Gestational Diabetes - immediately put on metformin and insulin without opportunity to try diet control?

[acaciabluebell]

I had my GTT last week and results were quite high: 6.5 fasting and after drink was 12.7 which I know is very high. I met with consultant yesterday who said I immediately have to start on Metformin 2x day, insulin 4x day including the fast acting and long acting one before bed. I haven't even been given the option to try diet control at all! So yesterday I started testing my glucose and readings have been:

1 hour after lunch: 5.2
Just before dinner: 4.1
1 hour after dinner: 5.4

Fasting this morning: 5.1

I feel like these numbers are fine and this is without any medication, just diet control. I don't mind the Metformin I am just wary to start insulin 4x a day if its not needed as it can cause hypos/low blood sugar. What would you do in my situation? I have bags and bags of insulin sitting in my fridge and I feel apprehensive to start it.

Or is it likely my machine is broken (it was brand new??)

I think it depends on a few things really. How far along are you? Do you have a high BMI? I’m not trying to be rude, I had gestational diabetes too so I know how you feel x

Also I wanted to add:

Yesterday's breakfast was 1 slice wholemeal toast with some grilled sausage.
I had a Costa coffee before lunch with sugarfree syrup
Lunch was a grilled chicken burger in a brioche bun
Dinner was beef lasagne with salad and coleslaw.

So not super restrictive in terms of carbohydrates.

@Nannyplumislotsofffun Not rude at all don't worry. I do have a high BMI, my BMI was 32 before pregnancy and is now currently around 35. I'm 29 weeks pregnant

That seems like a LOT to me, I’m not surprised you’re alarmed. If you really want to push back I would log readings for 3 days (fasting and 1 hour post all meals) and then ring back and explain clearly that your readings have been in range with diet only and you don’t want to start insulin until it’s actually necessary for glucose control. The diabetes specialist nurse might be easier to get a hold of/more understanding than the consultant.

Have they had any other reasons for concern eg. episodes of reduced movement, baby showing as large on scans?

I honestly think that they have a protocol that they have to follow when women tick certain boxes, perhaps your bmi being 35 and your high numbers on the test put you into that category. I wonder if you could speak to the diabetic midwife for them to explain why you had to go straight to insulin? Have you joined the gestational diabetes group on Facebook? I was just about able to control mine with diet but my baby was born quite poorly for the first few days and I wished I’d just taken the medications to be honest! X

That seems like massive overkill.

You can push back on the insulin (and the Metformin if you want to - can really give you a dodgy stomach).

Suggest to them doing a diet controlled approach for two weeks and record all your readings and then revisit medication.

That's a lot of carbs and then to have those good readings. I'd be reluctant to start insulin as well, I'd be worried about hypos. You definitely need to follow this further.

I don't know anything about GD specifically, but my DH is T1 diabetic. If he took insulin on top of those readings, he'd be having hypos left right and centre! To have readings of 5 after eating sounds sensible.

Can you get hold of a CGM at all? You can buy them online if the NHS won't give you one. That would mean you could track your levels continuously for 2 weeks without the need for finger pricking, and it will give you a LOT more information about what's happening. At the moment you have point in time measurements, but it would be handy to know what's happening in between those (and it will tell you a lot more about your base level too).

What's your 2 hour post eating sugar?

Unusual to be given insulin when your sugar is 4.1, I would be expecting a hypo and monitor at that stage until it hit 4 and then treat for hypo.

Your fasting sugar isn't too bad, a little over 5 so can understand long acting insulin before bed.

I don't think so... I had the GTT due to family history of diabetes and my high BMI. Baby was on the 80th percentile at 20 weeks and 28 week scans, so steady growth so far - head and abdomen both on 50th percentile, only the femur length was 97th percentile (my husband is 6'6, I am 5'7). Amniotic fluid was normal also. My fundal height was measuring 30 weeks at 28 weeks though, but as I had a 28 week growth scan they were not concerned.

I think so, the consultant seemed to be emphasising that my results were extremely high and I have to take drastic measures to control them. But I'm confused why it would 12.7 last week and now it seems normal. I'll admit I did used to eat carbs a lot before diagnosis and I have cut down on sugary snacks and junk food etc in the past few days. Unless the machine is faulty but I have checked it with the sample solution and seems to working fine.

This is what I'm thinking to do, maybe for a week. At my appointment the consultant was talking a lot about the risks of uncontrolled sugars which scared me but if I'm checking them regularly and they are normal it should be okay right? I'm worried about harming the baby of course

That's a really good idea actually, thank you!

That all sounds normal to me- my BMI was over 35 when I got pregnant (hasn’t really increased at all as I spent all the first trimester vomiting lol) and I’ve been allowed to gradually add metformin then insulin (still only take it at night as my post meal levels are ok) so although your BMI may trigger some sort of local policy it doesn’t seem to be a national one.

By sugar do you mean chocolate etc? Not sure as I didn't eat any pure sugar yesterday, but I did have carbs e.g the pasta in the lasagne, the bread in the sandwich and the burger.

I will keep monitoring just I case yesterday was a one-off.

And r.e the fasting levels, I wouldn't mind taking the bedtime insulin only but taking insulin pre-emptively before each meal seems really unecessary to me as it could bring my sugars too low. My husband works in healthcare himself and he was saying it doesn't make sense.

I think it sounds like the PP is asking for your post prandial number - what your glucose reading is 2 hours after a meal. The usual protocol is to test two hours, not one hour, after a meal.

What is your HbA1c? That would also impact the treatment protocol.

Not to be alarmist, but I was given the more aggressive treatment protocol in my second pregnancy and I ignored it, thinking that because I'd had good results with diet control in my first pregnancy it would be fine. It was not. So there may be underlying reasons you don't yet understand, and it might be worth considering the idea that the team you're under right now is correct.

Hi op, I had GD in my previous pregnancy.

I'd definitely get a second opinion. Do you have any other risk factors? Kidney/heart/liver problems in the past?

Oh I see, sorry!

@dearJayne

1 hour breakfast today it was 5.9
Two hours after breakfast: 4.8

I had 3 scrambled eggs, some crackers with cream cheese, and a cup of tea with whole milk.

@gwenneh I am really sorry to hear that your experience was not good. I'm not against the medication entirely I just want it to make sense, if you get what I mean.

I didn't have a hba1c done since being pregnant, only the GTT.

No other health conditions. My a1c has always been perfect outside of pregnancy.

In this pregnancy I have low Papp-A which I'm on aspirin for.

My a1c has always been perfect outside of pregnancy.

One of the risks of GD is the slower fall of your glucose levels as your placenta starts to interfere with your pancreas, which would give you a higher A1c overall right now and would result in the pre-prandial insulin dosing making sense.

I absolutely get that you want it to make sense, and TBH I'd be doing, and did do, much the same. I hate metformin with the passion of a thousand fiery suns so I would have done ANYTHING to avoid it. I think it would be a good idea to ask your team why you've gone to the aggressive protocol - they might be looking at the multiple risk factors of a family history and a high BMI and thinking that if it does get worse it will do so quickly and so a more aggressive control now might prevent that.

Will you be under consultant led care with more frequent checks with not just midwives?

@gwenneh I understand that, the doctor did say that it tends to get worse as pregnancy progresses and I would be fine taking the insulin if my numbers got worse as I got further along. I'm just worried about getting hypos and unecessary drugs that I don't need right now at this moment in time.

I am consultant led but I think my appointments will be mainly with the diabetes midwife, and honestly I don't know if I trust her as she seemed a bit confused when explaining the medications to me.

I'd be more inclined to listen to the consultant than anyone here tbh. Op if you must then ask for a second opinion from a qualified medical professional. Gestational diabetes can be dangerous and it's not just a case of having a bigger baby but I'm sure you're aware of the other dangers

I've definitely found that there are varying grades of experience in the diabetes midwives! Can you speak directly to the consultant about the care, rather than to the midwife, to get your questions about the medications addressed?

I admit I wasn't an enormous fan of my consultant but in the end he was right.

@gwenneh I might try that... She seemed like a reasonable person. I'm not sure how easy it will be to get an appointment with her though! 😅

I'm surprised they didn't let you at least try to control it with diet & exercise first.
I was allowed 2 weeks to try manage it myself. I would ask again and see if they can allow you some time to try get diet under control.