OB and other doctors trying to take over diabetes care?

Hey, everybody! I'm Katherine, diagnosed with diabetes in February/ March, and due to delivery my first baby January 31st. When I was diagnosed, my A1C was like 11.5. Now, last month's A1C check was 5.9! :D

I had a great OB and midwife who left my diabetes care to my equally wonderful endocrinologist and just asked to see my numbers at each appointment. But when I went for a ultrasound, the doctor I saw there wanted to mess with my insulin a little. It was fine with my endo, so no problem.

Then we moved about an hour away and I started seeing a new OB. (Well, I've only met his two midwives so far). The midwife I saw yesterday wants to totally change up how I do everything. She wants me to test fasting, and 2 hrs after breakfast, at 4pm, and at bedtime, so only 4 times a day instead of the 7 times recommended by my endo. She also wants to completely change up my insulin and all dosages are in "incriments of 5" which is how she likes to do it, she says. Previously I had been taking 12 units NPH at breakfast, 2 Regular at lunch, 2 Reg at dinner, and 14 NPH at bed, plus a sliding scale before meals as needed. No corrections for highs yet since my body is still making some of it's own insulin. So going from 2 Reg to 5 Reg is huge for me- more than double what I've been taking.

Granted, I've had more highs recently, but I really think that should be addressed by my endo, not my nurse-midwife!

I'm thinking now I should have told her to call my endo before trying to change anything with me and that my last A1C was proof that he's doing a good job, but it takes me time and talking to other people to think things through.

Has anyone else run into this struggle? What did you do about it? How did your BGs turn out (and your baby, if you've given birth already)?


Don't take any advice that you don't agree with.  If you're having highs for 2 days in a row at the same time, consider raising your insulin slowly.  Sounds like you you should consider calling the OBs office and ask if the endo can officially be in charge of insulin adjustment.  

When I was pregnant my endo turned all of my diabetes care over to the OB, but got updates after every appointment.  Frankly, the OB didn't have to do much for my diabetes because I'd been adjusting my own insulin for a long time before getting pregnant.  I had a 5.1 A1c and a completely healthy baby.  My non-diabetic son is going to be 6 tomorrow!  

Wow, that's an amazing A1C!  I'm so new to this diabetes thing that I appreciate help from someone, but I think my endo can do a way better job.

I'm glad your son was born so healthy! I'm worried about my baby, but trying not to stress. All the ultrasounds have come back normal and she is right on track for weight (as am I). My uterus is the right size too. So we shall see.

Did you have to be induced?

Do NOT listen to the midwife. Not only is that horrible advice, it is not in the least bit consistent with the recommendations with the ADA, ACOG or any other national organization. You should see a perinatologist. I don't believe that midlevel providers have any business caring for patients with pre-gestational diabetes. Perinatology or maternal fetal medicine is a subspecialty that deals with high risk pregnancies. They are experts in diabetes and pregnancy and know all of the different monitoring techniques necessary to increase the probability of a good outcome.

There are predictable changes in insulin needs throughout pregnancy. This requires frequent titration of doses up to delivery. The frquency of highs correlates to size of the neonate.

Obviously I am in medicine and some think that gives me a bias. However, I have witnessed the bad outcomes and know that i would do everything in my power to avoid having one myself.

Thanks, Hayley. That's how I feel too, but it's hard to tell her that!

So, if I go to a perinatologist, should I stop seeing my endo? Or will that be one more person to be in the middle of? :(

What do you do in medicine?


Some perinatologists do both, some don/t. Depends on the provider. If you trust your endo, maybe do a combination. It is kind of a "feel" thing for me.

Actually, I think it should be malpractice for a midwife to not refer a pregnant mom with type 1 diabetes to a higher level provider. I'd make a clean break. Most perinatologists don't take as long to get into given the risk of complications.

I'm actually an endocrine fellow! My experience (and my brother's) provided ample motivation. My doc/mentor in med school has diabetes and is a big inspiration.

I will say as a disclaimer that anything I state on this forum should not be substituted for actual medical advice/ care (it takes a lot more information to make those recommendations). On this forum I am a person with diabetes with some medical training.

Hope that helps! How far along are you?

Hayley offers good advice, but frankly if you have a 5.9 A1c with current endo then you and the doctor are doing a good job.  Think you'll be okay whether you stick with your endo or seek out a perinatologist.  

With your good control there's absolutely no reason you and your baby shouldn't be healty.  My 5.1 wasn't anything magic.  I aimed for a blood sugar of 80 and tested often so I wouldn't have lows.  Wouldn't have been possible without an insulin pump.

I still use a pump, but since pregnancy am back to my usual 6.5-6.9 A1cs.  That works well for me because I rarely have lows, but I also have a very relaxed approach to managing my diabetes.  I don't let it control me or do anything weird to get better blood sugars.

My pregnancy was induced, but wish I had trusted my instincts and not done it.  I thought since my baby and I were both healthy that I would be allowed to go to term.  But diabetes is still classified as a high risk pregnancy and most doctors will encourage any diabetic patient to deliver early and in a controlled manner.  If I had it to do over again I would ask to wait until I was ready to deliver or, if the doctor was really concerned, would have scheduled a cesarean.  My body wasn't ready to be induced and after laboring for a day I finally had a c-section.  Made my recovery time a lot longer and also greatly added to the hospital bill.  Talk very candidly with your doctor about how he or she expects your labor to go.  

Thanks, both Hayley and Jenna.

I really wish I could switch OB's but I haven't even met the doctor yet, and as far as I know, there's only one other OB in my area who takes diabetics (and I hear he's pretty bad). We'll see how it goes. If things get too crazy, maybe I'll switch bath to my 1.5-hours-away OB I had before, who was great!

BTW, I'm 27 weeks.

Jenna, that's an amazing A1C! I don't think I could achieve that since I'm not prescribed enough test trips or a CGM (although I might ask about one...) or enough insulin.

I will definitely have a serious conversation with the actual obstetrician (not just the midwife) about how far he will allow me to go if there are no complications. I will be pushing for 40 weeks. At least my body and the baby should be more ready than at 38 weeks even if I'm induced. I really don't want to go straight to a c-section though, because that's what makes the recovery time much longer.

I really, really just want to have a regular midwife with a home or birth-center birth next time. I've read that some T1's have, with a back-up doctor/hospital plan of course, and been very successful.

Hayley, I think my midwife has been with the OB long enough she feels like she knows what he would prescribe and so she prescribes it herself. But you're right, she has not had the training in T1. She's also very worried about some of the highs I showed her (I made the mistake of bringing my week-old BG's charts- which were the worst I've had so far- to show her). Everything I read, though, seems to indicate that it's the sustained highs that are really dangerous, not as much the jumps that come right back down.

Sounds like you have a good plan.  Ask your doctor (endo or OB) to increase your insulin and test strip prescriptions.  You're going to need more of both to handle your pregnancy.  

When you're at 37 weeks you can evaluate how you're feeling and you'll get some indicators if induction is going to work (baby is moving into place, you're starting to dialate, or have more Braxton Hicks contractions).  I knew from the beginning my body wasn't close to ready.  

Thanks, Jenna. I'm seeing my endo today, and I'm going to ask for more of both and/or a CGM.

OK, I'm so relieved. I finally got a chance to talk to the actual OB, not just the midwife, and he will allow my endo to control my diabetes, even though he thinks his way is better of course. He's way more flexible than the midwife. I still don't understand his position (although I do a little more- he wants me to be between 60-90 all the time). He actually told me to look at www.uptodate.com, click on For Patients or something, and look up diabetes and pregnancy. So I did that, and found exactly what I had been trying to tell him! But I think he's going to work out, so I'm relieved! Thanks for all your advice.