Gestational Diabetes Mellitus (GDM) is an intolerance of carbohydrates that appears during pregnancy. In simpler terms, it is diabetes while being pregnant which can complicate childbirth. The most common concern is the size of the child. Delivering large children can lead to a more difficult labor and delivery that may result in shoulder dystocia or a brachial plexus injury.
A recent study using new diagnostic criteria found that 18% of pregnancies are affected by gestational diabetes, much higher than previous estimates of 1-14%. Think about that. Almost one in five pregnant women. Doctors should be on the lookout. Still, misdiagnosis of gestational diabetes is all too common, carrying risks to both mother and fetus. Children born to mothers with GDM may have excessive birth weights resulting in high rates of cesarean delivery which carries the risk of trauma to both mother and child. Babies also have a risk of hypoglycemia (low blood sugar) and hyperinsulinemia (high blood insulin). They are also at risk for glucose intolerance and long-term obesity.
Following pregnancy, women who have gestational diabetes have a 40 to 60% chance of developing diabetes in the next 10 to 20 years and an estimated 5 to 10% of women who have had GDM develop diabetes immediately following pregnancy. Current practice has been under recent review to correctly diagnose GDM, with a goal of increasing the proportion of women diagnosed.Guidelines and Testing
Canadian healthcare guidelines suggest that HbA1c levels be ≤6.0% (normal), fasting blood glucose 3.8 to 5.2mmol/L, one hour post-prandial (post meal/glucose challenge) glucose of 5.5 to 7.7mmol/L and two-hour postprandial glucose of 5.0 to 6.6mmol/L. Similar guidelines are used in the U.S. but do not usually - for whatever reason - include HbA1c targets.
A two-step approach (glucose challenge test + oral glucose tolerance test) is recommended by the American Diabetes Association to help prevent missed opportunities for diagnosis and is reported to increase diagnosis rates from 80% to 90% although at least many of the doctors defending other doctors in medical malpractice cases sometimes disagree.
Others have suggested that glucose testing at 16 weeks of pregnancy has a high predictive rate (up to 96%) to detect those women at risk of developing GDM during the third trimester. Although there are additional costs associated with glucose challenge, due to the high rate of missed diagnoses of GDM, it may be best practice to test all women during pregnancy and not select those that should undergo a glucose challenge and OGTT based on risk factors. This is further supported by a study in Belgium that found that over half of the cases of GDM were missed when only subjects with risk factors were tested. Furthermore, testing during each trimester may be indicated to prevent missed diagnosis.
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Any woman can get gestational diabetes. Doctors should not stereotype who may have it based on anything other than proper assessment, evaluation, and testing. A study published in 2005 found that in a group of 532 patients tested for GDM without consideration of risk factors found that 47% of the women with GDM would have been missed if screened only based on risk factors. That said, women of Native-American/Aboriginal, Hispanic, South Asian, Asian and African descent are at increased risk. Other risk factors include age, obesity, use of corticosteroids and polycystic ovary syndrome.
The risk of a difficult delivery with a large baby leads many obstetricians to recommend that many women with gestational diabetes should have a C-section instead of vaginal birth. At the core of many birth injury lawsuits is the allegation that OB should have performed a C-section. Whether the failure to perform a C-section is medical malpractice depends on the unique facts of a given case.
There are two types of gestational diabetes malpractice cases:
- Failing to realize the woman has gestational diabetes
- Failing to properly treat the patient who has it.
Doctors must monitor a woman with gestational diabetes to make sure the child is growing at the appropriate rate and that the woman's glucose levels are under control. Insulin shots are sometimes necessary to keep diabetes under control so that it does not interfere with the pregnancy.Gestational Diabetes Medical Literature
In gestational diabetes malpractice cases, there is a body of medical literature frequently relied upon by experts. Here is some of that literature along with a new study that just came out:
- 2020: Artzi, N, et. al: Prediction of gestational diabetes based on nationwide electronic health records. Nat Med 2020; 26(1):71-76 (2020) (Israeli study that show that gestational diabetes can be diagnosed with a high degree of accuracy by asking nine questions).
- 2019: Scholtens, D, et. al: Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study (HAPO FUS): Maternal Glycemia and Childhood Glucose Metabolism, Diabetes Care 2019 Mar; 42(3): 381-392 (on the maternal glucose spectrum, exposure to higher levels in utero is linked with childhood glucose and insulin resistance, regardless of maternal and childhood BMI and family history of diabetes).
- 2018: Lowe, W. et. al: Association of gestational diabetes with maternal disorders of glucose metabolism and childhood adiposity. JAMA 320, 1005–1016 (2018).
- 2015: Peterson C, et al. Preventable health and cost burden of adverse birth outcomes associated with pregestational diabetes in the United States. Am J Obstet Gynecol 2015;212:74.e1–74.e9.
Below are gestational diabetes stories of complications and how the legal system handled the case, either by settlement or verdict.
- 2019, New York: $850,000 Settlement. A mother alleged that the physician's negligent delivery of her son caused his Erb's palsy, brain injury, and developmental delays. Her birth injury lawsuit claimed that he failed to treat her gestational diabetes, failed to consider macrosomia, failed to order a C-section, applied excessive force during a vacuum-assisted delivery, and failed to treat fetal distress. The physician denied liability. This case settled for $850,000.
- 2018, Minnesota: $8,986,957 Verdict. A mother alleged that the nurse-midwife's negligently delivered her son, causing a brachial plexus injury involving significant paralysis. She alleged that the nurse-midwife failed to consider gestational diabetes, despite having tested positive in two out of three tests. The mother argued that her gestational diabetes necessitated a C-section because of the macrosomia risk. Instead, the nurse-midwife performed a vaginal delivery, where she encountered shoulder dystocia. The mother claimed the physician used excessive force and failed to timely summon an available OB/GYN. She also alleged the nurse-midwife should have called for assistance rather than perform the delivery herself.. A jury awarded an $8,986,957 verdict.
- 2016, California: $950,000 Settlement. A newborn's parents alleged that the physician's negligent delivery of their daughter caused arm paralysis. The physician had delivered one of their prior children. During that delivery, he encountered shoulder dystocia but failed to inform the parents. Thankfully, the child was born uninjured. During this pregnancy, the physician diagnosed gestational diabetes but failed to inform the parents. The parents alleged that the physician's failure to inform them of these two birth complications prevented them from considering a C-section. They argued that the physician should have informed them about the prior shoulder dystocia because this increased the risk of another one. The parents also claimed that the physician and nurses performed inappropriate maneuvers when they encountered shoulder dystocia. They claimed that this caused their daughter to suffer a brachial plexus injury that left her arm paralyzed, despite undergoing surgery. The mother also suffered vaginal injuries, while the father suffered emotional distress. The defense argued they provided appropriate treatments and did not cause either the parent's or daughter's injuries. This case settled for $950,000.
- 2016, New York: $2,000,000 Settlement. A newborn girl's parents alleged that the physicians' negligence caused their daughter's brachial plexus injury. They claimed that the physicians failed to consider a C-section despite the mother's gestational diabetes and the daughter's macrosomia. The parents alleged that this resulted in a negligently performed vaginal delivery. They claimed that the physicians performed inappropriate maneuvers when they encountered shoulder dystocia. As a result, their daughter suffered Erb's palsy, Horner syndrome, and a left humerus fracture. Despite undergoing surgery, she ultimately suffered permanent injuries. The case settled for $2,000,000.
- 2014, Massachusetts: $950,000 Settlement. A mother alleged that the physician's failure to consider a C-section caused her child's brachial plexus injury. She argued that her gestational diabetes and her daughter's macrosomia necessitated a C-section. Instead, the physician attempted a vacuum-assisted delivery that failed to deliver her daughter. They then encouraged the mother to keep pushing, rather than order an emergency C-section. The physician made another attempt at a vacuum-assisted delivery, which delivered the head. However, they encountered shoulder dystocia, prompting them to attempt unsuccessful maneuvers. The physician ultimately performed a posterior arm delivery and applied suprapubic pressure. Two minutes later, the 10-pound baby was delivered. They suffered a permanent brachial plexus injury. The mother and child's birth injury attorney alleged that the physician's failure to timely perform a C-section caused her child's injuries. She also claimed they failed to consider several risk factors for shoulder dystocia including gestational diabetes and macrosomia. This case settled for $950,000.
Gestational diabetes is a challenge to pregnancy. But with good care and treatment, it can usually be managed in such a way that mother and child emerge unharmed.
If you believe you had gestational diabetes but were not properly diagnosed and treated, and there is an injury to you or your baby, you may have a medical malpractice case for which you and your child could receive compensation. If you believe this was the case with you, call 800-553-8082 or get a free online consultation.