Medication for gestational diabetes... "But I wanted to stay diet controlled"
The words, "but I wanted..." or "was hoping to stay diet controlled" come up in our Facebook support group very often and my answer is always the same; "of course you did. Not one member in the group WANTS to be taking medication for gestational diabetes or injecting insulin. But there is only so much you can do with diet and exercise alone."
Many women feel like a failure when they need to start medication or insulin to help lower and stabilise blood sugar levels. If you're a failure then so am I and so are all of us that ended up on medication or insulin! So stop saying you're a failure - how exactly have you failed???
Just because you need to start medication to help control your blood sugar levels does not mean you've failed! If that's the case, I failed at 13 weeks in my last pregnancy, in fact my whole Facebook admin team are failures! Please remember that many ladies who are diagnosed may need to go straight onto medication and/or insulin and are not even given a chance to try diet control. Does that make them failures from the word go? NO. Many mothers diagnosed with gestational diabetes will need help with medication to achieve lower levels.
Diet controlled gestational diabetics are not trying harder, or doing better because they have managed to control the condition by making changes to diet and exercise alone. They simply do not have insulin resistance 'as bad'. Going on metformin or insulin does not mean that you can eat whatever you like. It means you should be able to eat the same diet as a diet controlled mother.
QUESTION. Would you feel you failed if you needed to take medication for other illnesses and ailments? e.g. antibiotics for an infection that you can't get rid of on your own? Have you failed if you need to take iron tablets because you need more iron or tablets for high blood pressure? Why is gestational diabetes any different?
Gestational diabetes is not a cold, or a headache where you can try to just get on with it, not take the paracetamol and struggle through it. If you need help to lower the blood sugar levels, then unfortunately you need that help - it is for the safety of your growing baby. That doesn't make you a terrible mother or a failure.
To learn more about medications used to help lower and stabilise blood sugar levels, you can see further info on our Metformin for gestational diabetes page and our Insulin for gestational diabetes page.
Identifying the root cause of not wanting medication for gestational diabetes
From seeing the many posts in our support group around starting medication for gestational diabetes, it is usually very obvious that there are underlying reasons for these battles and concerns.
In order to understand and deal with those issues it's important to identify what the root cause is so that the true issues can be discussed and hopefully resolved, or at least discussed and concerns eased, making mothers be able to make better informed decisions.
The most common root causes for not wanting to start medication for gestational diabetes are the following:-
- Starting medication means that they will be advised to have an induction
- Concern over starting Metformin as they have heard that the gastric side effects are terrible
- Concern over starting Metformin as they have heard that it is not licensed for use in pregnant women
- Concern over having to inject insulin using needles
- Concern over having hypos if starting insulin
- They just have 'big babies' and don't really believe the high blood sugar levels will have a negative impact on the baby or the birth
- Blood sugar levels aren't over the recommended targets
- Disbelief in diagnosis or have been told they are borderline
*This is obviously not an exhaustive list as there could be many varying factors in the reasons why each individual has concerns over starting medication for gestational diabetes, but these are the most common reasons we have seen in our support group
1. Medication means induction of labour?
Without a shadow of doubt, the number 1 reason we see ladies say they are reluctant to start medication is because they have been advised or have heard that they will not be able to have a spontaneous birth if they are taking medication for gestational diabetes and it will mean a consultant led birth, being induced at an earlier gestation.
FACT or FICTION?
Well the truth is that we see many ladies being advised to have inductions if they are on medication for gestational diabetes, BUT we also see lots of ladies left to go into spontaneous labour too.
As it stands here are the recommendations in the 3 biggest health care guidelines used across the UK and ROI:
The NICE guidelines recommend:
Advise women with uncomplicated gestational diabetes to give birth no later than 40+6 weeks.
1.4.4 Advise women with gestational diabetes to give birth no later than 40+6 weeks, and offer elective birth (by induction of labour, or by caesarean section if indicated) to women who have not given birth by this time. [new 2015]
1.4.5 Consider elective birth before 40+6 weeks for women with gestational diabetes if there are maternal or fetal complications. [new 2015]
The SIGN (Scottish) guidelines recommend:
- Women with diabetes requiring insulin or oral glucose-lowering medication who have pregnancies which are otherwise progressing normally should be assessed at 38 weeks gestation with delivery shortly after, and certainly by 40 weeks.
- Women with diabetes should be delivered in consultant-led maternity units under the combined care of a physician with an interest in diabetes, obstetrician, and neonatologist.
The HSE (Irish) guidelines recommend:
5.4.4 Timing and mode of delivery
- In the setting of excellent glycaemic control, adherence to treatment and absence of maternal and fetal compromise, women with diabetes may await spontaneous labour up to 39-40 weeks gestation.
It is important to remember that these are purely recommendations and hospitals do not 'have to' follow them. Many hospitals will have their own policies and expertise which they follow. Also, every patient is different and so advice and opinion can be very different from one mother to another. We are all individuals and can having varying contributing factors.
The bigger question is usually, "if the medication helps lower and stabilise my blood sugar levels, along with good diet and exercise, surely my baby is not at any further risk than someone who is only diet controlled, therefore why would I need to be induced?"
Obviously each and every patient is different, but the reasoning for this comes from the fact that if you need medication for gestational diabetes then you have higher levels of insulin resistance, your gestational diabetes is more severe than that of someone controlling by diet alone. Therefore you could be at higher risk of related complications which could mean that it is safer for your baby to be delivered earlier.
Make an informed decision around induction
At the end of the day, it is up to each mother to make a decision over their birth. No one can be forced into having an induction, but if it is advised then it is best to find out the reasons for it being advised in your situation, not just because it is the 'hospital policy'.
There are many different methods of induction and there are many ways to plan a very calm and relaxed induction with the use of lighting, music, a birthing pool and breathing techniques.
Dealing with the real issue, the concern of induction
If the concern of starting medication for gestational diabetes is the fact that you have been told you will need an induction if you cannot control by diet alone, then speak to your diabetes team and explain that to them.
Controlling the high blood sugar levels is extremely important and failure to do so could result in some devastating outcomes. To read the complications which gestational diabetes can cause, please read this page. Discussion is key to finding a solution that you are happy with. The Supervisor of Midwives can be a very good person to discuss things with if you are struggling to get your consultant or team to understand your concerns.
Don't let induction and your birth become the barrier to not looking after your baby's health the best way possible.
2. Metformin will make me poorly?
FACT or FICTION?
Just like with any medication, not all people suffer side effects with Metformin. You won't know until you try.
Metformin can very often cause gastric side effects such as nausea, loose stools (diarrhoea) cramps or stomach upset. Sometimes people can get these side effects when starting the medication, but after a few days they should stop. It is also common to experience side effects when a dose is increased.
There are tips to help ease side effects, such as starting on a low dose and slowly increasing and taking the dose in the middle of the meal. If side effects still remain then there is a prolonged release Metformin which many people find better. Metformin is also available in liquid form if there are concerns over swallowing tablets.
Those that have or are experiencing sickness with hyperemesis, or conditions such as IBS, or Crohn’s disease, you may want to ask to use insulin instead of Metformin.
3. Metformin is not licensed for use in pregnancy?
FACT or FICTION?
It's a fact! Metformin is not licensed for use in pregnancy in the UK. This is because no drugs are licensed for use during pregnancy.
It is however safe for use in pregnancy according to many medical research trials. The biggest research trial to date on the use of Metformin for gestational diabetes, was the MiG trial and the follow up MiG TOFU trial.
To read more about Metformin, how it works, FAQs and for links to these research publications, you can read more here.
4. Fear of needles!
A big fear for many is having to take insulin as they have a fear of needles.
In the UK & ROI we are fortunate that insulin is no longer in a bottle which needs to be drawn up with a hypodermic needle and syringe.
All insulin used here is in the form of flexpens or pre-loaded devices where you dial up the dosage and a small needle is screwed onto the end.
The screw on insulin needles are very small and have protective caps over them which are removed just before use. They come in a range of sizes from 4 to 8mm long. They really are very small and the pens style devices make injecting and administering the insulin very simple.
Many ladies will still be worried, anxious, upset, possibly distraught at needing to inject insulin.
The key with this is support, understanding and encouragement. Partners, family and friends can all help with this. That tiny needle may seem like nothing to them but until you have to inject yourself, even more so if you have a fear of needles, it is very hard to understand what it is like to cope with.
Some ladies find it easier to let their partners or family members inject for them, but for the majority it is something that they are able to work on and overcome.
We will help you...
The Gestational Diabetes UK Mums Facebook group will always offer as much support and encouragement as possible when it comes to ladies taking their first injections. Just post a thread and lots of ladies will support anyone needing a hand to hold.
Injecting is not painful and hurts much less than the finger prick testing. The first is always the worst, but once you've overcome that hurdle they get easier each time.
We also have a visual guide and links to videos showing how to inject insulin and FAQs on this page.
5. Fear of having hypos
When starting on insulin, you are started on very small doses (usually 2 - 4 units) and then usually increase in small amounts until you reach doses which lower your blood sugar levels effectively.
Not everyone taking insulin will experience a hypo and many will test and get hypo levels, yet will not experience any of the hypo symptoms which are cause of concern.
True life threatening hypos are extremely rare with gestational diabetes and you cannot have true hypos taking metformin. Metformin works by making your body use it's own insulin more effectively and so it cannot lower your blood sugar levels below what is safe. Hypos type symptoms during the use of metformin are known as false hypos. To learn more about false hypos, please read more here.
Our advice is to be aware of what to do in the event of a hypo and have a hypo kit ready to hand in many places so that you are prepared if you do need to treat one. To read about hypos and how to treat them, then please take a look at this page.
6. "I just have big babies"
If you have been diagnosed as having gestational diabetes then uncontrolled blood sugar levels will lead to the excess sugar being passed through to the baby. This can cause excessive growth but along with excessive growth it can also cause many other complications. To see the complications linked to gestational diabetes, please take a look here.
We have seen many ladies say that they have had previous big babies, yet on the baby where they have been diagnosed, monitored and controlled blood sugar levels they have gone on to have much smaller babies in comparison. Obviously depending on genetics of the parents, some ladies may just have bigger babies, but where diagnosed babies have been much smaller, have they had previously undiagnosed gestational diabetes in previous pregnancies?
7. Blood sugar levels are under the recommended targets
Capillary blood glucose tests are only a guide as to what is going on and they are not 100% accurate. There may be other reasons that you are advised to start medication, one of which being excessive fetal growth on growth scans.
If you are unsure why medication is required when your levels are showing below the recommended targets then you should discuss this with your consultant and diabetes team.
8. "But I don't have it that bad"
Many ladies will be diagnosed as borderline gestational diabetics. Some may be told by their diabetes team that as they are borderline that they will be able to control their blood sugar levels by diet alone and so it can come as a bit of a shock when they then may struggle to control the condition and are advised to start medication for gestational diabetes. Unfortunately this is not uncommon and we have found that the result of the GTT does not necessarily pave the way forward for the rest of the pregnancy.
To read some experiences of those that have been diagnosed as borderline, please take a look at this page.
Gestational diabetes, a progressive condition
Gestational diabetes is progressive which means it worsens as the pregnancy goes on. Typically the hardest time we see ladies struggle with is between 32 - 36 weeks (although it should be understood that not everyone will see an increase in insulin resistance at this time). It is therefore very common for ladies to require a little bit of help with medication for gestational diabetes if diet and exercise are no longer keeping blood sugar levels and baby's growth in line.
To read about the how gestational diabetes progresses and what causes this increase in insulin resistance, then please see this page.
If you have got to the point of having to severely cut or omit all starchy carbs in order to achieve under target levels then it can lead to ketosis which in turn can cause problems with oxygen delivery to the baby.
High levels of ketones are something that should be avoided in pregnancy and so medication for gestational diabetes may be required to help strike a balance between enough carbs and keeping blood sugar levels lowered too. To read more about ketones, please see this page.
It can take a while to get doses right, so please don't expect an immediate fix, but so many ladies experience a great sense of relief when they finally come to terms with taking medication and start seeing their blood sugar levels drop lower and start to stabilise. Many ladies have struggled desperately trying to eat and the medication means that they can start to eat a bit better again.
The amount of ladies that post they wished they hadn't put so much pressure on themselves around trying to control with diet and exercise alone as they were so worried about starting meds is phenomenal. It can make a huge difference to helping control and manage gestational diabetes.