July 31, 2013 CDAPP Webinar presented by Dr Lois Jovanovic
Can you explain why the a1c level cut off a 5.3 is used as risk increase for macrosomia complications and anomalies when 4.8 to 5.6 is normal outside of pregnancy outside of pregnancy okay we’re simple yeah i all my studies are really relating to pregnancy i’m not talking about what the lab reports is a normal range to you i’m also talking about the point of care
A1c oh so it’s a little six-minute test that you do right there in clinic i’m not talking about the laboratory column chromatography they’re different assays for doing a1c and they’re further cut-offs are different and they’re not comparable so the point of care a1c little machines that you can do with finger stick that the cutoff is 5.3 in those machines with
A large sample size and i collaborated with dr. aluri who because she’s from japan she’s got thousands of patients doing this point of carrie once he has confirmed that also the 5.3 percent really is it separates the two groups very nicely between those women who do well with diet and exercise in those women who really need therapy almost instantaneously we have
Probably undiagnosed type 2 diabetes thank you okay the physicians that refer to our center are still using a call guidelines for diagnosing dmn pregnancy in addition they often are late to start insulin any suggestions for how to get their physician to listen to us p.m. educators wow you are asking the question of the universe because they they know i’m not an
Obstetrician has been very difficult to get the opposition’s change this so worried that we’re going to increase the number of women who get upset with the diagnosis of gestational diabetes who are going to need carole burning increased costs i think as educators we have to convince the obstetricians that we can handle talking to the women teaching the nutritional
Principles we can handle teaching them self bugger coast winery we could probably even convince the drug companies to donate capillary blood glucose monitors so that we can use them and get the women hooked on them to convince the obstetricians that you can handle teaching to women as opposed to teaching one will win it is time you can teach classes if it really
Doesn’t increase the health care costs and we’re not forcing obstetricians in world work we really are we’re taking on extra work as educators okay and do you find that there are still providers out who are still using cutoff values of 95 for fastings and 134 post brand girls and how do you talk to them how do i answer them well i usually start with well lois’s
Is it so much easier to take everybody knows that i am glucose centric and i say that i mean i almost will famous for glucose is yelling toxin so i say if it’s not an almost unknowable and i don’t like it and so i just go back to my safe haven which is making the blood sugar normal and then if the obstetrician says well what how am i increasing the risk of anything
Well you know the only way to answer that question is to ask well how many malpractice cases are there of women who have had macro soumik infants or babies of slip shoulder dystocia who sued and won and actually that’s a terrible way to change medicine it’s the attorneys are in the law you know changes of malpractice suits are going to get the physicians to change
This a terrible thing to say you have to have a sick hurt baby in order to change practice of medicine that’s why i go back to just what is louis a my opinion is that normal is better than abnormal and the sugars that you’re using our abnormal yeah i go back to an easy answer rather than give myself caught into arguing with any of them okay so first one is it what
Is your opinion on glyburide ah it’s a sulfonylurea cross this will send and i can’t stand it there were only 12 cord blood analyzed mayo de langer paper in the new england journal of medicine at a 492 women treated with glyburide he only measure cord blood in 12 patients and it wasn’t clear when the last dose of ligar i’d was given it also wasn’t clear what dose
Of women there on does he escalated the dose from two point five milligrams up to 20 milligrams and he claims he couldn’t measure glyburide in 12 carbons that is not proved to me that library does not cross the placenta so if glyburide crosses the placenta it’s going to cause fetal hyperinsulinemia so my opinion is very strong that i don’t use glyburide what’s
Even stronger than that because it doesn’t treat the postprandial okay type 2 patients usually need larger amounts of insulin have you found instances where increasing the dose has not been effective how do you deal with extreme insolence with insulin resistance okay what you have to do is calculate the insult o space on body weight and a constant then what you do
Is if indeed the dose of insulin is more than 30 years in one injection i make the woman’s split the injections because what will happen if they take more than 30 units in one injection site the lysozyme end up denature izing say insulin and it turns into water so that’s why increasing the dose of insulin is not the right way to go the way to go is once you get to
A number greater than 30 either for they ask for advice for or denim er or mph you end up telling a woman zap zap she doesn’t even have to change syringes or change her pen it just zap zap put it in two different pockets so that it absorbs faster and women understand very quickly that the absorption of a little droplet is easier than a large puddle of influence
And it hurts less so what we do with women who need large doses of insulin say needed 300 units of insulin for breakfast they would take four injections because we have to keep each injection less than or equal to about 30 units we don’t let them use syringes that are greater than 30 unions the other way if they tend up you know pulling the syringe up to 50 and
Things think they can get away with one month injection but but you’ll see it doesn’t work and you put it all in one pocket it just goes no or decomposing okay thank you very much sir can you explain why the a1c level cut off a 5.3 is used as risk increase for macrosomia complications and anomalies when 4.8 to 5.6 is normal outside of pregnancy outside of pregnancy
Okay we’re sifl yeah i all my study that really relating to pregnancy i’m not talking about what the lab reports is a normal range to you i’m also talking about the point of care a1c now so it’s a little six minute test that you do right there in clinic i’m not talking about the laboratory column chromatography the different assays for doing a1c and they’re further
Cut-offs are different and they’re not comparable so the point of care a1c little machines that you can do with finger stick that the cutoff is 5.3 in those machines with a large sample size and i collaborated with dr. amore who because she’s from japan she’s got thousands of patients doing this point of kerry once he has confirmed that also the 5.3 percent really
Is it separates the two groups very nicely between those women who do well with diet and exercise in those women who really need therapy almost instantaneously who have probably undiagnosed type 2 diabetes thank you ok the physicians that refer to our center are still using a call guidelines for diagnosing dmn pregnancy in addition they often are late to start
Insulin any suggestions for how to get their physician to listen to us damn educators wow you are asking the question of universe because they they know i’m not an obstetrician has been very difficult to get the opposition’s change this so worried that we’re going to increase the number of women who get upset with the diagnosis of just tional diabetes who are
Going to need careful running increased costs i think as educators we have to convince the obstetricians that we can handle talking to the women teaching of nutritional principles we can handle teaching them self uh glucose monitoring we could probably even convince the drug companies to donate capillary blood glucose monitors so that we can use them and get the
Women hooked on them to convince the obstetricians that you can handle teaching to women as opposed to teaching one will one at a time you can teach classes if it really doesn’t increase the health care costs and we’re not forcing obstetricians in world work we really are we’re taking on extra work as educators okay and do you find that there are still providers out
Who are still using cutoff values of 95 for fastings and 134 post brand rules and how it again talked about how do i answer them well i usually start with well lois is is it so much easier to take everybody knows that i am glucose centric and i say that i mean i almost will famous for glucose is yelling toxin so i say if it’s not an almost unknowable and i don’t
Like it and so i just go back to my safe haven which is making the blood sugar normal and then if the obstetrician says well what how am i increasing the risk of anything well you know the only way to answer that question is to ask well how many malpractice cases either of women who had macro soumik infants or babies of slip shoulder dystocia who sued and won and
Actually that’s a terrible way to change medicine if the attorneys are in the law you know changes of malpractice suits are going to get the physicians to change this a terrible thing to say you have to have a sick hurt baby in order to change practice of medicine that’s why i go back to just what did louis a my opinion is that normal is better than abnormal and
The sugars that you’re using our abnormal yeah i go back to an easy answer rather than get myself caught into arguing with any of them okay we are at 115 so i’m going to give you two more questions and then we’ll deal with anything that we haven’t discussed yet via email okay so first one is it what is your opinion on glyburide ah it’s a sulfonylurea cross this
Will sent and i can’t stand it there were only 12 core bloods analyzed me odette langer paper in the new england journal of medicine at a 492 women treated with glyburide the only measure card blood in 12 patients and it wasn’t clear when the last dose of ligar i’d was given it also wasn’t clear what dose of women they were on does he escalated the dose from two
Point five milligrams up to 20 milligrams and he claims he couldn’t measure glyburide in 12 cards that is not proved to me that library does not cross the placenta so if glyburide crosses the placenta is going to cause fetal hyperinsulinemia so my opinion is very strong that i don’t use glyburide what’s even stronger than that because it doesn’t treat the postprandial
Okay type 2 patients usually need larger amounts of insulin have you found instances where increasing the dose has not been effective how do you deal with extreme insolence asst insulin resistance okay what you have to do is calculate the instils of space on body weight and the constant then what you do is if indeed the dose of insulin is more than 30 years in one
Injection i make the woman’s split the injections because what will happen if they take more than 30 units in one injection site the lysozymes end up denature izing say insulin and it turns into water so that’s why increasing the dose of insulin is not the right way to go the way to go is once you get to a number greater than 30 either for they ask for advice bro
Or denim er or mph you end up telling a woman zap zap she doesn’t even have to change syringes or change or pen it just zap zap put it in two different pockets so that it absorbs faster and women understand very quickly that the absorption of a little droplet is easier than a large puddle of influence and it hurts what so what we do with women who need large doses
Of insulin they needed 300 units of insulin for breakfast they would take four injections because we’d have to keep each injection less than or equal to about 30 units we don’t let them use syringes that are greater than 30 unions the other way if they tend to you know pulling the syringe up to 50 and thing is it think they can get away with one month injection
But but you’ll see it doesn’t work and you put it all in one pocket it just goes no or decomposes okay thank you very much
Transcribed from video
Preconception & Interconception Care of Women with Pre existing DM or History of GDM, Q & A 3 of 3 By CDAPPSweetSuccess