This Heavy Baby
Posted by realityrounds on September 25, 2009
A 8.7 kg (19 pound) infant was born in Indonesia on Wednesday. This is the largest baby ever born in this country. The baby was born by C-Section (naturally) and the verdict is still out as to whether the baby is healthy or not. Of course the world wide media has devoured this story as a cute feature piece about a gigantic baby. How cute. But in reality, a baby born at 19 pounds is anything but natural or healthy. The sketchy reports out of Indonesia is that the mom likely had gestational diabetes, but was not monitored for it. According to reports:
“This heavy baby made the surgery really tough, especially the process of taking him out of his mum’s womb. His legs were so big,” said Obstetrician, Binsar Sitanggang.
The boy is in a healthy condition despite having to initially be given oxygen to overcome breathing problems, the gynaecologist said.
“This baby boy is extraordinary, the way he’s crying is not like a usual baby. It’s really loud.”
The boy’s massive size was likely the result of his mother, Ani, 41, having diabetes, Sitanggang said.
These stories always make me cranky. They make me cranky because the media portrays them as cute human interest pieces about gigantic babies and “oh, look how cute and big and bouncy that gigantic baby is.” They gloss over the real dangers and risks of having such a large infant. It bothers me because the lay public may be duped into believing that bigger is better when it comes to babies, and what’s the big deal anyway? (Try saying that sentence out loud, ten times, real fast…I dare you). I guess it does bother me a little personally when I see patients who blow off their glucose tolerance tests, and who ignore dietary advice, and who are not compliant with their insulin. I remember one diabetic mom who would not take her insulin prenatally, she came in at 34 weeks with decreased fetal movement, and an estimated fetal weight of 12 pounds. We did an emergency C-Section and out came a preemie infant weighing over 12 pounds, and was a train wreck (I will post that story another time).
I can understand the public’s fascination with these massive babies. Hey, it got my attention. But just from a public health perspective, I think the risks of maternal diabetes on the infant should also be addressed. So, that is where I come in. I will give you some of the fetal and neonatal adverse effects of maternal diabetes. Next time you see these bogus human interest stories on big ole’ babies, you will be armed with the knowledge of how serious this can be.
A diabetic pregnancy is associated with an increased risk of complications for both the mother and the fetus. Maternal hyperglycemia can have teratogenic effects in an infant, with the majority of harmful effects occurring in mom’s with preconception diabetes. The vast majority of bad outcomes occur in insulin dependent mom’s (or worse, mom’s who should be on insulin and are not, who are not compliant with the insulin regimen, who were never diagnosed with diabetes, or are brittle diabetes with resulting renal, cardiac, and retinal disease, etc.). The increases in metabolic demands in pregnancy require a delicate balance of hormonal regulation of carbohydrates, protein and lipid metabolism. Reduced insulin production in pregnant diabetic women can lead to a metabolically hostile environment for the fetus. Subsequently the embryo and fetus gets an overload of glucose in utero with subsequent birth defects and adverse outcomes.
For the neonate there is a high risk of morbidity which includes: congenital anomalies, prematurity, perinatal asphyxia, respiratory distress syndrome, polycythemia, and severe hypoglycemia (due to hyperinsulinemia from the excessive glucose loads in utero. Once the baby is born, the glucose infusions from the mother are rapidly shut down, but the baby continues to produce excessive amounts of insulin. This can lead to massive drops in blood sugar for the infant.)
Perinatal Mortality and Neonatal Morbidity
Condition Rate/percent
| PERINATAL MORTALITY | 0.6-4.8 |
| CESAREAN DELIVERY | 32-45 |
| PREMATURITY | <37 WEEKS: 24-33<34 WEEKS: 14-16 |
| CONGENITAL ANOMALIES | 1.7-9.4 |
| PERINATAL ASPHYXIA | 9-28 |
| MACROSOMIA | 9-28 |
| IUGR | 2-8 |
| RDS | 2-6 |
| HYPOGLYCEMIA | 5-25 |
| HYPOCALCEMIA | 4 |
| POLYCYTEMIA | 5-33 |
| HYPERBILIRUMINEMIA | 11-29 |
| CARDIOMYOPATHY | SYMPTOMATIC: 5-10ASYMPTOMATIC: 30-50 |
Common Congenital Anomalies in Infants of Diabetic Mothers
| System | Manifestations |
| NEUROLOGIC | Anencephaly, microcephaly, holoprosencephaly, neural tube defects |
| CARDIOVASCULAR | Transposition of the great vessels, VSD, coarctation of the aorta, ASD, single ventricle, hypoplastic left ventricle, pulmonic stenosis, pulmonary valve atresia, double outlet right ventricle, truncus arteriosus. |
| GASTROINTESTINAL | Duodenal atresia, imperforate anus, anorectal atresia, small left colon syndrome, situs inversus |
| GENITOURINARY | Ureteral duplication, renal agenesis, hydronephrosis |
| SKELETAL | Caudal regression syndrome (sacral agenesis), hemivertebrae |
| OTHER | Single umbilical artery |
*Adapted from UpTo Date, Tyrala, EE. Obstetric Gynecolgical Clinics of North America. 1996, and Reece, Ea, Homko, CJ. Seminars in Perinatology. 1994.
*Interesting side note to this story, it is also reported that out of her three previous deliveries, this was the first time this Indonesian mom did not see a traditional midwife. Just sayin’.*
Post Update: 9/26/09
*Other people talking about this: The Unnecesarean and Gloria Lemay. Go find out what they are saying.
RR
Star said
I agree this should not have happened and the media should not portray it as cute. But at the same time, many doctors here in the US unnecessarily freak out about mild, diet-controlled GD. This woman’s case must have been pretty severe (and most likely she had undetected type 2 pre-pregnancy, right?) to yield this outcome. There has to be a middle ground between no monitoring and this type of result and the “induce or prophylactic section at 37-38 weeks” mentality that has developed here and the excessively strict numbers providers want to see now (under 90 fasting in the third trimester? really?).
realityrounds said
Stat,
Agreed. Doing a prophylactic C-Section or induction on a late preterm with controlled diabetes would also make me cranky, because then I would have another admission in the NICU. Very bad.
R. May said
And that is why I hate the media.
It has gone from being an institution of reporting news to an institution whose sole purpse is to get as high ratings as possible which = crap (and often flat out lies or lies by omission or disinformation) for news.
Elizabeth said
Thank you for posting on this! It has been driving me crazy. All the focus is put on comparing this baby up next to other little babies and no one is saying anything about how unhealthy this is. It should be used as a great opportunity to show how import a healthy diet and healthy mother is during pregnancy. Ugh.
Rachel said
Hey thanks for this post. I read your site all the time and rarely post a comment.. but this one is dear to my heart. I am diet controlled diabetic outside of pregnancy but am insulin dependent during pregnancy. Im preggers with number 4 right now (even after husband had a vasectomy 10 months ago, because of all my health issues!) and I start the insulin earlier with each pregnancy.
I did just want to say that I don’t think that the GTT is for everyone. Especially someone who is already diagnosed as diabetic. My first pregnancy (I did not know that I was diabetic) I had a 350 on my one hour postprandial.. but when I declined the test on my second you would have thought I was an IDIOT by the doc’s shigrin. But i had a glucometer and could tell you exactly when it was time for insulin.
Besides.. I believe that one day that GTT will be obsolete.. why is it a good idea to pump that much sugar into people when there is a possibility that they could be diabetic and then make them feel like crap the rest of the day? Why not do a “eat a regular meal” approach and then take their numbers?? Anyway.. just a thought..
love your blog!! you are hilarious!!
realityrounds said
Rachel,
Thanks! You sound like an ideal patient. I know the GTT is controversial. I have had many patients with normal GTT, but out comes a baby who definitely looks like an IDDM. We must remember this is a screen, it is not diagnostic, and I do not know if there is any research being done on better screening tools for gestational diabetes. Anyone else know?
Kathy said
RR, the latest I’ve heard is what I wrote about in this post which is from May 2008. It includes a link to the U.S. Preventive Services Task Force (USPSTF) guidelines on GD, and it says, “the overall evidence is poor to determine whether maternal or fetal complications are reduced by screening.” It also discusses the lack of studies in this, and notes the differences in diagnosis (one doctor may have a glucose level of X, while another doctor may not consider it to be GD until glucose level Y) Also later in the document, “The USPSTF was unable to estimate the magnitude of net benefit, or indeed the existence of a benefit, of screening or treatment for GDM.”
Isn’t the point of a screen to catch *everyone* who *might* be at risk? That’s why there are so many false-positives that are then eliminated at the 3-hour test. It would make sense, perhaps, to test high-risk women, but I wonder why — especially since there isn’t a uniformity of standards, no set criteria for diagnosis for GD — at-risk women can’t just check their blood sugar for a day or 3 days or whatever while eating a normal meal to see how they react. Some other commenters have mentioned a “meal test” rather than the glucose drink. I’ve heard of women fainting or vomiting or other similar adverse reactions from the test, and I have to admit it makes absolutely no sense to me to force pregnant women to fast, and then guzzle a high-sugar drink, and then fast some more.
Lisa said
My first child was 10 lbs 8 oz at 39 wks 5 days. My GTT were always fine (and they did two or three with that pregnancy). During my second pregnancy, my thyroid was removed at 16 weeks and my endocrinologist INSISTED that any baby over 10lbs must be because of gestational diabetes. My second child was 10 lb 5 oz at 39 wks 2 days but this time my ob didn’t bother with doing more than one GTT; her words, “we know you aren’t diabetic”. THAT pissed off the endocrinologist.
Kathy said
SidneyMidwife just posted this post which said that Germany has decided that routine screening is better than not — because although there is no single standard, or single threshold for good vs. bad outcomes in GD, that the risk of complications caused by GD outweighs the negatives of the test. However, although the article seemed to pitch GD testing as a good thing, I kept waiting for the evidence, and it seems pretty slim — almost like, “Well, there isn’t *much* harm in doing the test, and it *might* do some good, so we ought to do it.” That almost sounds superstitious, rather than evidence-based.
Ladydilee said
In reply to the media, what gets me is the idea that this is Indonesia’s “biggest baby” on record. As if it were a goal to attain, or at the very least, something to be proud to lay claim to, if it should happen. I think humans as a species are fascinated with extremes, and this record keeping can be unhealthy. I don’t think most women would set out to break this record, but I do know that Guiness has discontinued some records due to the danger in attempting them. This category should be as well. Bigger is not better for babies.
mommymichael said
Hey Rachel,
My midwife does the meal approach. At the time of my first pregnancy, my friend and I were only 2 days apart. So we also had our GTT within a week of each other. We were going to different practitioners, and I remember the severe crash she had and just how horrible she felt after having her test done. The fasting, and the nasty sugary drink made her feel terrible.
Myself? I ate two large pancakes with 3 tbs of syrup, and a glass of orange juice. I was told that I could eat more but not less. They had different options for meals that I could make but I had to pick one off their list, and not just do my own.
The day of testing was like any other day. I felt fine and full. No crashing.
mommymichael said
Also, as a side note:
My friend Laura switched from and ob to a home birth midwife. She has to be very careful about her sugar intake because it makes her pretty sick. Almost as if she’s allergic to it. So she only eats sugar free things. When it came time for her GTT, she asked her ob to do a meal plan approach and he adamantly refused. Then proceeded to tell her that she was going to end up killing her baby if she didn’t do this test.
She wasn’t refusing the test. She was refusing the sugary drink that she knew would have horrible consequences for her. HE knew how her body reacted to sugar, she’d told him during her medical history.
So she switched to a CPM, did the GTT meal approach with her and had a home birth.
Kelli said
RR,
Great post. I agree completely. Love your blogs.
Joy said
When I saw this story I immediately wondered how safe and healthy this little baby truly was. I’m afraid for him and what the future might hold (obesity for one? He’s as large as most 1-year-olds!).
Rosemary said
This also drives me crazy but for a different reason. I just gave birth to a 5.17kg (11 pound, 7 ounces I think is the conversion) 37 week baby. (Spontaneous labour etc etc) and if one more person tells me that I just had to have had GD I think I am going to kill that person. He came out fine. No breathing problems. No crashing blood sugars. A few hours of phototherapy to help him process all that bilirubin that he had by being 56cm tall. I agree that this Indonesian baby was not well, but why the hell does everyone think they have the right to diagnose me and my baby without knowing a damn thing about me. No sign of GD here. I just had a big baby.
BUT, and here is the big BUT, my diet was very good and my pre-natal care was very good. I certainly wouldn’t want ot downplay the risks of uncontrolled diabetetes. I’m just really annoyed with the crazy way in which the OB community insists that the GTT is the only way to check for diabetes, when they can’t even agree on the standards for measurement and who should be screened. Rant over. Time to go feed by my beautiful little baby.
Gloria Lemay said
I’m glad you did this post and thanks for linking it to my blog.
I find that the longer I’m in the birth business the more scared I am of “infant of a diabetic mother” syndrome. Before you’ve seen a few disasters, innocence is bliss. Doctors, nurses and midwives aren’t just being mean with women, there is a real fear of baby death in situations where diabetes is at play.
One time I was sitting in a movie theatre and the two women behind me were talking. One said to the other “I had my glucose tolerance test and I don’t have gestational diabetes so I can eat all the chocolate I want for the rest of the pregnancy.” The other one laughed in agreement. Her poor baby. Little babies in the womb are a small living organism and are affected by sugar and caffein just as a small dog is. Your little poodle dog can die from eating a bunch of chocolate.
One of my student midwives had an interuterine death happen in her own family. Her sister was expecting her 3rd baby in another province. We were getting regular updates on the pregnancy because it was to be a VBA2C. One day she came to class in tears. Her sister had gone the a.m. before to have an u/s (probably a non stress test) at 40 w.g.a. She was driven into town by a neighbour who also had 2 kids. They arrived early for the appt so they took the 4 kids to Dairy Queen. Her baby had been moving normally that a.m. The pregnant woman ate a caramel sundae and that tasted so good, she had a second one. When she went for the u/s her baby had died. It was a full term beautiful baby that couldn’t cope with that much sugar at the end of pregnancy. Devastating loss.
The other place where this gest. diabetic thing comes into play, in my experience, is with women who have repeated unexplained miscarriages. The testing isn’t done till 28 w.g.a. because that’s when the placenta is big enough to really be taxing the woman’s insulin but what of the women who have fetal loss before that? I’ve worked with 2 women who finally carried to full term when I supported them to eat and exercise like a gest. diabetic right from the early weeks of pregnancy.
The thing about a G.D. regimen is that it’s good for everybody, anytime. It’s basically the Zone Diet. Small amounts often, no binging, no starving. No processed sugar or flour. Brisk exercise after meals. That’s the way humans are designed to eat and move.