Dr. Martinez shares two cases from Medicos-Nashville. Neither of the cases below meet currently accepted standards for GDM. Close , but no cigar.
These cases highlight the confusion surrounding the the non-disease of glucose intolerance during pregnancy. Headlines in the Memphis newspaper this morning.--The frequency of diabetes has doubled during the past ten years. They failed to mention that a substantial part of the increase was due to lowering the number at which diabetes was diagnosed.
MEDICOS has chosen to use conservative measures for the diagnosis of "gestational diabetes mellitus".The following cases with abnormal urine glucose tests are interesting but insufficient to require intervention.
How interesting that the 3 h GTT at 35 weeks was normal. Even at this late date, the test probably provides "cover" should the patient develop complications. I can't blame the physician who ordered it, and it is his right to do so. We always see something new at MEDICOS. If it had been abnormal, biweekly NST's and AFI's would have ensued with probable induction at 39 weeks.
Notations regarding "borderline(abnormal)" anything do not serve the patient. In the event that there is an unexpectedly bad outcome, this notation can be used by plaintiff's attorney to imply failure to diagnose. Please do not use this 'borderline" terminology in the notes of Medicos patients. It only serves to raise the red flag of potential liability for all other members of the group.
--wmr
CASE #1: Pt #38025, Pt is 21yo G1P0 EDC 11/22/08, 1 hr glucola at 25wks was 110. Fundal height had been appropriate at each visit thus far.
seen 10/26 for pnc by Dr. xx at 37wks, noted to have urine glucose of 250, and urine protein of 30. She has had glucose in her urine 3 other times during her pregnancy (at 15, 23, and 32 wks), and has had protein trace or 30 in her urine at each visit except for one. and has notation in her chart that she is 'Borderline Glucose Intolerant' and should consider metformin or Glucotrol at next visit.
CASE #2: Pt #39779, Pt is 26 yo G1P0 with EDC 11/23/08. 1hr glucola at 26wks was 127. Fundal height has been appropriate at each visit.
Seen 10/21 by Dr. xx at 35wks gestation. Was noted to have >1000 glucose in her urine, and also noted to have 500 and 250 glucose in her urine the two previous visits. Pt was given a 1 hr glucola at her 35wk visit and results were 153. 3hr glucola was performed at 36wks and returned normal (62/136/113/99).
DISCUSSION: Glucosuria when found in a non-pregnant individual can be worrisome and warrants further testing. My understanding is that glucosuria is common in pregnancy, and most of the time, it is ignored. I am not aware of criteria to diagnose glucose intolerance based on findings in the urine, nor of beginning therapy because of this.
The most I have ever done with a patient with recurrent glucose in the urine was to counsel on decreasing refined sugars in her diet, and perhaps serial fingerstick blood sugars... I suppose doing a HgbA1c would also be possible. I have never done a glucose challenge on a patient late in pregnancy, and am not sure I would have even considered it.
Your comments would be appreciated.
Conchita
Bill:
I agree with most of the statements. I do try to "protect" our FHC patients from unnecessary tests, which in general carries more unnecessary test, that harms the patient with fear and sadness for a very poor gain.
If one of our patients has glucose in the Urine I do an Accucheck............. that simple. if it is 85........... you are done: glucosuria in the preganacy. Nothing else is necessary. If it is 150 I order a 3 hs GTT. If normal............ stop.
Agree with you that there is nobody "bordeline pregnant" then there is nobody "borderline .................. anything". I do delineate a f/u, discuss it with the patient and I always follow the chart myself later.
In the second patient I would NOT do the 1 hr that is a very unreliable screening test, but I'll order a a 3 hr GTT and and HbA1C.
I'll copy this to my residents then they know that I'm not the only one that thinks about GDM the way I thinks. I'll try to involve them in this dialogue to enrich them and increase the awareness of bad medicine.
Eduardo
Rockford
My Comment:
The lowering of the glucose renal threshold during pregnancy is common, and I have always ignored late in pregnancy if the patient was screened at 28 weeks with glucola. It does warrant a glucola testing early in the pregnancy if glucosuria is observed, but in the event of a negantive glucola, a repeat glucola at 28 weeks should still should be perfomed.
I agree, that over-zealous documentation in the chart is the equivalent of slipping a noose around one's neck while balanced on a tree branch.
Greg Laurence
Index--OB, GDM ambiguities
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