Do I need a high risk OBGYN prior to conceiving?


#1

Just had an appointment at a OBGYN that I thought was high risk, but she informed me that once I’m pregnant she would have to transfer me to a high risk doc. Is this anyone’s experience, starting with one and getting transferred after conception? Then she became concerned with my low thyroid, which is being treated and monitored by my endo, and irregular periods, (my cycles are quite long), and both of these things I kinda thought went hand and hand with being Type 1. What do you think? Worth it to spend the time getting started with her, or just find a high risk doc from the start? Also do I need a doctor lined up before we conceive? We are still planning to start trying this Autumn, but not quite there yet? Thanks.


#2

I will tell you my experience (I am T1D and am currently 7 months pregnant with my first child) as an example, but I imagine it partly depends on what exactly is available where you live.

So, when in mid-2015 I told my endo that my husband and I will be starting TTC, the endo informed me that once I become pregnant he will not be able to see me at all for T1D management. I was quite shocked and disappointed (we have a good relationship) and he explained that this is a limitation of his professional insurance. Also, that in the region there isn’t a single endo who is allowed to see pregnant T1D patients. In the meantime I was seeing my regular OBGYN who knew I have T1D and also that I will be an AMA patient (advanced maternal age = over 35), which are both high-risk categories, but didn’t seem to have any such limitations on her practice. So technically I could have continued seeing her. Based on your post, it sounds like in your case it is the OBGYN that might have some such limitation and will need to refer you to an MFM (maternal-fetal medicine specialist; the kind of OBGYN who treats high-risk women).

In my case it was the endo who gave me the referral and advised that I go for a pre-conception consultation without yet transferring all my care there. So my husband and I did that and found the consultation helpful. It could seem a little overwhelming (they will walk you through the various risks for the average woman in your risk categories, the biggest challenges and the various percentages of this whole list of things that could go wrong with you, the baby, the pregnancy and the labor and delivery), but on the plus side, they will also advise you if there are steps you can take to minimize the risks or at least various tests that might be available to you to discover if your baby does have one thing or another. (For instance, that you should take higher levels of folate supplements from the TTC start in order to lower the chance of baby with a spina bifida, which T1D women are at a significant risk for.)

Your reaction to this consultation will probably depend on your general level of knowledge about these things, as well as your preference for having more info vs. less. In the case of my husband and me, we wanted to know as much as possible, followed up with our own reading of actual medical research and generally felt a little more in control (in a process that is admittedly all about not being in control) being armed with information in advance rather than not, or rather than discovering things after the fact.

Also in my case, once I did become pregnant, I decided to solely see the MFM practice since they really substitute for the OBGYN care (even though in my case they had to also replace the endo; that latter part would not have been my choice). So since late January this is the only place I have been going to. But I don’t believe you can start going to this particular MFM practice unless and until you are pregnant. So this is what I meant when I wrote above that it depends on what is available where you live. Maybe there are MFM specialists who would take you on even before you are pregnant and have a mixed (high-risk and regular risk) clientele. Here this simply didn’t seem to be the case.


#3

Gotcha. Thanks for sharing! And congrats on your pregnancy!
My endo is a specialist in pregnancy, so I will be staying with her (and paying out of pocket) to see her every month, once I am pregnant. I’ve done quite a bit of reading on pregnancy with Type 1, I too like to be informed, so I have a good idea of what to expect. However I don’t want to do a ton of tests and hear how impossible it seems before we even attempt to conceive, which is what OBGYNs without spefcific knowledge of Type 1 will tend to do, IMO. I do like the idea of an AMA consult beforehand however, so we can get ahead of problems specific to T1. Maybe I’ll ask my endo for a referral. I too am 35 yrs old.


#4

I doubt the MFM will leave you feeling that it’s impossible (unless they are really old school, in which case you should look for a different one anyway). Their whole focus is making it possible and even as close to “normal” for T1D women to become mothers. :slight_smile:

At least that’s the vibe I get from mine. But, at the same time, he is pretty blunt about the increased risks and the need for closer monitoring throughout, as well as the need to have excellent control established before TTC. The other benefit of a preconception consultation is that you establish some basic relationship for when you do become pregnant and they give you an idea of the typical process (and if they don’t you should certainly ask) during the nine months: what monitoring they provide/require, frequency of visits, testing schedules, protocol for delivery. It might seem far away to think about all these details before even TTC, but it’s good to know the outlines of what to expect. If you work, you might want to think in advance how to ensure you have the time/flexibility for the pretty frequent appointments you will need to have, etc.

(Since you mentioned your age, I would take the liberty to share some more of our experience: it actually took us much longer to conceive than I originally thought and we had to use fertility treatments too. (I have no other complications and my T1D has always been in great control and my husband’s tests were all fine, so I think it was purely my age factor.) None of this has to do with the original question about the MFM, but I know how nerve-wracking that whole ordeal was and how worried I was about the impact of the fertility procedures on my BG (they really didn’t seem to have any in the end), so wanted to offer that if you have further questions as you proceed with this journey, I am happy to chat in private messages too.)

Best of luck!


#5

That is all good to know, thanks for sharing your individual story! I think I’m convinced to look for a MFM. I may be contacting you again in the future Dessito! Good luck and pregnancy vibes to you too!


#6

@Dessito it’s great to hear your pregnancy is going well and that you’re in the home stretch. Almost there!

@GigiMarie, during my pregnancy, I had a whole team: my endo kept working with me and managed my diabetes. My MFM did all the ultrasounds and, because I insisted on the qualifications of and my relationship with the endo, the MFM did not manage the diabetes. Then, I worked with an OB practice for regular prenatal check-ins and for the delivery; they did not handle high risk pregnancies.

I did a consult with the MFM before I got pregnant. The OBs referred me to the MFM. They sent me to do a bunch of preliminary lab work and then did some follow-ups on any non-routine results. Once I got clearances from all my doctors, we got the go-ahead to start trying. The MFM ran through the various risks of both T1D and age, and the screening tests that were available.

To be honest, the MFM was a bit scary (doom and gloom) and was a bit stuck in their ways with regards to diabetes during pregnancy. They were more accustomed to GD than T1D and did not really exhibit any flexibility in what they wanted to see on the diabetes. Luckily I was knowledgeable and well-controlled and would push back, and had an endo and OBs that had a handle on T1D during pregnancy and backed me up. That said, I had full confidence in the MFMs to make sure my pregnancy went well. But if I wasn’t as confident, I would have been terrified by the MFM (my DH sure was!).

Good luck with your journey. At the end of it, everything went smoothly. But it was quite the journey.


#7

Gigi, I’m wondering how you’re doing and if you’ve managed to conceive yet. Sorry if it’s a sensitive topic.

I’m also wondering why you say you thought your OBGYN was high risk but turned out she wasn’t. I recently started seeing a new OBGYN who is absolutely awesome, and her credentials on her website list her as specializing in high risk pregnancies, but I have yet to actually ask her about it.

My endo told me I’d have to see her more often, as well as a high risk obgyn and also a MFM whenever we do manage to get pregnant.


#8

Hi there, Yes I am pregnant, currently 22weeks, and I’ve stayed with my initial OB team. However I rely heavily on my endocrinologist. I send her food/insulin/exercise records twice a week and she tweaks my pump settings, and gives advice. I also see if in office for blood tests and physical check up every month (instead of every 3).
My OB team (2 doctor partnership) has been great with monitoring and have a plan to induce me around 39weeks and hook me up to an insulin IV drip for labor. I want to try to let her come naturally but I prob won’t be allowed to wait past 39 weeks due to protocols.
I did have a consult appointment with a high risk OB but he didn’t speak to my insulin needs much, and rather was more informative on genetic testing. I believe this doctor reviews my anatomy scans and gives analysis to my OB team.
My baby is measuring well, active during ultrasounds and strong heartbeat. Plus I feel her moving a lot! So doing well so far.
My A1c is the best it’s ever been, 5.6! My best advice is to be vigilant during the 1st trimester (as well as the whole pregnancy) and really count carbs, check often, make adjustments, but don’t overcorrect. The other thing I do is if I see a rising blood sugar, I go for a run around the block, b/c that brings my number down quicker than just waiting for correction insulin to work. (Sometimes I need both).


#9

I’m so glad you’re pregnant and doing well! Sounds like you do pretty much
everything I’m doing, just with a baby on board! Lol. Although I did just
start on metformin to help me lower my insulin requirements some. It
doesn’t sound like you have a Dexcom or other cgm though (apologies if I
missed that in a previous post or reply!). I can’t imagine not having one
during pregnancy! Btw, I think that “protocol” of not being “allowed” past
39 weeks is really outdated. I think its supposed to be done on a case by
case basis now. Maybe talk to your doc and see if you can come to a
compromise. I am a huge proponent of safe, natural birth, so I know its a
fight I’ll have to have eventually too.


#10

KCCO, Thanks so much! I actually do have a Dexcom, and Agree it’s a useful tool, but it can get wildly inaccurate from time to time so I do fingersticks a lot! I do one before every bite and every insulin adjustment just to be sure. (And also when the number just doesn’t look right).
I agree on the hospital protocol being old school, and find a ton of stereotypes about pregnancy and diabetes being mixed up with Type 2, and gestational, so I ask a lot of questions. Thankfully my team is somewhat flexible on “the plan” but I’m also flexible on my expectations. My team and I really want To avoid C-section if possible, so we agree on the goal. As far as the timing I’m prepared to push back but I’m also prepared to trust them and do whatever they think is best to get a healthy baby born and keep me healthy too. One thing I’ve started looking into is birthing position. It’s a bit early for me to implement, but the idea is that if baby is in the best position prior to labor, birth will be easier and shorter and (fingers crossed) less painful, and extra interventions have a better chance of being avoided.

I’m type 1 diabetic so I have let go of the idea of having a birth without all the extra care and protocols, but I’m the kind of person that if there is something within my power that can do to improve the situation I’m all over it! Thus, tight control, regular exercise, healthy diet, and now just getting into birthing plan stuff.

I believe it’s a process we have to go through mentally, but I’m so glad we have this forum to bounce ideas and educate one another. Keep me posted on your progress and thanks again for your good wishes!


#11

Well I think I just got a positive pregnancy test myself so I’m not too far
behind you!
I’ll test again in the morning and then send my docs emails (endo & obgyn).


#12

Congrats!


#13

thanks! 8 positive test now and the nausea has set in.

here’s something my cousin-in-law just mentioned to me (and I’m not sure if this is a case of what you said above, part of the stereotypes of pregnancy & diabetes and it all being mixed up with T2 and GD, etc) but she said they’ll want to induce at 39 weeks because the insulin can possibly deteriorate the placenta faster and “solidify” the amniotic fluid. to me that sounds insane. i have literally never come across anything like that in all my readings. because i know you need 3 or 4 times the insulin in your last trimester - or even more. so…maybe that’s a case of something that could happen that they’ll want to keep an eye on, but not a guaranteed result? idk. have you heard anything like that??


#14

The reason my OB gave for induction at 39 weeks is a fear of placenta break down. (No mention of insulin being the cause of that). She may be halfway there… You are right to question such hear-say comments and seek to research the facts. Like this task is not hard enough right? We gotta battle the nonsense floating around as “concern” as well.
On a personal note some of my husband’s family initially all seemed pretty concerned that I wanted to have a baby “in my condition” (We’re not living in the time of Steel Magnolia!!) I’ve taught myself to put up an emotional wall for stuff like that and not take it all in. If something bugs me though I def seek factual answers and bring it up with either my OB or my Endo.

If you haven’t already, I highly recommend reading “Balancing Pregnancy with Pre-existing Diabetes”

For nausea, I wore the Sea bands, I drank lemon water all day long, and sometimes chewed on ginger. good luck honey! You’re super power has begun!


#15

Hello all,

I really need to write a “birth story” update for this forum, but with a 12-week-old active little girl, have zero time. So just very quickly now on the 39-week induction protocol, about which I feel very strongly (negatively). Yes, the placental deterioration is one concern, a large (or extra large if continued longer) baby is another, and an increased risk of stillbirth is the biggest one. All these are based on studies from the 1970s and 80s where “good control” looked very different and management technologies were much less developed. No matter, that is what doctors go by. If you really are in great control and have zero complications prior to and during the pregnancy (my case), and depending on your willingness to confront the authoritative doctors, you CAN push to delay. I managed to go all the way to 40 weeks and 3 days, but in the end had the induction largely because my husband started freaking out. It’s hard not to when one has to hear about the stillbirth rate for the umpteenth time and is not the one with any control over the situation. I don’t regret making a compromise for him because we are in this together and I wanted to be considerate of his feelings AND at least I had the baby grow as much as she needed to, but in the end the induction was terrible and not particularly effective (I honestly think it was influenced by my mindset that we’re not ready yet). My labor lasted 36 hours and the Pitocin receptors in my uterus didn’t seem to be working efficiently, so the doctors in the hospital stopped and re-started it at one point, ramping up the amount from the initial dose of 2 again. Since I didn’t want any pain-relieving medication and the Pitocin contractions are worse than the natural ones (due to the pause, I was able to experience some of both kinds), the whole thing was more intense and way longer than it probably would have been had I waited the few more days at home, but here we are…

Bottom line, if you are preparing to not allow induction (oh, and you have every right to, nobody can drag you to the hospital by force), do plan what to do if you – and I mean you, your partner, and whatever other members of your circle have any impact on your decision – reach and go past 40 weeks too! We were really not that well prepared for that psychologically.


Are you being induced?
#16

@Dessito
Congrats on your baby! Thanks for sharing this! It’s good to get others real world experiences. I’m going to continue the conversation on waiting for natural with my doctor team. I’m a small person and so is my husband so no one is surprised that our baby is measuring ‘a week behind’ (behind what?!) YET we’ve been sent to another MFM for consultation (he is not concerned either) and told this hyper monitoring is part of pregnancy with diabetes. “Respect the diabetes b/c things can change quickly” was the latest quote from new MFM. Although I’m grateful to have access to such good healthcare, I too am seeking the balance b/w that and excessive intervention on what seems so far to be a well controlled and healthy pregnancy. Having A1C’s in the 5’s the whole time has earned me good will with all the doctors so hopefully we can leave arrival up to our little one!