer on the Uselessness of Standard Management of Gestational Diabetes

    Gestational Diabetes: The Emperor Has No Clothes
    by Henci Goer

    Good medicine demands that diagnosis and treatment of any disease fulfill four criteria:
    • The condition has to pose a health risk;
    • Diagnosis must accurately distinguish between those who have the disease and those who don't;
    • Treatment should be effective; and
    • The benefits of diagnosis and treatment should outweigh the risks.
    An entire medical industry has grown up around diagnosing and treating gestational diabetes (GD) in the belief that doing so prevents perinatal deaths, congenital anomalies, neonatal complications, macrosomic babies, and because of fetal macrosomia, birth injuries and excessive cesarean rates. However, diagnosis and treatment of gestational diabetes don't fulfill any of the above criteria.

    To begin with, GD doesn't fit the definition of a disease. GD as a concept began in 1964 when O'Sullivan and Mahan performed a 100g 3- hour oral glucose tolerance test (OGTT) on 752 pregnant women and tracked all women with at least two values above two standard deviations beyond the mean to see if hyperglycemic women were predisposed to develop diabetes down the road (O'Sullivan 1964). They were, leading the two researchers to conclude that the metabolic stress of pregnancy revealed a woman's "pre-diabetic status." This should not surprise anyone since overweight women are more likely to have hyperglycemia in pregnancy and to develop diabetes later in life.
    Since insulin-dependent diabetes was known to threaten the fetus, researchers extrapolated that sub-diabetic glucose elevations might also do harm. This leap in logic was faulty on its face because GD does not share the risk factors of either type of true diabetes. In Type I diabetes, extremes of low and high blood glucose early in pregnancy can cause congenital anomalies or kill the forming embryo. Gestationally diabetic women make normal or above-normal amounts of insulin and have normal blood sugar metabolism in the first trimester. With either Types I or II, diabetes of long standing may damage maternal blood vessels and kidneys, causing hypertension or kidney complications. These may in turn jeopardize the fetus. Gestational diabetics do not have long- standing diabetes. The one problem GD shares with both types is that chronic hyperglycemia can overfeed the fetus, resulting in macrosomia (generally defined as birth weight greater than 4000 g) or large-for- gestational-age (LGA) (greater than the 90th percentile) babies.
    Logic notwithstanding, these concerns launched a series of studies into the risks of mild glucose elevations. Unfortunately, they were badly flawed.
    • Studies selected women for glucose testing based on such factors as prior still birth or hypertension in the current pregnancy and then compared outcomes with the general population. Hunter and Keirse observe that according to Sutherland and Stowers' 1975 edition of CARBOHYDRATE METABOLISM IN PREGNANCY AND THE NEWBORN, the rate of fetal loss increases eightfold as the number of indications for glucose tolerance testing increasing from one to four. Glucose intolerance does not add to this risk (Hunter and Keirse 1989).
    • Studies included women who were known diabetics prior to pregnancy.
    • Studies failed to account for confounding factors such as that glucose intolerance associates with increasing maternal weight and age, which themselves are strong independent predictors of macrosomia and maternal hypertension.
    • Studies used management protocols that increased risks such as starvation diets, early elective induction, and withholding nourishment from the newborn.
    In addition, glucose level turned out to be a poor predictor of macrosomia. Other factors such as race, age, parity, sex, and especially maternal weight, far outweighed glucose intolerance in determining birth weight. Hunter and Keirse observed that GD mothers had a 3-fold risk of giving birth to a baby weighing over 4500 g compared with normoglycemic women. However, a woman weighing over 90 kg had a 26-fold risk of having a baby this heavy compared with normal weight women (Hunter and Keirse 1989). Oats and colleagues could not find a significant association between glucose levels and birth weight until birth weight exceeded the 90th percentile. Even then, 77 percent of women had normal glucose tolerance (Oats et al. 1980).

    Nonetheless, researchers concluded that mildly deviant glucose values in pregnancy constituted a new form of diabetes that required diagnosis, surveillance, and treatment. Researchers have gone on adding rooms and stories to the GD edifice, never noticing that they have built a house on sand.
    Secondly, the OGTT, the standard diagnostic test, has many problems. A diagnostic test should be reproducible, its thresholds should be values at which morbidity either first appears or incidence greatly increases, and normal ranges should apply to the population undergoing testing. The OGTT is none of the above.
  • RedCatWavesRedCatWaves Posts: 31,259Registered Users Curl Connoisseur
    Part 2
    Obstetricians adopted O'Sullivan and Mahan's curve as the normative curve for all pregnant women, but it is not representative. For one thing, O'Sullivan and Mahan tested women without regard to length of gestation, whereas today, women are typically tested at the beginning of the third trimester. Glucose values rise linearly throughout pregnancy, but no corrections have been made for this. For another thing, O'Sullivan and Mahan studied a population that was 60 percent white and 40 percent black. Hispanics, Native Americans, and Asian women average higher blood sugars than black or white women. Since diagnostic thresholds are set at two standard deviations beyond the mean, values for O'Sullivan and Mahan's population have arbitrarily been established as the norms for all women. This means that some women are being identified as diseased simply because of race.
    Worse yet, studies show that when pregnant women undergo two OGTTs a week or so apart, test results disagree 22 percent to 24 percent of the time (Catalano et al. 1993) (Harlass et al. 1991). An individual's blood sugar values after ingesting glucose (or food) vary widely depending on many factors. For this reason, the OGTT has been abandoned as a diagnostic test for true diabetes in favor of excessive fasting glucose values, which show much greater consistency, or postprandial values of 200 mg.dl or more, which are rare. Moreover, pregnancy compounds problems with reproducibility. Because glucose levels rise linearly throughout pregnancy, a woman could "pass" a test in gestational week 24 and "fail" it in week 28. These same problems hold true for the glucose screening test that precedes the OGTT (Sacks et al. 1989) (Watson 1989).
    More importantly, no threshold has ever been demonstrated for onset or marked increase in fetal complications below levels diagnostic of true diabetes. O'Sullivan and Mahan chose their cutoffs for convenience in follow-up, but all studies since then have used their criteria or some modification thereof as a threshold for pathology in the current pregnancy. Numerous studies since have documented that birth weights and other outcomes fail to correlate with O'Sullivan's or anybody else's thresholds.
    A test with arbitrary diagnostic thresholds is akin to claiming that all people over six feet tall have a growth abnormality or all people with a cough and a fever have pneumonia. The authors of A GUIDE TO EFFECTIVE CARE IN PREGNANCY AND CHILDBIRTH relegate "screening for gestational diabetes" to "Forms of Care Unlikely to be Beneficial" (Enkin 1995).
    The original intent of treating GD was preventing excess perinatal mortality and congenital anomalies. Whatever the cause of increased deaths, it wasn't hyperglycemia. O'Sullivan and colleagues randomly assigned gestational diabetics to treatment with diet and insulin and compared outcomes among treated diabetics, untreated diabetics, and a normoglycemic control population. They found more perinatal deaths in the GD population, treated or not (O'Sullivan et al. 1966). Perinatal mortality statistics among non-insulin dependent diabetics remained unchanged between 1946 and 1972 in a Copenhagen study despite aggressive treatment throughout the timespan (Pedersen, JL et al. 1974) (Pedersen J 1977). Conversely, a Swedish study showed a marked reduction in perinatal mortality rates between 1961 and 1971, also while treating vigorously (Karlsson et al. 1972).
    As for congenital anomalies, GD cannot cause congenital anomalies because glucose metabolism is normal in the first trimester. Even if it did, testing isn't done until the third trimester.
    The main rationale for current GD management is to reduce the incidence of birth injuries and cesarean section by reducing the incidence of macrosomia. The goal of reducing birth weight raises philosophical problems. As with glucose values, doctors are defining deviation beyond an arbitrary point as inherently pathological. Moreover, can we justify manipulating the growth mechanism of a group of babies roughly 75 percent to 80 percent of whom will fall below the 90th percentile for weight if left alone?
    Philosophical considerations aside, we have little evidence that GD management succeeds. As mentioned above, macrosomia associates with maternal weight, age, race, parity, and male fetus. Maternal overweight cannot be rectified during pregnancy; the rest cannot be altered at all. According to M.J. Stephenson, there have been only four randomized trials of diet or diet and insulin. All were flawed and taken together achieved a reduction in birth weight of 87 g, a benefit "of questionable clinical significance" (Stephenson 1993). A GUIDE TO EFFECTIVE CARE IN PREGNANCY AND CHILDBIRTH also lists insulin and diet therapy for GD under "Forms of Care Unlikely to be Beneficial."
    Santini and Ales report results from a national trial that occurred in the early 1980's when some doctors at Cornell University Medical Center screened women for GD routinely and others did not. No differences in perinatal mortality, morbidity, LGA or macrosomia rates were found between screened and unscreened populations, but women in the screened population were more likely to have primary cesarean sections (19 percent versus 12 percent), more clinic visits, more fetal surveillance tests, and more prenatal hospitalization (Santini et al. 1990).
    Non-randomized trials show that diet modification rarely works without severely limiting calories or the liberal or universal use of insulin. Even where it does work, only two studies of GD management reduced operative delivery or cesarean rates to reasonable levels, the main point of preventing macrosomia (Langer et al. 1994) (Coustan et al. 1984). In both studies, doctors knew which women were treated and which were controls. If they believed their therapy prevented macrosomia, which other work shows they did, this belief could well have influenced management decisions. A third study also reported similar cesarean rates in GD women and the total hospital population, but these were 27 percent and 25 percent respectively (Thompson et al. 1994).
    As Santini and Ales' study suggests, not only does GD management offer little benefit, it confers risks, the gravest being a marked increase in cesarean section. The cesarean rate in a population of gestational diabetics cared for by midwives was 9 percent to 11 percent including women transferred to obstetric management, or about half the primary cesarean rate reported in populations managed by obstetricians in the same or an earlier time period (O'Brien et al. 1987). Goldman and colleagues reported that gestational diabetics had one-third more cesareans compared with a matched population with normal glucose tolerance, although birth weights were similar (Goldman et al. 1991). In another study, gestational diabetics were randomly assigned to insulin or standard treatment in the third trimester in an effort to minimize macrosomia. Insulin reduced LGA rates to 13 percent compared with LGA rates of 45 percent in the diet group and 38 percent in the group that refused randomization. Despite this, cesarean rates were 14 percent and 21 percent in the diet-treated groups versus 43 percent in the insulin-treated group, a difference attributed to transferring women on insulin to the high-risk service (Buchanan 1994).
    Many doctors view high cesarean rates as a reasonable trade-off for preventing shoulder dystocia. This ignores that many shoulder dystocias occur in non-macrosomic infants (Keller 1991) and that the increase in cesarean rate for infants weighing over 4000 g has not improved outcomes (Boyd et al. 1983); not to mention the role typical obstetric management plays in causing shoulder dystocia.
    Increased likelihood of cesarean is not the only risk of GD management. Insulin increases the risk of small-for-gestational-age babies and causes symptomatic hypoglycemic episodes (Langer et al. 1994) (Buchanan et al. 1994). Reducing calories by more than one-third in overweight gestational diabetics causes ketosis (Knopp et al. 1991). Finally, the poor predictability of the fetal weight estimates and surveillance tests doctors feel obliged to order, even the belief that GD is a high-risk condition, undoubtedly lead to countless unnecessary inductions and operative deliveries.
    Few have noticed that the diagnosis and treatment of GD is a spectacular failure. A review article analyzes the OGTT, finds it worthless, and recommends continuing to use it to diagnose GD (Nelson 1988). After showing that current cutoffs fail to discriminate a group of women at high risk for macrosomia, obstetricians conclude in defiance of logic that they should lower the values or that insulin should be given to more women or that cutoffs should be chosen by fiat (Sacks et al. 1995) (Neiger et al. 1991) (Weiner 1988) (Tallarigo et al. 1986). Researchers take note that sonography to estimate fetal weight did no better than a coin toss at predicting macrosomia and recommended it anyway (Combs et al. 1993). Doctors find that rigid glycemic control did not improve infant outcomes and assume that means they should try harder (Hod et al. 1980). Goldman and colleagues, with similar birth weights but one-third more cesareans in the GD group, congratulated themselves on the success of their management (Goldman et al. 1991).
  • RedCatWavesRedCatWaves Posts: 31,259Registered Users Curl Connoisseur
    Part 3
    The gestational diabetes literature reads more like ALICE IN WONDERLAND than science. Still, midwives can winnow some grain from the chaff. Maternal weight has the strongest correlation with macrosomia rate; it makes sense to advise heavily overweight women to lose weight before becoming pregnant. Pregnancy makes extra demands on insulin production; to minimize the pressure, pregnant women should eat a diet low in simple sugars, high in complex carbohydrates and fiber, and moderate in fat. Moderate, regular exercise also improves glucose tolerance. Within the GD population lurk a few women who were either undiagnosed pregestational diabetics or who were tipped into true diabetes by the metabolic stress of pregnancy; a fasting glucose to screen for them might be prudent. And, of course, midwives already use strategies that help women minimize the likelihood of operative delivery or birth injury. Finally, to reduce the chance of neonatal hypoglycemia, the baby should be put to breast soon after the birth, especially if the baby is big, small, or the labor has been difficult.

    http://gentlebirth.org/archives/gdhgoer.html

    http://parenting.ivillage.com/pregnancy/pcomplications/0,,9z3m,00.html
  • deezee02deezee02 Posts: 1,509Registered Users
    GTT=Glucous test right???

    Personally, I would not skip it. Last time I had to sit in the office, I scheduled my monthly appointment around the test...so I went, drank the drink, went up for my appointment and then came back down for the bloodwork. This time, my midwife gave me the drink with instructions...I drank it 45 mins before arriving at the testing place, this made it super easy to do.
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  • NalliaNallia Posts: 2,979Registered Users
    You have the right to decline any testing you don't want. Than said, I didn't have GD with my first pregnancy and had it with my second. I didn't even have the 1 hour or 3 hour test done with my second pregnancy. I started spilling glucose into my urine at 22 weeks so my endocrinologist had me monitor my blood sugar with a meter and checked it herself (I have an endo because I have a thyroid disorder). At 24 weeks my postprandial numbers were over 200, sometimes as high as 300. Diet couldn't control it for me while pregnant--any carbs at all sent my blood sugar too high and ketosis is not healthy during pregnancy. So I was put on insulin by my endo (my OB did not manage my GD) along with a strict diet.

    My GD was so severe that I was afraid it wasn't gestational and wouldn't go away after my daughhter was born. But it was, and it did, thankfully. I now have to get annual glucose tolerance tests because I am at high risk of developing type 2 diabetes.

    I know my experience is not the norm but I was always considered low risk. I was not overweight and had none of the other risk factors.
    "...just because you're paranoid doesn't mean that there isn't an invisible demon about to eat your face." ~Harry Dresden

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  • webjockeywebjockey Posts: 2,786Registered Users
    Is it the special cocktail they make you that you oppose to? If so, there are other options. I didn't drink anything weird - just a certain type of breakfast ( I forget what the balance was of carbs, sugars, fats etc.)
    hello.world.
  • medussamedussa Posts: 12,993Registered Users
    webjockey wrote: »
    Is it the special cocktail they make you that you oppose to? If so, there are other options. I didn't drink anything weird - just a certain type of breakfast ( I forget what the balance was of carbs, sugars, fats etc.)

    Oh no, that orange drink is delicious. My issue is the lab I am forced to go to for the test. My insurance company has a contract with LabCorp and they're awful. The staff is slow, unfriendly and unprofessional. Plus there's a certain "element" that uses that lab, that I'm not very fond of. I guess my options are to wait in the car and put on a movie for Lilly or go on a Saturday, when I can leave Lilly home with my husband.

    Thanks for the links, RCW. I tend to agree with the writers. I don't think I'm at risk for GD. This is my 4th baby and I think my chances are pretty low. I know anyone can develop it, but I'm somewhat willing to take my chances.

    I'll talk to the midwife today.
  • geekygeeky Posts: 4,995Registered Users
    Talk to the midwife about your options. She may be open to some alternatives.
    To Trenell, MizKerri and geeky:
    I pray none of you ever has to live in a communist state.

    Geeky is my hero. She's the true badass. The badass who doesn't even need to be a badass. There aren't enough O's in cool to describe her.
  • rainshowerrainshower Posts: 4,420Registered Users
    my girlfriend had GD with both pregnancies. She's not overweight and didn't have any symptoms, complications, or abnormal indications that made her think anything was wrong. and her numbers were high! they were prepared for it the second time, but the test still confirmed it.
    "Dogs stink too, but I like dog stink." ~ rileyb
  • goldygoldy Posts: 5,463Registered Users Curl Connoisseur
    I'm thinking about doing some alternative testing, like Webbie said.

    I'm lucky that my midwives office draws all the labs there and then sends out to whichever lab your insurance is contracted with.

    I plan to talk to midwife about this on Thursday (if I remember to bring it up this time ;) )

    Let us know what you and your midwife decide to do.
    Poodlehead wrote:
    Ah, it all makes sense now. Goldy is the puppet master! :lol:
  • webjockeywebjockey Posts: 2,786Registered Users
    goldy wrote: »
    I'm thinking about doing some alternative testing, like Webbie said.

    I'm lucky that my midwives office draws all the labs there and then sends out to whichever lab your insurance is contracted with.

    I plan to talk to midwife about this on Thursday (if I remember to bring it up this time ;) )

    Let us know what you and your midwife decide to do.


    That's what my midwife did as well. Although I think she tries to work with specific labs in town that are midwife-friendly.

    Even with the crappy service, Unless you think that they botch the job, I'd go ahead and do it - a few hours of discomfort can save you headaches later.
    hello.world.
  • medussamedussa Posts: 12,993Registered Users
    webjockey wrote: »
    goldy wrote: »
    I'm thinking about doing some alternative testing, like Webbie said.

    I'm lucky that my midwives office draws all the labs there and then sends out to whichever lab your insurance is contracted with.

    I plan to talk to midwife about this on Thursday (if I remember to bring it up this time ;) )

    Let us know what you and your midwife decide to do.


    That's what my midwife did as well. Although I think she tries to work with specific labs in town that are midwife-friendly.

    Even with the crappy service, Unless you think that they botch the job, I'd go ahead and do it - a few hours of discomfort can save you headaches later.

    I'm not sure why this practice cannot perform in-office blood draws and send them out. They used to at one time.

    Anyway, I got the same blah, blah, the baby could be too big, blah, blah, your baby could be stillborn, blah, blah, that I expected. No surprises there.

    I'm going for the test tomorrow and bringing a dvd and snacks to keep Lilly busy for 60 minutes. I completely forgot to get the HIV test done 10 weeks ago, so this visit will take care of both tests. After that, I never have to go back to that place again.

    Thanks for the advice.
  • WileE-DeadWileE-Dead Banned Posts: 24,963Banned Users Curl Neophyte
    medussa wrote: »
    webjockey wrote: »
    goldy wrote: »
    I'm thinking about doing some alternative testing, like Webbie said.

    I'm lucky that my midwives office draws all the labs there and then sends out to whichever lab your insurance is contracted with.

    I plan to talk to midwife about this on Thursday (if I remember to bring it up this time ;) )

    Let us know what you and your midwife decide to do.


    That's what my midwife did as well. Although I think she tries to work with specific labs in town that are midwife-friendly.

    Even with the crappy service, Unless you think that they botch the job, I'd go ahead and do it - a few hours of discomfort can save you headaches later.

    I'm not sure why this practice cannot perform in-office blood draws and send them out. They used to at one time.

    Anyway, I got the same blah, blah, the baby could be too big, blah, blah, your baby could be stillborn, blah, blah, that I expected. No surprises there.

    I'm going for the test tomorrow and bringing a dvd and snacks to keep Lilly busy for 60 minutes. I completely forgot to get the HIV test done 10 weeks ago, so this visit will take care of both tests. After that, I never have to go back to that place again.

    Thanks for the advice.
    :clown:
    you hope...
    
    Yep, I'd do it...may be have someone watch L~ for you :dontknow:
  • iris427iris427 Posts: 6,002Registered Users
    Wait, you actually like how that Glucola tastes??
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  • deezee02deezee02 Posts: 1,509Registered Users
    I think the orange is pretty good too :)
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    Come swag with me!
  • medussamedussa Posts: 12,993Registered Users
    iris427 wrote: »
    Wait, you actually like how that Glucola tastes??

    It's delicious! But I've always liked orange flavored drinks like Sunkist and Fanta. I don't drink them anymore, so this is a treat for me. :lol:

    The waiting wasn't too bad. We hung out in the car. Of course, the dvd drive stopped working. So Lilly sat in her carseat and ate animal crackers while I tried to fix the stupid thing for 45 minutes.
  • cymprenicympreni Posts: 9,609Registered Users Curl Neophyte
    .
  • medussamedussa Posts: 12,993Registered Users
    I'm really glad I didn't have to fast for this test. Some providers require it for the 1 hour, others don't. Makes no sense to me.

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