Contributor: Sara (Mandy) Reece, PharmD, CDE
In partnership with
Women who live with diabetes during their pregnancy have a very special place in my heart. My story of learning from many women with gestational diabetes began approximately ten years ago. I was asked by a colleague to serve as educator and provider in the indigent diabetes clinic (for women who did not have health insurance) at the local health department. It was a steep learning curve initially, as I lacked experience in this arena. At first, I was more caught up with making sure that I would complete my checklist for each visit…review blood glucose logs, ask about frequency of urination during the night, and assess and adjust medications for follow up visits. After a year of digging deep to become proficient, I shifted my focus to the patient’s experience. I started really learning about gestational diabetes from their perspective, not my own as a clinician and diabetes educator. This changed my world.
I always begin the first visit with “it’s not your fault,” then discuss the creation of insulin resistance by the placental hormones. This statement, which works to eliminate the guilt, contributes to a relationship of trust with the patient. Reframing from guilt to an opportunity to make lifestyle changes and create positive changes now for mom and baby.
Each patient and I have a dialogue of necessary lifestyle changes, with nutritional changes being based on current dietary habits. General nutritional principles that I emphasize are moderating carbohydrates at each meal (i.e., rice, beans, pasta, potatoes, fruit), portion control, incorporating non-starchy veggies (i.e., green leafy vegetables, tomatoes, onions), eating rather than drinking calories, and drinking lots of water throughout the day. I highly encourage 30 minutes of walking each day (except if their provider advises against it) as it improves insulin sensitivity.
The particular clinic in which I serve has grant funds that provide glucose monitors, blood glucose test strips, lancets, and insulin and syringes (when needed). Using the teach-back method, I demonstrate how to use the glucose meter, then have the patient check their blood glucose. When educating the patient on how to use a blood glucose log sheet, I emphasize that honesty matters. I here to help them manage their gestational diabetes, not judge them based on their specific glucose values. The target blood glucose values I recommend are fasting < 95 mg/dL and 2 hours after meals < 120 mg/dL (per American Diabetes Association).
For patients who are unable to reach target blood glucose values, I have a discussion explaining that they have not done anything wrong. Sometimes lifestyle changes alone are not enough. I feel strongly that a dialogue must occur with the patient to determine the best medication for each individual. Metformin, glyburide, and insulin are the only diabetes medications approved for use during pregnancy.
During the last office visit before the patient delivers their baby, we discuss returning to clinic for a 2-hour oral glucose tolerance test six weeks after delivery occurs. Additionally, we discuss the elevated risk for developing type 2 diabetes after having gestational diabetes, and the necessity of continuing with lifestyle changes made since the gestational diabetes diagnosis.
In closing, I dedicate this blog to the numerous women with gestational and pre-existing diabetes that I have had the privilege of learning from and serving at the Hall County Health Department over the last ten years.
Dr. Reece has a diverse background in the pharmacy arena. She has held positions in community pharmacy, state pharmacy association, public health, primary care, and diabetes education. Her passion for diabetes and caring for patients with diabetes has led to her area of clinical and research specialty – endocrinology, with a focus in diabetes. She actively mentors colleagues who are pursuing a practice focused in diabetes. She is a Certified Diabetes Educator, Board Certified in Advanced Diabetes Management and Board Certified Ambulatory Care Pharmacist who actively serves as a clinician and educator. She provides clinical and education services at Northeast Georgia Physicians Group Family Medicine (Family Medicine Graduate Medical Education Program) in Gainesville, Georgia. She currently serves as Treasurer, American Association of Diabetes Educators. In 2017, she was inducted as a Fellow of AADE. Most recently, Dr. Reece developed a blog, Reece's Pieces in a Diabetes World, that offers practical information about medications for patients living with diabetes. Dr. Reece enjoys spending time with her family. Additionally, she is actively involved in her church's Prayer Ministry and serves as a facilitator for Divorce Care for Kids.