The Neglectful Pregnant Woman with DM

Hala MosliPGY-5

May 19th, 2010

Facts about Pregnant Women:

• Are very protective of their unborn child

• Hesitate to take medications even if reassured that they are safe in pregnancy

• Prepared to endure labor/birth pain to protect baby from effects of analgesics

Some Physiology…

• Pregnancy is a complex metabolic state that involves dramatic alterations in the hormonal milieu

• Increases in estrogen, progesterone, prolactin, cortisol, β-HCG, placental growth hormone and HPL)

• Decreases in adiponectin and increases in leptin and TNF α

• Increasing burden of fuel utilization by the conceptus

• The first trimester is characterized by increased insulin sensitivity

• Women with diabetes are at increased risk for hypoglycemia, especially if accompanied by nausea and vomiting in pregnancy.

• The second and third trimesters, in contrast, are characterized by insulin resistance with a nearly 50% decrease in insulin mediated glucose disposal (assessed by the hyperinsulinemic-euglycemic clamp technique) and a 200-300% increase in the insulin response to glucose

• Glucose transport to the fetus occurs in direct proportion to maternal glucose levels, and is augmented by a five-fold increase in a placental glucose transporter, (GLUT-1) which increases transplacental glucose flux even in the absence of maternal hyperglycemia.

• At the same time it has been demonstrated that in the third trimester of normal pregnancy there is decreased expression of the GLUT-4 glucose transporter protein in maternal adipose tissue and decreased translocation of GLUT-4 to the plasma membrane in skeletal muscle, both of which contribute to the insulin resistance of pregnancy.

• The placenta is responsible for the production of hormones which reprogram maternal physiology to become insulin resistant in the 2nd and 3rd trimester of pregnancy to ensure an adequate supply of nutrients to the growing fetus

• The role of other hormones such as HPL, GH, placental GH, etc

• Therefore, tight glucose control in women with preexisting diabetes (both Type 1 and Type 2) often requires insulin administration with each meal with a short acting insulin preparation such as Lispro or Aspart.

• Frequent monitoring allows appropriate insulin dosage adjustments.

• The maintenance of normal glucose control is the key to prevention of complications such as fetal malformations in the first trimester, macrosomia in the second and third trimesters, and neonatal metabolic abnormalities.

Ok, now the ethics part!

• Difficult talk

• No clear guidelines

• Medical grounds for care recommendations, but no clear grounds for further intervention in most cases

…. You know, Mrs. Buckman, you need a license to buy a dog, to drive a car - hell, you even need a license to catch a fish. But they'll let any “bleep bleep” be a father…

Parenthood, 1989

• This can also apply to being a mother!

Case:

• C.A. is a 22 yr old young woman of First Nations descent, referred to Endocrinology for management of GDM.

• Past history as follows:

• In 2003(age 15):

– Pregnant

– Early miscarriage

– No D&C required

• 2004(age 16):

– Pregnant with twins

– GDM ? Insulin…control unknown

– C/S (twin A breech) @36/40

– CAS involved…twins living with father’s aunt

– Postpartum depression

• 2005(age 17)

– Another pregnancy

– Another miscarriage

– No D&C

• 2006(age 19):

– Pregnant again

– GDM on insulin

– BG 4-15

– Forceps-assisted delivery at term, VBAC

– Baby weighed 9lbs

– This baby also apprehended by CAS soon after delivery

– Unclear if returned to live with mother

• 2010(age 22):

– Patient presented to the Obstetrical Triage Unit at SJHC on February 17th, 2010

– LMP sometime in August 2009

– NO prenatal care up to this point in the pregnancy

– Wanted to make sure the baby was OK

– Based on LMP, GA≈26/40

– SFH on examination 41cm

– Based on US measurements of fetal size, GA 39/40, EFW 3740g

– 50g OGTT done while admitted

– 2hr BG 13.6

– GDM diet, insulin…blood sugars variable

– Given baby’s size, OB team elected to proceed to induction with mother’s consent

– Cervix 3cm, 50% effaced prior to beginning induction

– Baby girl delivered by VBAC

– Discharged home with baby.

• Strong family history of DM 2, IHD

• An aunt has FAS

• Father of third child developmentally delayed (unclear if also the father of the twins, youngest child or different partner)

• No history of substance abuse, although smoker from early age.

• Questions:

– Is this patient old enough to make decisions regarding reproduction? Treatment decisions?

• Doctors and ethicists alike worry about children’s ability to understand medical information and to understand the consequences of their decisions, about children’s changing sense of self and values, and about their capacity to reason.

• These abilities and sense of self vary with age, as children grow and develop.

• Some people use the designation “child” to refer to all people under the age of 18.

• However, the group of people under age 18 is a diverse group, and some members of that group are allowed to drive, to leave school and to consent to sexual activity.

• The World Health Organization refers to

– The life stage between the ages of 10 and 19 years as “adolescence”,

– Also defines “youth” as the life stage between the ages of 15 and 24

• The Canadian Pediatric Societyuses the following statement indiscussions regarding children and decision-making: “Children and adolescents should be appropriately involved in decisions affecting them. Once they have sufficient decision-making capacity, they should become the principal decision maker for themselves.”

• The American Academy of Pediatricsalsourgesphysiciansto seek the agreement of the child, to the greatest extentpossible, in addition to parental permission.

• These definitions apply to TREATMENT decisions, but not REPRODUCTION!

• In this situation, the patient’s decision does not only involve her own care, but also affects the life of her unborn child

• In most cases, when people decide to reproduce they are aware of the implications and the need to be emotionally as well as financially responsible for a dependent.

• Issue of autonomy and competence/capacity

• Individuals are presumed to be competent to make health care decisions.

• The legal and ethical presumption that capable individuals are entitled to make important decisions about their health and well-being is grounded in the medical principle of respect for persons.

• While the obligation to meaningfully involve “competent” persons in health care decisions can be seen as an expression of respect for their autonomy, it is perhaps most appropriate to view the meaningful inclusion of patients in health care decisions in a broader context.

• Rather than focusing solely on another’s autonomy, the broader principle of respect for persons not only includes respect for another’s capacity to be self-directing, but also recognizes our ethical and legal obligations to persons who may be vulnerable or who are no longer able to participate in a meaningful way in decisions about their health care.

• Those who were once able to participate in a meaningful way in decision-making about health care may have lost their decision-making capacity because of disease or illness. Such a loss of capacity may be temporary or permanent.

• Other persons may never have had decision-making capacity, and never will, because of developmental disabilities.

• Still others, because of their age or stage of development, have yet to acquire the ability to meaningfully participate in decisions about health care

• Back to our case, and the issue of capacity and autonomy

– If the outcome of the first pregnancy was thought to be affected by the inadequate control of the mother’s sugars, does the mother understand this association?

– Does she understand that this can recur in future pregnancies?

– Was contraception discussed?

• Yes, there was a documented discussion with the mother after the birth of her third child regarding contraception, and recommendations were made

• Unlikely followed, asshebecame pregnant again shortly after

• Apart from the risks of ELEVATED sugars on the fetus, are there any other risks, eg from recurrent lows?

• Several clinical studies did not establish an association between maternal hypoglycemia and diabetic embryopathy.

• However, animal studies clearly indicate that hypoglycemia is potentially teratogenic during organogenesis.

• Increased rates of macrosomia continue to be observed despite near normal HbA1c levels.

• This may, at least in part, be the result of rebound hyperglycemia elicited by hypoglycemia.

• Exposure to hypoglycemia in utero may have long-term effects on offspring including neuropsychological defects.

Maternal hypoglycemia during pregnancy in type 1 diabetes: maternal and fetal consequences, terBraak et al, Diabetes/Metabolism Research and Reviews, Volume 18, Issue 2 ,Pages 96-105, March 2002

• Throughout her care, glycemic control was documented

• Variable control

• The weight of the baby following the twins (9 lbs) suggests suboptimal control of her sugars despite documented discussions around this between the patient and the health care team

Our patient:

• Beyond counseling regarding the potential risks of elevated sugars on the fetal development, and the long-term risk of developing DM 2 what more could have been done in the care of this young patient to improve the outcome?

• What is our role as endocrinologists in all of this?

A few additional thoughts

Children’s Aid Society

• OACAS is a membership organization representing CASs in Ontario

• There are 53 Children's Aid Societies in Ontario. 50 agencies are members of OACAS

•Follow the Child and Family Services Act of Ontario

• Special responsibilities of professionals and officials, and penalty for failure to report - CFSA s.72(4), (6.2):

– Professional persons and officials have the same duty as any member of the public to report a suspicion that a child is in need of protection.

– The Act recognizes, however, that persons working closely with children have a special awareness of the signs of child abuse and neglect, and a particular responsibility to report their suspicions, and so makes it an offence to fail to report.

• Any professional or official who fails to report a suspicion that a child is or may be in need of protection, where the information on which that suspicion is based was obtained in the course of his or her professional or official duties, is liable on conviction to a fine of up to $1,000

– Professionals affected - CFSA s.72(5)

• Persons who perform professional or official duties with respect to children include the following

– health care professionals, including physicians, nurses, dentists, pharmacists and psychologists;

– teachers, and school principals;

– social workers and family counselors;

– priests, rabbis and other members of the clergy;

– operators or employees of day nurseries;

– youth and recreation workers (not volunteers);

– peace officers and coroners;

– solicitors;

– service providers and employees of service providers;

– any other person who performs professional or official duties with respect to a child.

• This list sets out examples only. If your work involves children but is not listed above, you may still be considered to be a professional for purposes of the duty to report. If you are not sure whether you may be considered to be a professional for purposes of the duty to report, you should contact your local Children's Aid Society, professional association or regulatory body.

– Professional confidentiality - CFSA s.72(7),(8)

• The professional's duty to report overrides the provisions of any other provincial statute, specifically, those provisions that would otherwise prohibit disclosure by the professional or official. That is, the professional must report that a child is or may be in need of protection even when the information is supposed to be confidential or privileged. (The only exception for "privileged" information is in the relationship between a solicitor and a client.)

What gets reported?

• If a person, including a person who performs professional or official duties with respect to children, has reasonable grounds to suspect one of the following, the person shall forthwith report the suspicion and the information on which it is based to a society:

1. The child has suffered physical harm, inflicted by the person having charge of the child or caused by or resulting from that person’s,

i. failure to adequately care for, provide for, supervise or protect the child, ii. pattern of neglect in caring for, providing for, supervising or

protecting the child.

2. There is a risk that the child is likely to suffer physical harm inflicted by the person having charge of the child or caused by or resulting from that person’s,

i. Failure to adequately care for, provide for, supervise or protect the child,

ii. Pattern of neglect in caring for, providing for, supervising or protecting the child.

3. The child has been sexually molested or sexually exploited, by the person having charge of the child or by another person where the person having charge of the child knows or should know of the possibility of sexual molestation or sexual exploitation and fails to protect the child.

• Plus other situations

• Reports go directly to the CAS

• Ongoing reporting is mandated if the harm/risk of harm persists

• Functions of society– The functions of a children’s aid society are to,

a) investigate allegations or evidence that children who are under the age of sixteen years or are in the society’s care or under its supervision may be in need of protection;

b) protect, where necessary, children who are under the age of sixteen years or are in the society’s care or under its supervision;

c) provide guidance, counseling and other services to families for protecting children or for the prevention of circumstances requiring the protection of children;

d) provide care for children assigned or committed to its care under this Act

e) supervise children assigned to its supervision under this Act;

f) place children for adoption under Part VII;

g) perform any other duties given to it by this or any other Act. R.S.O. 1990, c. C.11, s. 15 (3).

Where child an Indian or native person

• Where a person is directed in this Part to make an order or determination in the best interests of a child and the child is an Indian or native person, the person shall take into consideration the importance, in recognition of the uniqueness of Indian and native culture, heritage and traditions, of preserving the child’s cultural identity. R.S.O. 1990, c. C.11, s. 37 (4).

• Place of safety:– For the purposes of the definition of “place of safety” in subsection (1), a

person’s home is a place of safety for a child if,(a) the person is a relative of the child or a member of the child’s extended family or community; and

(b) a society or, in the case of a child who is an Indian or native person, an Indian or native child and family service authority designated under section 211 of Part X has conducted an assessment of the person’s home in accordance with the prescribed procedures and is satisfied that the person is willing and able to provide a safe home environment for the child. 2006, c. 5, s. 6 (4).

• Where parent a minor

– Parent will be represented by a children’s lawyer.

Fetal rights in Canada:“In protecting rights of the unborn child to adequate care however, the Criminal Code seems to come up short. In an effort to avoid both the heated and oft politically volatile abortion debate and the rights of the mother to control her own body, no section of the Code exists that protects for the health and well being of the unborn developing child in utero. Section 223(1) of the Criminal Code says that a child becomes a human being when it has "completely proceeded, in a living state, from the body of its mother." In other words, the child has no protection until after birth (Byfield, 2002)”

References:• www.endotext.org• Royal College of Physicians and Surgeons website• HAPO, NEJM, 2008• Maternal hypoglycemia during pregnancy in type 1

diabetes: maternal and fetal consequences, terBraak et al, Diabetes/Metabolism Research and Reviews, Volume 18, Issue 2 ,Pages 96-105, March 2002

• Children’s Aid Society of London Middlesex• Ontario Association of Children’s Aid Societies• Child and Family Services Act of Ontario• The Issue of Fetal Rights in Canada, Colleen D'Orsay

Wintermans, Cape Breton University, November 25, 2005