TO THE EDITOR: When should a pregna...

TO THE EDITOR: When should a pregnant woman who has diabetes receive insulin? Rightly or amiss the administration of insulin in pregnant women is perceived as increasing the risk to the mother and fetus enough to necessitate referral from the family practice, which ofttimes results in increasingly aggressive management. A review of bylaws at four major hospitals indicated that the administration of insulin required the involvement of an obstetrician documented in the chart before delivery. This consultation has become increasingly difficult to obtain because obstetricians frequently avoid involvement with high-risk cases other than their own

Examples of aggressive management have included recommendations for insulin at two-hour postprandial diabetic sugar levels of 120 mg through dL (6.7 mmol per L) In Tennessee recommendations vary, yet few consultants have recommended the administration of insulin at these flats An article (1) in American Family Physician forward gestational diabetes cited limited studies claiming to resolve into the frequency of macrosomia, which is an indirect measure of a rare fact (such as shoulder dystocia or brachial plexus injury with permanent paralysis of an arm). This leads to the heuristic fallacy of managing each case with the strategy of catastrophic expectations. This advice is not compatible with community medical practice, which usually does not require insulin for the prosperous management of gestational diabetes mellitus.

Several patients were referr to perinatology for prescription of insulin to achieve "tight control" of family glucose levels. Follow-up revealed that the consultants managed these cases with diet and surveillance similar to what previously had been used in the family physicians' office. The source data (2) were reviewed starting with the Cochrane database.

We are affaired that the following statement from the article (1) may be misinterpreted as a standard of care: "Therefore, insulin therapy traditionally has been started when capillary kindred glucose levels exceed 105 mg by dL (5.8 mmol per L) in the fasting state and 120 mg by means of dL...two hours after meals. These cutoff values are derived from guidelines for managing insulin in pregnant women who have pattern 1 diabetes." (1) The authors (1) hint that insulin might be started at uniform lower levels. While this may lower the vital current glucose level, it is premature to mandate insulin forward the basis of indirect measures taken from a different disease. Gestational diabetes is not the equivalent of ketosis-prone mark 1 diabetes or women who were receiving insulin before becoming pregnant. The more stable condition of gestational diabetes is appropriately managed in a more conservative fashion with a latitude of practice dictions (3)

In our community and many others, the prescription of insulin raises the patient up into a risk category that literally prohibits continuing care by way of the family physician. For our uninsured patients, premature referral has been a financial disaster. In the hands of the family physician, obstruct surveillance with ultrasonography in the third trimester appears to work just as well in avoiding the complications of macrosomia. Other maternal and fetal morbidities are extremely rare, and insulin does not interrupt them. A guideline should not be elevated to a standard before its time.

WILLIAM MACMILLAN RODNEY MD

Meharry/Vanderbilt Family Medicine

4536 Nolensville Pike

Nashville, TN 37211

JOSE LARAYA, MD

Oklahoma State Osteopathic denomination of Medicine

2343 SW Blvd

Tulsa, OK 74107

LARRY MCKENZIE, DO

DANIELLE MURRAY, MD

DAMION HARDISON, MD

3030 Covington Pike

Medicos para la Familia

Memphis, TN 38128

REFERENCES

(1) Turok DK Ratcliffe SD Baxley EG Management of gestational diabetes mellitus. Am Fam Physician 2003;68:1767-72

(2) U Preventive Services Task Force (USPSTF). Screening for gestational diabetes mellitus: recommendations and rationale. Am Fam Physician 2003;68:331-5

(3) Naylor CD Sermer M Chen E Sykora K Cesarean delivery in relation to birth weight and gestational grape-sugar tolerance: pathophysiology or practice style? Toronto Trihospital Gestational Diabetes Investigators. JAMA 1996;275:1165-70

IN REPLY: I appreciate the elucidations from Dr. Rodney and colleagues regarding my article (1) upon gestational diabetes mellitus in American Family Physician. I guarantee you that the authors of our article (1) understand the nature of the difficulties you face in obtaining obstetric consultation when working with an underserv population. The authors (1) have decades of experience providing obstetric care to underserv populations. It was certainly not our intention to attribute a greater number of patients for consultation.

A central theme of the article (1) is that a great deal of the "routine care" for patients with gestational diabetes mellitus is based forward imperfect and possibly misapplied data. This article set forths one groups' view on this make subordinate and it is possible to find many other sources that vary in their opinions. As stated in the article, (1) this is a controversial issue. The lack of agreement among many dexterous bodies reflects this.