Level 3, Placement 2: I’ll see you in the NICU

Premature babies are cute. Premature babies sleep a lot. Premature babies have tiny diapers and tiny feet to draw blood from.

I’m in the midst of a placement in a neonatal intensive care unit (NICU) and I’m learning a whole bunch about both premature babies and term babies that have special care needs. This includes babies who are hypoglycemic because their mothers had gestational diabetes, babies with respiratory distress, babies withdrawing from substances their mothers were addicted to, and babies that are just not thriving.

The hypoglycemic babies are the ones I’ve been most commonly be exposed to, even before this placement in the NICU. It’s been good for me to see the care management that happens after a midwife identifies that the baby has low blood sugar, and needs extra care, because now I feel I can better educate clients on the impacts of excessive sugar intake in pregnancy, as well as prepare them for what they might see in the NICU.

Why do babies become hypoglycemic?

Gestational diabetes can affect any woman in pregnancy, though some women are more at risk based on their history.

Normally, insulin regulates our blood sugar when it gets too high. Pregnancy hormones, however, naturally suppress the action of insulin in order to maintain a higher than normal blood sugar level in the body. That higher than normal level helps the baby grow.

causesofgestationaldiabetes

 

What are the risks associated with gestational diabetes?

Occasionally, as in the case of gestational diabetes, the blood sugar level uncontrollably high and has an impact on the baby. The concern is two-fold:

  1. The big baby. The high, uncontrolled sugar levels often, but not always, grow a larger than average baby. This increases the risk for shoulder dystocia and prolonged labours.
  2. The sugar crash. Babies make their own insulin in response to the mother’s blood sugar level. If the mothers blood sugar is high, then the baby responds by making lots of insulin to soak all that sugar up. That’s nice in-utero, because the baby is getting an unlimited supply of free, high-dose sugar (makes you rethink the term “sugar momma” …).Well, once the baby is born, the sugar supply is cut-off, cold-turkey. The baby is accustomed to high sugar, so its body keeps producing lots of insulin to soak up any remaining sugar.  Low  sugar + high insulin = baby can’t maintain a physiologically appropriate level of blood sugar. Just like a diabetic whose blood sugar is too low, the baby crashes.

cdiabetes-39-638
How are hypoglycemic babies managed?

So the clinical concern with gestational diabetes isn’t only the size of the baby; it’s what happens after the baby is born.

Babies who are born and can’t manage their sugars usually end up in the NICU.  Sometimes these babies are given IV sugars and are slowly weaned down until they can balance their blood sugars on their own. Other times, the baby receives sugars and a macromolecule called glucagon that counteracts that action of insulin. This is all done and monitored until the baby’s insulin and sugar levels are within normal limits and the baby can be sent home without risk of a crash.

Even though this NICU management is out of midwifery scope, it’s nonetheless important for us as future midwives to understand when counselling our clients prenatally. In that spirit, here are a few things that I’ve learned about gestational diabetes and its impact:

Who is at risk?

  • Everyone is at risk for gestational diabetes (GDM) because of the naturally suppressive action of pregnancy hormones on insulin. This is why we counsel all women on this around 24 – 28 weeks.
  • Some women are at higher risk for GDM. Those with a history of diabetes, family history of diabetes, high BMI, or a previously large infant should be made aware of this increased risk.

How is GDM diagnosed? 

  • Testing right now has mixed evidence for its usefulness in diagnosing GDM. The test involves drinking a sugary drink and taking your blood to see how your body responds to this sugar increase. Do the sugar levels regulate quickly? Or do they remain high?
  • Often this glucose challenge test will reveal mothers whose sugar levels don’t regulate within normal limits; that’s how it catches GDM. After diagnosis, we can try to manage GDM first with diet or, if the sugar levels are very high, with maternal insulin injections. In Ontario, diet-controlled GDM is within the midwifery scope, while insulin-injection management is a transfer of care to an obstetrician.
  • Sometimes, the test doesn’t catch GDM and we don’t know until after the baby is born hypoglycemic. That happens.

I’ll be able to tell I have GDM even without the test, right? 

  • You cannot tell if you have GDM just by how you feel (for the most part; if there are symptoms, they can be very similar to the symptoms of pregnancy). There are no signs and symptoms to watch out for. You could feel fine in your pregnancy, and yet still have high sugar levels reaching your baby.

If I watch my weight, I won’t have a big baby right? 

  • Remember, it’s not just about a big baby; it’s about a baby at higher risk of a sugar crash after it’s born. That could be life threatening.
  • Take some time to read up on GDM and weight gain in pregnancy (beyond “baby centre” and “what to expect” websites).
  • My personal opinion is this: give yourself a break on the scale and actual pounds gained, and instead try to look at it from a nutrition/sugar management/exercise stand point. Weight gain is still worth monitoring, but more important is what you are ingesting and how your body is responding to that. Look at the bigger picture of your pregnancy; it might alleviate some anxiety to think of it that way!

 

References

  1. Tied J, McPhee AJ, Crowther CA, Middleton P. The Cochrane Library: Screening and subsequent management for gestational diabetes for improving maternal and infant health. 2014;2.
  2. National Institute for Health and Clinical Excellence. Antenatal care: routine care for the healthy pregnant woman, 2nd Ed., Chapter 11 Screening for Clinical Problems: Gestational diabetes. London: Royal College of Obstetricians and Gynaecologists. 2008;205-217.
  3. Society of Obstetricians and Gynaecologists. Clinical Practice Guideline 334: Diabetes in Pregnancy. 2016. Available from: http://www.jogc.com/article/S1701-2163(16)39087-9/pdf 
  4. Association of Ontario Midwives. Clinical Practice Guideline Review. No.7 – Screening for Gestational Diabetes. 2006. Available from: http://www.aom.on.ca/files/Health_Care_Professionals/Clinical_Practice_Guidelines/No_7_-_Screening_for_Gestational_Diabetes.pdf

 

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