MiM Mail: A hard pregnancy during residency

Hi,

I've been a lurker on the Mothers in Medicine blog for awhile, and let me just say, the stories and posts have been so comforting to me, especially on my tough days. I'm a third year resident, currently in my third trimester of my first pregnancy in a two-resident household. I wanted to share my pregnancy experience to see if I could gather some advice from fellow mothers in medicine. I feel quite isolated as the only resident in my male-dominated program to be a new mother/pregnant in a long time, and at a hospital system where few female residents are mothers/get pregnant during residency, in general.

My pregnancy has been hard, to say the least. I envy all of those mothers who have the pregnancy glow, who have boundless nesting energy, and who just "love being pregnant!!!" My pregnancy has not been like that. First, it was unplanned, and happened about a month after my husband and I got married. I found out the day after my 24 hour call; I was so nauseous and I was late. I took the pregnancy test two times before I could truly believe that the two lines were actually there. After I confirmed the positivity and announced the news, it seemed like everyone was happy about it, but me. I had unknowingly performed multiple fluoroscopy procedures, and I was so worried about what the effects would be on the baby. I consulted my OB, a radiation physicist, and multiple radiologists, who assured me that this early, the effects should be all or nothing, and if the baby had made it through to this point, everything should be fine. My husband and I made the decision to proceed with the pregnancy. We felt that women go through pregnancies in worse situations and conditions, and we should be so lucky to get pregnant this easily with a supportive environment there to welcome the baby when he/she arrives.

Anyway, fast forward through first trimester, which was fraught with all- day morning sickness that even lasted through my night shifts and into my second trimester, to third trimester, where I now find myself having failed the 1 hour and 3- hour glucose tolerance tests. Just barely. I'm now diagnosed with gestational diabetes, and I feel like a failure. Prior to being pregnant, I was skinny, fit, and perfectly healthy. The only risk factor I had was being Asian. The news was terrible; I had been feeling like I couldn't excel as a resident, and now, I felt like I couldn't handle my duties to be a healthy pregnant mother. As someone who has been usually been able to balance multiple plates somewhat successfully, these two losses felt like huge blows.

I've been dealing with gestational diabetes the way that I deal with most challenges in my life; through hard work. I've been increasing protein intake, decreasing carbohydrates, logging my food religiously in a diary, pricking my finger 4 times a day, and walking at least 5 miles a day. My post-prandial sugars have been great. They're super tight, and well below the cut-off of 140. In fact, I haven't had an abnormal number. On the other hand, my fasting sugars in the morning are a touch high. The cut-off is 95 at my physician's office, and mine ranges from mid eighties to mid-to-upper 90's. Actually, there have only been 3 values from 95-100. My physician has given me until Monday to get the values down, before I have to go on insulin. I've tried everything to no avail. I still have 2-3 values hovering at 96. I feel like considering these numbers high is like splitting hairs. But I think my physician disagrees.

It's not that I'm against using insulin. I'm all for using insulin... that is, if I'm truly and outrageously hyperglycemic. I've done my research (on primary literature resources) and read that physicians will use cutoffs of less than 90, 95, 100, even 105. My range is in a gray area. There's also been a paper published showing that if the pregnant woman has no risk factors (the baby is not measuring large, there's no polyhydramnios, etc.), then the physician will let the fasting glucose ride to 105 before initiating insulin. The paper showed that aggressively treating lower risk gestational diabetes women (below 105, and with normal to smaller fetuses) with insulin may be associated with restricted fetal growth. I would be considered a "lower risk" mother, as my latest ultrasound this past week showed the baby was measuring below average, and everything else was normal. I also don't want to run the risk of being hypoglycemic, which I think is a valid concern, given that I'm about to enter a much busier rotation in which it will be harder to eat, and in which, if i become hypoglycemic, would be disruptive to patient care.

Do you guys think that my hesitancy about insulin in my situation is unreasonable? How should I approach the conversation with her? Of course, if more of my numbers are abnormal, then I'll definitely initiate insulin. I already superficially brought up this concern to my OB, which is why she has let me wait until Monday. But it seems like she is pretty set on starting me on insulin that day no matter what I tell her. She dropped the cutoff, saying that normal pregnant patients' fasting blood sugars run from 70-90's, and that tight control is necessary to prevent macrosomia and to improve the baby's transition (and to lessen NICU admission). I don't want to be "that patient." But at the same time, even though this is not my field of expertise, I do have health literacy, and I don't want to act too aggressively to make an already stressful situation more stressful. I don't feel like I'm as high risk as she's making this out to be.

I really appreciate your thoughts and opinions.

By the way, I have been and will continue to work 24 hour shifts and nights into my 9 month. But that's another dilemma for another day.

Thank you!