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IN THIS ARTICLE

Indications and advantages of transvaginal and transobturator slings

Fast Track

The adjustable sling may be especially useful in patients at risk of postoperative voiding dysfunction

Complication rates may reflect early evolution, and may improve with time and experience

There hasn’t been time.

Transobturator sling

Although the TOT is thought to be safer in this regard, complications including urinary retention, obturator hematoma and nerve injury, and urethral injury/erosion have been reported.⁶

A variety of TOT sling kits are available, none with proven superiority.

Which sling for which patients?

TABLE

Transvaginal vs transobturator sling

INDICATIONS	ADVANTAGES
Transvaginal (retropubic)
Physically active patient	Avoids groin discomfort with activity
Thin, young patient	Long term data available
Limited urethral hypermobility/internal sphincter dysfunction	Data supports use/dynamic backboard
Transobturator
Elderly patient	Less postop voiding dysfunction
Significant overactive bladder/urge incontinence	Less urethral obstruction
Previous retropubic surgery	Less risk of retropubic complication
Obesity	Less risk of needle-passage complication
Inexperience with TVT	Less risk of periop complications

Adjustable suburethral sling

Graft/mesh augmentation for prolapse repair

The author receives grant/research support and/or serves as a consultant for American Medical Systems, Boston Scientific, CR Bard, Mentor, Novartis, and Pfizer.

IN THIS ARTICLE

Indications and advantages of transvaginal and transobturator slings

Fast Track

The adjustable sling may be especially useful in patients at risk of postoperative voiding dysfunction

Complication rates may reflect early evolution, and may improve with time and experience

There hasn’t been time.

Transobturator sling

Although the TOT is thought to be safer in this regard, complications including urinary retention, obturator hematoma and nerve injury, and urethral injury/erosion have been reported.⁶

A variety of TOT sling kits are available, none with proven superiority.

Which sling for which patients?

TABLE

Transvaginal vs transobturator sling

INDICATIONS	ADVANTAGES
Transvaginal (retropubic)
Physically active patient	Avoids groin discomfort with activity
Thin, young patient	Long term data available
Limited urethral hypermobility/internal sphincter dysfunction	Data supports use/dynamic backboard
Transobturator
Elderly patient	Less postop voiding dysfunction
Significant overactive bladder/urge incontinence	Less urethral obstruction
Previous retropubic surgery	Less risk of retropubic complication
Obesity	Less risk of needle-passage complication
Inexperience with TVT	Less risk of periop complications

Adjustable suburethral sling

Graft/mesh augmentation for prolapse repair

The author receives grant/research support and/or serves as a consultant for American Medical Systems, Boston Scientific, CR Bard, Mentor, Novartis, and Pfizer.

References

1. Ulmsten U, Petros P. Intravaginal slingplasty (IVS): an ambulatory surgical procedure for treatment of female urinary incontinence. Scand J Urol Nephrol. 1995;29:75-82.

2. Kilonzo M, Vale L, Stearns SC, et al. Cost effectiveness of tension-free vaginal tape for the surgical management of female stress incontinence. Int J Technol Assess Health Care. 2004;20:455-463.

3. Holmgren C, Nilsson S, Lanner L, Hellberg D. Long-term results with tension-free vaginal tape on mixed and stress urinary incontinence. Obstet Gynecol. 2005;106:38-43.

5. Delorme E, Droupy S, de Tayrac R, Delmas V. Transobturator tape (Uratape). A new minimally invasive method in the treatment of urinary incontinence in women. Prog Urol. 2003;13:656-659.

6. Game X, et al. Obturator infected hematoma and urethral erosion following transobturator tape implantation. J Urol. 2004;171:1629.-

10. Milani R, Salvatore S, Soligo M, Pifarotti P, Meschia M, Cortese M. Functional and anatomical outcome of anterior and posterior vaginal prolapse repair with Prolene mesh. BJOG. 2005;112:107-111.

References

1. Ulmsten U, Petros P. Intravaginal slingplasty (IVS): an ambulatory surgical procedure for treatment of female urinary incontinence. Scand J Urol Nephrol. 1995;29:75-82.

2. Kilonzo M, Vale L, Stearns SC, et al. Cost effectiveness of tension-free vaginal tape for the surgical management of female stress incontinence. Int J Technol Assess Health Care. 2004;20:455-463.

3. Holmgren C, Nilsson S, Lanner L, Hellberg D. Long-term results with tension-free vaginal tape on mixed and stress urinary incontinence. Obstet Gynecol. 2005;106:38-43.

5. Delorme E, Droupy S, de Tayrac R, Delmas V. Transobturator tape (Uratape). A new minimally invasive method in the treatment of urinary incontinence in women. Prog Urol. 2003;13:656-659.

6. Game X, et al. Obturator infected hematoma and urethral erosion following transobturator tape implantation. J Urol. 2004;171:1629.-

10. Milani R, Salvatore S, Soligo M, Pifarotti P, Meschia M, Cortese M. Functional and anatomical outcome of anterior and posterior vaginal prolapse repair with Prolene mesh. BJOG. 2005;112:107-111.

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Defusing the angry patient

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Defusing the angry patient

Author(s)

James R. Woods Jr, MD

Patricia A. Bennett, PhD

Fay A. Rozovsky, JD, MPH

Fast Track

The correct response to anger is empathy, heartfelt if at all possible

Set an appointment to talk over her concerns

Allow 2 hours
Don’t sit behind a desk
Ensure security
Rehearse what you’ll say
Don’t delay

It may take 2 hours of talking or longer for extreme anger to soften

Admitting your mistakes may make the patient angrier, but it also lessens the risk of litigation

IN THIS ARTICLE

The 4 faces of anger
Anger’s fingerprints: Watch for these clues
When rage is only reasonable

Forego anger and save yourself 100 days of trouble, the Chinese proverb advises. If only it were that simple. Consider the angry patient, possibly the most feared and least understood of all patients. Effective risk management goes far beyond things that stand to reason, such as “listening.”

The cases below show why patients get angry, what clues signal anger, what to say, and what not to say. But the focus throughout is how to prepare yourself and your staff to defuse the angry patient, from the first encounter through the essential follow-up: the office visit that you set up specifically to address her anger and reduce the risk of legal action.

Tracing anger’s fuse

KIM’S CASE

Kim is a 21-year-old G1P0000 with type 1 diabetes who did not comply well with her insulin and diet regimens. At 39 weeks’ gestation, with an estimated fetal weight of 4,000 g, she demands a vaginal delivery. At delivery, severe shoulder dystocia occurs, resulting in what the family later recalls as chaotic activity in the delivery room and severe nerve damage to the newborn’s left arm. When you meet with the couple and the wife’s sister later that day, all 3 express intense anger at you.

How should you respond?

Anger can occur when there is an unexpected adverse outcome, or when a patient feels responsible for a poor outcome. Either way, you may be a “safer” target than the actual cause.

In Kim’s case, each family member feels angry for a different reason, and you should try to draw their reasons out in conversation so they can be addressed. Don’t assume all are angry for the same reason.

The new mother feels terrible because her noncompliance contributed to the outcome. She expresses her anger at you to overcome feelings of failure.
The husband is angry with his wife because she did not follow her diet and insulin instructions carefully, but he is afraid to confront her after nearly losing their newborn son. He therefore directs his anger at you.
The sister is angry with you out of a sense of helplessness and a desire to “make someone pay.”

How do you sort out these different causes of anger? Even a simple phrase can initiate an open-ended discussion, such as, “There are many reasons people become angry. Perhaps in our conversation we will be able to identify those reasons.” Then, using a hypothetical “third-person” approach, you can safely explore the patient’s guilt, the husband’s misdirected anger, and the sister’s need for vengeance. Addressing the guilt, for example, you might say, “In some cases a patient’s choice of medical care may differ from what is suggested by her doctor. If that care is not contrary to medical standards, yet results in a bad outcome, the patient may feel very guilty, and that guilt sometimes masquerades as anger. Have you felt any of these emotions?”

In conversation, describe each step of the delivery process, to clarify misconceptions, and discuss the controversy over how best to manage a 4,000-g infant when the mother has diabetes. Also realize that the “chaotic activity” the family witnessed during the delivery may have contributed to their anger. An explanation of what was actually taking place may allay some of their concern.

In this case, knowing the patient was diabetic, the physician should have discussed the risks of various delivery methods well before the actual birth.

4 faces of anger

When is anger a healthy response and when is it pathologic?

It is beneficial when we use it to inform our actions. For example, if a physician feels angry about the proposed changes to Medicaid and writes a letter to her congressman, she is using anger constructively.

Anger is a problem when it changes to aggression, is buried, or is used to manipulate others. Research has linked chronic anger-management problems with interpersonal strife, difficulties at work, poor decision-making, increased risk-taking, substance abuse, coronary heart disease, stroke, chronic pain, disruption of motor activities (such as driving), and susceptibility to depression, guilt, and shame.²

Greenberg³ identified 4 ways of classifying expressed emotions such as anger, which the following 4 cases illustrate:

CASE 1. When anger sparks a change for the better A patient expresses anger at having to wait more than an hour to see you. By bringing it to your attention, she makes it possible for you to address the issue with office staff.

When anger is a primary adaptive response, it enables one to organize for action and to hold another responsible for injuring her. This is a healthy expression of anger; it lets a person act in congruence with both cognition and emotion.

CASE 2. When anger gets stuck Upon arrival, a patient informs your staff that she has no intention of being kept waiting. This woman considers even the slightest delay a personal affront.

When anger is a primary maladaptive response, it indicates a stuck pattern of behavior and emotional expression in which anger becomes a reflexive reaction, rather than an action. When anger takes this form, it can cause an individual to overestimate the threat to herself and damage relationships through aversive behavior.

CASE 3. Anger as a cover A woman with a newly discovered breast lump is afraid she has cancer. Rather than express this fear, she accuses you of withholding information.

In this instance, anger conceals an underlying emotion, and is therefore the secondary emotion. Sometimes the person is aware of the underlying feeling, sometimes not.

CASE 4. Anger as manipulation A patient wants cab fare provided for her and her children to get to their appointments; the norm is to provide bus fare. The patient threatens action and negative word-of-mouth, complains to the insurance company, and ultimately gets the cab fare.

Anger can be used as an instrument to manipulate others, to bring about a desired outcome.

How anger rears its head

“In your face”

Although a woman may express—or contain—her anger in any number of ways, a few styles tend to predominate. Probably the most fearsome patient is the one with an “in your face” style, who yells, swears, or threatens people. If a nurse doesn’t jump to her demands, she asks for the supervisor and threatens to file a report.

Although it can be intimidating, there is one advantage to this style of anger: At least you know where you stand.

“I don’t do anger”

At the other end of the continuum is the woman who denies her anger. We once had a patient who proclaimed, “I don’t do anger,” but the midwife who referred her described her as one of the angriest patients she had ever seen. In our encounter, she was visibly tense and responded in short, clipped sentences, but we could not address her anger directly because she refused to admit its existence.

Noncompliance as power struggle

Indirect anger falls somewhere between the above 2 extremes. Women tend to be socialized to withhold their anger to preserve relationships, so they often feel safer expressing it indirectly. Passive-aggressive behavior is one example. The patient may arrive late or forget her insulin logs, or she may say everything is fine but call later in the day with an important concern. This conduct may seem like noncompliance, but noncompliance can be rooted in anger. Communication can become a power struggle in which the patient demonstrates her anger by refusing to do as you ask. Dropping out is the ultimate expression of indirect anger; the patient merely quits.

Somatization

Another way indirect anger manifests is through somatization, an unconscious process in which the patient does not articulate her emotions but experiences them physically. Treatment often has little effect.

The quiet woman

Also be aware that women often stifle their emotions until they feel overwhelmed and resentful, at which point they may explode.

Anger’s fingerprints: Watch for these clues

PHYSIOLOGIC

Shortness of breath
Rapid breathing
Pressured speech: louder and faster
Clenched teeth, fists
Muscle tension
Rapid heart rate
Shakiness, trembling
Tight jaw
Indigestion, nausea, diarrhea
Headache
Flushing, sweating
Fatigue

BEHAVIORAL

Pointing a finger
Getting in another person’s “space”
Leaning toward the other person
Rolling eyes
Raising the voice
Profanity
Harsh or hostile tone
Strong or extreme language
Sarcasm
Making accusations
Slamming doors or phones
Aggression toward a person or object

COGNITIVE

Dichotomous thinking: all or nothing, black or white
Exaggeration and generalization: always, never
Distorted thinking
Rigid ideation: “It must be this way or else,” “I will not stand for this,” etc

The slippery slope of how to respond

The correct response to anger is empathy, which should be heartfelt, if at all possible.

Unfortunately, personality and personal issues sometimes impede our ability to empathize openly. It is important to avoid paternalism, evasiveness, and self-blame.

Paternalism in many ways is built into the medical hierarchy. Our specialized knowledge is the reason we’re consulted in the first place, and an intellectual or condescending remark on our part may be a natural defense to a patient’s angry attack, but such a reaction only fuels the fire. Nor should we ever use our role as an authority to dismiss the patient’s anger.

Evasiveness is another frequent response to anger, but can lead to detachment and feed the patient’s perception that you are unfeeling.

Acquiescing to her demands in hopes of avoiding further confrontation or a lawsuit may decrease her anger, but increase your own resentment.

Worst of all is self-blame, in which the physician assumes and internalizes responsibility for failing the patient or lacking perfect knowledge. Though this approach may quickly quell the patient’s anger, it can harm the physician-patient relationship and your emotional health.

When rage is only reasonable

Loss of control. Some diseases or conditions have uncontrollable outcomes. For example, a woman with ovarian cancer may feel angry when she realizes she cannot necessarily get better by following a particular plan of action.

“Why me?” Feelings of perceived injustice arise when circumstances seem particularly unfair, as when a woman experiences fetal death in utero despite responsible self-care, and sees less responsible women deliver healthy babies.

Not listening, inattention. Poor communication often leaves the patient feeling as though you failed to listen to her concerns. For example, when you give her less than full attention, an obese woman with gestational diabetes may feel blamed for her own problems.

History of sexual abuse. In women with a history of sexual trauma, obstetric or gynecologic procedures can sometimes remind them of abuse, and themes of powerlessness and lack of control may be reenacted. While it may have been unsafe—or even fatal—for these women to express anger at the original perpetrator, they may feel safer directing it at you.

When a patient pushes your buttons

ERIN’S CASE

At 36 weeks’ gestation, Erin calls your office at the end of the day on a Friday with an emergency: She couldn’t sleep the day before. You feel angry; why? Is it because you had plans to go out to dinner and now will be late? Is it because Erin has been demanding and needy throughout her pregnancy? Is it because Erin doesn’t follow the protocol for nonemergencies and acts as though everything is an emergency? Is it because no matter what you do, Erin hasn’t been satisfied with her care?

These questions can help you decide how to proceed. In any tense situation, the first step is to identify the angry party. This is not always as straightforward as it sounds, since anger is frequently displaced. It may be the patient or her family who shows signs of anger. It may be you. Or it may be both.

Dealing with an angry patient is easier if you keep sight of your own triggers and sore spots. This self-awareness allows you to assert control and contain your emotional reaction.

Coach yourself through an angry encounter. When you recognize your own limits, it is easier to manage difficult situations using “self-talk” to coach yourself through them. For example, when your patient becomes angry, you might remind yourself, “Take a deep breath.” As she complains, you might tell yourself, “This is not personal, even though it feels that way. What is she trying to tell me?”

Formal role-playing and informal discussions of real or hypothetical cases are another strategy.

How to conduct an anger-defusing visit

Set an appointment to talk it out

When a patient expresses anger that does not abate with empathetic listening, consider scheduling a special visit to address her concerns. And prepare for it:

Don’t sit behind a desk. Determine where the conversation will be held, including the seating arrangement. It is inappropriate to sit behind a desk for the discussion, as this arrangement can exacerbate the division between you and the patient. If your office is not conducive to a “relaxed” talk, consider a more neutral site.

Check the exits. Always consider the possibility that the patient or a family member may feel outraged to the point of physical abuse. Make sure security personnel are readily available; if necessary, agree upon a prearranged signal for them to intervene. Also consider whether you will have easy access to the door. During the conversation, do not accept or tolerate threats.

Make it soon. When emotions run high, it is probably best to talk within a week. Avoid a delay of several weeks in hopes that anger will dissipate. What usually happens during such a long interval is that the family becomes angrier and seeks outside advice, much of which is negative. The patient also may change doctors because of the anger and abandonment she feels.

Schedule plenty of time. When enough time is devoted to the discussion, anger generally begins to dissipate. Therefore, do not limit conversation if the case is especially contentious and the risk of a lawsuit very real. On the contrary, it may take 2 hours or longer for the anger to soften.

Rehearse. A role-playing scenario with a colleague can help you experience the full impact of how anger alters a discussion.

Here’s what to say

JULIA’S CASE

A 48-year-old patient reported a breast lump at her last annual visit. At that time, upon examination, you palpated a small mass. Since Julia also has fibrocystic breast disease, you explained that the lump was probably benign, but you referred her for a mammogram and encouraged her to get it as soon as possible. When she finally did—8 months later—invasive carcinoma was diagnosed, necessitating a lumpectomy and chemotherapy.

At her next annual visit, Julia is confrontational, accusing you of downplaying the risk of breast cancer and causing her delay in seeking a mammogram. When she remains outraged despite your calm reminder that you recommended an expeditious mammogram, you schedule an appointment to discuss the matter.

What are your next steps?

Though the logistics are straightforward, success depends on the specific patient and any family members involved.

In general, you should strive to:

Establish an agenda and review it with the patient.
Describe the facts of the case in lay terms so that the patient, her family, and any others receive the same information. This helps eliminate erroneous assumptions and misinformation. For example, Julia’s family may not be aware that you encouraged her to obtain a mammogram as soon as possible.
Express empathy that she has to go through this serious time in her life, and acknowledge that a cancer diagnosis and treatment are tremendously stressful.
Search for the reasons behind the anger. Ask how the patient and her family have arrived at their conclusions.
Control anger and prevent it from escalating. Keep your voice steady and maintain an open body language. Avoid signs of your own anger.
Ask for her perception of what has been said, at the conclusion. If family members are present, ask for any other issues that need clarification.
Close the discussion respectfully.
Document the conversation by noting the time, persons present, what was discussed, attitudes of the family, and any plans for follow-up. How thorough should this medical note be? If you were to read your own documentation 5 years from now (the length of time it often takes a disputed malpractice claim to come to trial), would the written facts of the conversation enable you to reconstruct the complete interaction with the family? If the answer is yes, the documentation is complete.

In short, directly address the causes of the anger after laying out the facts and expressing your empathy or condolence.

When anger flares

Ask the question. The first step is intervening to interrupt the momentum. One way is to ask, “What would you have wanted us to do?” This usually changes the pace of the conversation by giving the patient a chance to talk at some length.

Acknowledge. Another tactic is saying, “I would be very angry, too, if I were in your shoes, and I would want explanations as well.” By making such a statement, you co-opt the patient’s anger momentarily, which can be enough to defuse the situation.

From that point on, making sure the anger doesn’t get out of control is the challenge.

Uphold principles. During such a conversation, basic principles should prevail:

Express respect
Be honest
Remain calm
Articulate empathy for the patient’s loss or injury.

What if the patient is right? You must be prepared to admit your mistakes when the patient and her family are correct in their assumptions. This honesty will not necessarily make the patient forgive you. In fact, she may become even angrier. But she is less likely to sue if you are honest.

Practices that prevent suits

Address absence of facts

In the early aftermath of an event, key information may remain unknown. It takes time to complete and evaluate interviews, equipment analysis, and test results.

When the patient asks, “Why did this happen?” it is appropriate to respond: “We do not know and will not know until all the necessary information is collected and reviewed. I think you would agree that it would not be helpful for me to speculate or conjecture. But as soon as we have all the facts we can present them to you.”

Get key information from patients

Not only is it important for you to share information with the patient, but she should provide key details about the event in question, too. This step is especially important when there is a concern about patient noncompliance.

If such noncompliance comes to light, share it with the people who must complete an incident evaluation. It will help put the outcome in context and neutralize lingering hostility.

Identify 1 spokesperson

Angry, dissatisfied patients and their families often seek out answers from other health professionals, such as nurses who participated in treatment. Instruct staff members and colleagues to decline to comment directly to the patient.

Train staff in verbal control

Staff should be taught how to respond when confronted by an angry patient. Unfortunately, shouts and threats to go to the press or to sue are not unusual.

Books on negotiation or conflict management are available in most libraries, and many colleges or other institutions offer classes on anger management. Unfortunately, such training remains only a peripheral part of medical education.

Dr. Woods and Dr. Bennett report no financial relationships relevant to this article. Ms. Rozovsky is President of Quality Medical Communications LLC, a company that produces video and written material for care provider education.

References

1. Woods JR, Rozovsky FA. What Do I Say? Communicating Intended or Unanticipated Outcomes in Obstetrics. San Francisco: Jossey-Bass; 2003.

2. Kassinove H, Tafrate RC. Anger Management: The Complete Treatment Guidebook for Practitioners. Atascadero, Calif: Impact Publishers; 2002.

3. Greenberg LS. Emotion-Focused Therapy: Coaching Clients to Work Through Their Feelings. Washington, DC: American Psychological Association; 2002.

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James R. Woods, Jr, MD
Henry A. Thiede Professor & Chair, Department of Obstetrics and Gynecology, University of Rochester, School of Medicine and Dentistry, Rochester, NY
Patricia A. Bennett, PhD
Senior Instructor, Department of Psychiatry, University of Rochester, School of Medicine and Dentistry, Rochester, NY

Fay A. Rozovsky, JD, MPH
Vice President and Manager, Health Care Risk Management, Chubb Specialty Insurance, Simsbury, Conn

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Read more about Defusing the angry patient

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James R. Woods Jr, MD

Patricia A. Bennett, PhD

Fay A. Rozovsky, JD, MPH

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James R. Woods Jr, MD

Patricia A. Bennett, PhD

Fay A. Rozovsky, JD, MPH

Author and Disclosure Information

Fay A. Rozovsky, JD, MPH
Vice President and Manager, Health Care Risk Management, Chubb Specialty Insurance, Simsbury, Conn

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Vice President and Manager, Health Care Risk Management, Chubb Specialty Insurance, Simsbury, Conn

Article PDF

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Fast Track

The correct response to anger is empathy, heartfelt if at all possible

Set an appointment to talk over her concerns

Allow 2 hours
Don’t sit behind a desk
Ensure security
Rehearse what you’ll say
Don’t delay

It may take 2 hours of talking or longer for extreme anger to soften

Admitting your mistakes may make the patient angrier, but it also lessens the risk of litigation

IN THIS ARTICLE

The 4 faces of anger
Anger’s fingerprints: Watch for these clues
When rage is only reasonable

Tracing anger’s fuse

KIM’S CASE

How should you respond?

Anger can occur when there is an unexpected adverse outcome, or when a patient feels responsible for a poor outcome. Either way, you may be a “safer” target than the actual cause.

The new mother feels terrible because her noncompliance contributed to the outcome. She expresses her anger at you to overcome feelings of failure.
The husband is angry with his wife because she did not follow her diet and insulin instructions carefully, but he is afraid to confront her after nearly losing their newborn son. He therefore directs his anger at you.
The sister is angry with you out of a sense of helplessness and a desire to “make someone pay.”

In this case, knowing the patient was diabetic, the physician should have discussed the risks of various delivery methods well before the actual birth.

4 faces of anger

When is anger a healthy response and when is it pathologic?

Greenberg³ identified 4 ways of classifying expressed emotions such as anger, which the following 4 cases illustrate:

CASE 2. When anger gets stuck Upon arrival, a patient informs your staff that she has no intention of being kept waiting. This woman considers even the slightest delay a personal affront.

CASE 3. Anger as a cover A woman with a newly discovered breast lump is afraid she has cancer. Rather than express this fear, she accuses you of withholding information.

In this instance, anger conceals an underlying emotion, and is therefore the secondary emotion. Sometimes the person is aware of the underlying feeling, sometimes not.

Anger can be used as an instrument to manipulate others, to bring about a desired outcome.

How anger rears its head

“In your face”

Although it can be intimidating, there is one advantage to this style of anger: At least you know where you stand.

“I don’t do anger”

Noncompliance as power struggle

Somatization

The quiet woman

Also be aware that women often stifle their emotions until they feel overwhelmed and resentful, at which point they may explode.

Anger’s fingerprints: Watch for these clues

PHYSIOLOGIC

Shortness of breath
Rapid breathing
Pressured speech: louder and faster
Clenched teeth, fists
Muscle tension
Rapid heart rate
Shakiness, trembling
Tight jaw
Indigestion, nausea, diarrhea
Headache
Flushing, sweating
Fatigue

BEHAVIORAL

Pointing a finger
Getting in another person’s “space”
Leaning toward the other person
Rolling eyes
Raising the voice
Profanity
Harsh or hostile tone
Strong or extreme language
Sarcasm
Making accusations
Slamming doors or phones
Aggression toward a person or object

COGNITIVE

Dichotomous thinking: all or nothing, black or white
Exaggeration and generalization: always, never
Distorted thinking
Rigid ideation: “It must be this way or else,” “I will not stand for this,” etc

The slippery slope of how to respond

The correct response to anger is empathy, which should be heartfelt, if at all possible.

Unfortunately, personality and personal issues sometimes impede our ability to empathize openly. It is important to avoid paternalism, evasiveness, and self-blame.

Evasiveness is another frequent response to anger, but can lead to detachment and feed the patient’s perception that you are unfeeling.

Acquiescing to her demands in hopes of avoiding further confrontation or a lawsuit may decrease her anger, but increase your own resentment.

When rage is only reasonable

When a patient pushes your buttons

ERIN’S CASE

Dealing with an angry patient is easier if you keep sight of your own triggers and sore spots. This self-awareness allows you to assert control and contain your emotional reaction.

Formal role-playing and informal discussions of real or hypothetical cases are another strategy.

How to conduct an anger-defusing visit

Set an appointment to talk it out

When a patient expresses anger that does not abate with empathetic listening, consider scheduling a special visit to address her concerns. And prepare for it:

Rehearse. A role-playing scenario with a colleague can help you experience the full impact of how anger alters a discussion.

Here’s what to say

JULIA’S CASE

What are your next steps?

Though the logistics are straightforward, success depends on the specific patient and any family members involved.

In general, you should strive to:

Establish an agenda and review it with the patient.
Describe the facts of the case in lay terms so that the patient, her family, and any others receive the same information. This helps eliminate erroneous assumptions and misinformation. For example, Julia’s family may not be aware that you encouraged her to obtain a mammogram as soon as possible.
Express empathy that she has to go through this serious time in her life, and acknowledge that a cancer diagnosis and treatment are tremendously stressful.
Search for the reasons behind the anger. Ask how the patient and her family have arrived at their conclusions.
Control anger and prevent it from escalating. Keep your voice steady and maintain an open body language. Avoid signs of your own anger.
Ask for her perception of what has been said, at the conclusion. If family members are present, ask for any other issues that need clarification.
Close the discussion respectfully.
Document the conversation by noting the time, persons present, what was discussed, attitudes of the family, and any plans for follow-up. How thorough should this medical note be? If you were to read your own documentation 5 years from now (the length of time it often takes a disputed malpractice claim to come to trial), would the written facts of the conversation enable you to reconstruct the complete interaction with the family? If the answer is yes, the documentation is complete.

In short, directly address the causes of the anger after laying out the facts and expressing your empathy or condolence.

When anger flares

From that point on, making sure the anger doesn’t get out of control is the challenge.

Uphold principles. During such a conversation, basic principles should prevail:

Express respect
Be honest
Remain calm
Articulate empathy for the patient’s loss or injury.

Practices that prevent suits

Address absence of facts

In the early aftermath of an event, key information may remain unknown. It takes time to complete and evaluate interviews, equipment analysis, and test results.

Get key information from patients

If such noncompliance comes to light, share it with the people who must complete an incident evaluation. It will help put the outcome in context and neutralize lingering hostility.

Identify 1 spokesperson

Train staff in verbal control

Staff should be taught how to respond when confronted by an angry patient. Unfortunately, shouts and threats to go to the press or to sue are not unusual.

Fast Track

The correct response to anger is empathy, heartfelt if at all possible

Set an appointment to talk over her concerns

Allow 2 hours
Don’t sit behind a desk
Ensure security
Rehearse what you’ll say
Don’t delay

It may take 2 hours of talking or longer for extreme anger to soften

Admitting your mistakes may make the patient angrier, but it also lessens the risk of litigation

IN THIS ARTICLE

The 4 faces of anger
Anger’s fingerprints: Watch for these clues
When rage is only reasonable

Tracing anger’s fuse

KIM’S CASE

How should you respond?

Anger can occur when there is an unexpected adverse outcome, or when a patient feels responsible for a poor outcome. Either way, you may be a “safer” target than the actual cause.

The new mother feels terrible because her noncompliance contributed to the outcome. She expresses her anger at you to overcome feelings of failure.
The husband is angry with his wife because she did not follow her diet and insulin instructions carefully, but he is afraid to confront her after nearly losing their newborn son. He therefore directs his anger at you.
The sister is angry with you out of a sense of helplessness and a desire to “make someone pay.”

In this case, knowing the patient was diabetic, the physician should have discussed the risks of various delivery methods well before the actual birth.

4 faces of anger

When is anger a healthy response and when is it pathologic?

Greenberg³ identified 4 ways of classifying expressed emotions such as anger, which the following 4 cases illustrate:

CASE 2. When anger gets stuck Upon arrival, a patient informs your staff that she has no intention of being kept waiting. This woman considers even the slightest delay a personal affront.

CASE 3. Anger as a cover A woman with a newly discovered breast lump is afraid she has cancer. Rather than express this fear, she accuses you of withholding information.

In this instance, anger conceals an underlying emotion, and is therefore the secondary emotion. Sometimes the person is aware of the underlying feeling, sometimes not.

Anger can be used as an instrument to manipulate others, to bring about a desired outcome.

How anger rears its head

“In your face”

Although it can be intimidating, there is one advantage to this style of anger: At least you know where you stand.

“I don’t do anger”

Noncompliance as power struggle

Somatization

The quiet woman

Also be aware that women often stifle their emotions until they feel overwhelmed and resentful, at which point they may explode.

Anger’s fingerprints: Watch for these clues

PHYSIOLOGIC

Shortness of breath
Rapid breathing
Pressured speech: louder and faster
Clenched teeth, fists
Muscle tension
Rapid heart rate
Shakiness, trembling
Tight jaw
Indigestion, nausea, diarrhea
Headache
Flushing, sweating
Fatigue

BEHAVIORAL

Pointing a finger
Getting in another person’s “space”
Leaning toward the other person
Rolling eyes
Raising the voice
Profanity
Harsh or hostile tone
Strong or extreme language
Sarcasm
Making accusations
Slamming doors or phones
Aggression toward a person or object

COGNITIVE

Dichotomous thinking: all or nothing, black or white
Exaggeration and generalization: always, never
Distorted thinking
Rigid ideation: “It must be this way or else,” “I will not stand for this,” etc

The slippery slope of how to respond

The correct response to anger is empathy, which should be heartfelt, if at all possible.

Unfortunately, personality and personal issues sometimes impede our ability to empathize openly. It is important to avoid paternalism, evasiveness, and self-blame.

Evasiveness is another frequent response to anger, but can lead to detachment and feed the patient’s perception that you are unfeeling.

Acquiescing to her demands in hopes of avoiding further confrontation or a lawsuit may decrease her anger, but increase your own resentment.

When rage is only reasonable

When a patient pushes your buttons

ERIN’S CASE

Dealing with an angry patient is easier if you keep sight of your own triggers and sore spots. This self-awareness allows you to assert control and contain your emotional reaction.

Formal role-playing and informal discussions of real or hypothetical cases are another strategy.

How to conduct an anger-defusing visit

Set an appointment to talk it out

When a patient expresses anger that does not abate with empathetic listening, consider scheduling a special visit to address her concerns. And prepare for it:

Rehearse. A role-playing scenario with a colleague can help you experience the full impact of how anger alters a discussion.

Here’s what to say

JULIA’S CASE

What are your next steps?

Though the logistics are straightforward, success depends on the specific patient and any family members involved.

In general, you should strive to:

Establish an agenda and review it with the patient.
Describe the facts of the case in lay terms so that the patient, her family, and any others receive the same information. This helps eliminate erroneous assumptions and misinformation. For example, Julia’s family may not be aware that you encouraged her to obtain a mammogram as soon as possible.
Express empathy that she has to go through this serious time in her life, and acknowledge that a cancer diagnosis and treatment are tremendously stressful.
Search for the reasons behind the anger. Ask how the patient and her family have arrived at their conclusions.
Control anger and prevent it from escalating. Keep your voice steady and maintain an open body language. Avoid signs of your own anger.
Ask for her perception of what has been said, at the conclusion. If family members are present, ask for any other issues that need clarification.
Close the discussion respectfully.
Document the conversation by noting the time, persons present, what was discussed, attitudes of the family, and any plans for follow-up. How thorough should this medical note be? If you were to read your own documentation 5 years from now (the length of time it often takes a disputed malpractice claim to come to trial), would the written facts of the conversation enable you to reconstruct the complete interaction with the family? If the answer is yes, the documentation is complete.

In short, directly address the causes of the anger after laying out the facts and expressing your empathy or condolence.

When anger flares

From that point on, making sure the anger doesn’t get out of control is the challenge.

Uphold principles. During such a conversation, basic principles should prevail:

Express respect
Be honest
Remain calm
Articulate empathy for the patient’s loss or injury.

Practices that prevent suits

Address absence of facts

In the early aftermath of an event, key information may remain unknown. It takes time to complete and evaluate interviews, equipment analysis, and test results.

Get key information from patients

If such noncompliance comes to light, share it with the people who must complete an incident evaluation. It will help put the outcome in context and neutralize lingering hostility.

Identify 1 spokesperson

Train staff in verbal control

Staff should be taught how to respond when confronted by an angry patient. Unfortunately, shouts and threats to go to the press or to sue are not unusual.

References

1. Woods JR, Rozovsky FA. What Do I Say? Communicating Intended or Unanticipated Outcomes in Obstetrics. San Francisco: Jossey-Bass; 2003.

2. Kassinove H, Tafrate RC. Anger Management: The Complete Treatment Guidebook for Practitioners. Atascadero, Calif: Impact Publishers; 2002.

3. Greenberg LS. Emotion-Focused Therapy: Coaching Clients to Work Through Their Feelings. Washington, DC: American Psychological Association; 2002.

References

1. Woods JR, Rozovsky FA. What Do I Say? Communicating Intended or Unanticipated Outcomes in Obstetrics. San Francisco: Jossey-Bass; 2003.

2. Kassinove H, Tafrate RC. Anger Management: The Complete Treatment Guidebook for Practitioners. Atascadero, Calif: Impact Publishers; 2002.

3. Greenberg LS. Emotion-Focused Therapy: Coaching Clients to Work Through Their Feelings. Washington, DC: American Psychological Association; 2002.

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Current management of diabetic pregnancy

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Current management of diabetic pregnancy

Author(s)

Oded Langer, MD, PhD

Fast Track

I advise 20 to 30 minutes of exercise 3 to 4 times weekly, if women are willing and able, as it can improve postprandial blood glucose levels and insulin sensitivity

In my opinion, insulin lispro can and should be used in pregnancy because it produces more physiologic insulin patterns

Hypoglycemic episodes occurred in 63% of insulin-treated women with gestational diabetes, but in only 28% of women taking glyburide

Compromised lung maturity in a live infant is preferable to healthy lungs in a deceased infant

IN THIS ARTICLE

Treatment or consequences
Insulin requirements for pregestational diabetes
2 destructive complications

New agents such as insulin analogs (mainly insulin lispro) and oral antidiabetic drugs (mainly glyburide) have profoundly altered the management of diabetes, producing obstetric outcomes comparable to those among the general population. Furthermore, in all types of diabetes, self-monitoring of blood glucose plus intensified drug therapy may help women achieve glycemic control and enhance perinatal outcomes at a lower cost than conventional management—and patients readily accept this approach.

This article describes the rationale for intensive treatment with these agents and other interventions to prevent both hypoglycemia and hyperglycemia.

Intensive therapy requires:

memory-based self-monitoring of blood glucose, which empowers patients to take charge of glycemic control and provides feedback on the timing and dose of insulin administration,
dietary regulation,
strict criteria for initiation of pharmacologic therapy,
multiple injections of insulin or its equivalent when diet alone is insufficient, and
an interdisciplinary management team.

Two breakthrough studies in nonpregnant patients first showed the effectiveness of intensive therapy: the Diabetes Control and Complications Trial¹ and the United Kingdom Prospective Diabetes Study.^2,3 In the first, intensive therapy reduced the risk of retinopathy and lowered rates of microalbuminuria, albuminuria, and clinical neuropathy. In the second, intensive therapy substantially reduced the risk of microvascular complications.

Neither race nor ethnicity predicts treatment duration or success.^5-7

Blood glucose goals

Regardless of the treatment, the primary goal is always to achieve glycemic control, because it reduces the incidence of hypoglycemia, hyperglycemia, and ketosis. For type 1 and type 2 diabetes, glycemic control is important to prevent further deterioration of complications such as vasculopathy and nephropathy.

Goals of treatment are achieving the following blood glucose concentrations (in milligrams per deciliter):

mean: 90 to 105
fasting: 60 to 90
preprandial: 80 to 95
postprandial: less than 120

At each visit, the clinician evaluates these values and, when necessary, increases the dose of insulin or the oral agent to meet these goals.⁴

In the process, the clinician needs to anticipate how pregnancy will affect preexisting disease, and how diabetes will affect pregnancy outcomes, in patients with any of the 3 types of diabetes.

2 diet protocols

For all types of diabetes, the foundation is diet—specifically, using nutritional therapy to achieve and maintain a maternal blood glucose profile comparable to that of a nondiabetic woman.

Two approaches are recommended:

reducing carbohydrate intake to 40% to 50% of total calories or
limiting carbohydrate consumption to foods with a low glycemic index for approximately 60% of calories.

Only women who achieve targeted levels of glycemic control improve insulin secretion and sensitivity. Those who fail to achieve it may exhibit slightly improved sensitivity, but do not attain the same level of insulin response and sensitivity as non-diabetic women.^4,5

Calculating calories: Same for all

The daily caloric intake is based on the prepregnancy body mass index (BMI) and uses the same formula for all 3 types of diabetes^10,11:

For a BMI less than 20 (underweight), daily caloric intake should be 35 to 38 kcal/kg.
For a BMI of 20 to 25 (normal weight), the patient should consume 30 kcal/kg.
For a BMI of 26 and higher (overweight, obese, morbidly obese), caloric intake should be 20 to 25 kcal/kg.

Calories per day are then calculated according to the patient’s weight during pregnancy and are adjusted throughout pregnancy as that weight increases.

In addition, the daily allotment of calories is divided into 3 main meals and 3 to 4 snacks, with adjustments for the patient’s time constraints, work schedule, and other individual factors.

To encourage compliance, the diet also should reflect the patient’s cultural preferences.

How do you know when diet fails?

Women with pregestational diabetes are usually already taking insulin or other pharmacologic agents by the time they conceive. There is no consensus or hard data on how long a woman who develops gestational diabetes mellitus should remain on a diet before starting drug treatment.

In a study evaluating the time required to achieve glycemic control with diet alone during a 4-week period, 70% of patients with fasting plasma below 95 mg/dL achieved established levels of glycemic control within 2 weeks with no substantial improvement thereafter.^8,9 In contrast, in patients with fasting plasma glucose of more than 95 mg/dL, most patients failed to achieve the desired level of glycemic control throughout the 4-week period.

Hypoglycemia after exercise can be a positive marker

I recommend 20 to 30 minutes of exercise 3 to 4 times weekly for gravidas with diabetes, provided they are willing and able to perform it, because it can improve post-prandial blood glucose levels and insulin sensitivity.¹²

Blood glucose should be measured after exercise, especially in women with type 1 diabetes.

Hypoglycemic reactions during and after exercise may be positive markers of improved insulin sensitivity. Low blood glucose necessitates adjustment of the insulin dose and carbohydrate intake. Extra monitoring is warranted after evening exercise, as glucose uptake increases for several hours after exercise and can cause nocturnal hypoglycemia.

Intensive therapy: Why, when, how

The healthy body secretes insulin over 24 hours independent of nutrient intake. Basal insulin secretion maintains metabolic homeostasis by preventing excessive hepatic glucose production and the mobilization of free fatty acids from adipose tissue stores. This also helps maintain protein balance. Insulin secretion increases several times in response to the ingestion of food.

INTEGRATING EVIDENCE AND EXPERIENCE

Treatment or consequences

Langer O, Yogev Y, Most O, et al. Gestational diabetes: The consequences of not treating. Am J Obstet Gynecol. 2005;192;989-997.

When diabetic women receive adequate preconception care and counseling and achieve glycemic control, the rate of congenital anomalies declines to levels seen in the general population.^69-72

On the other hand, maternal hyperglycemia and resultant fetal hyperinsulinemia are central to the pathophysiology of diabetic complications:

type 1 and type 2 diabetes—congenital malformations
all pregnancies compromised by diabetes—increased rates of deviant fetal growth (macrosomia and intrauterine growth restriction), neonatal metabolic, hematological and respiratory complications, birth trauma, stillbirth, cesarean delivery and intensive care admissions.

I tell patients, “Some improvement is better than none” I explain to my patients how pregnancy itself imposes risk, and why it is crucial to follow protocols and achieve glycemic control. I explain the maternal and fetal complications associated with various glucose thresholds, and the added risks of maternal age, body composition, disease severity, and so on.

However, I also stress that even some improvement in glucose control is better than no improvement.

In the diabetic patient, the aim of intensive insulin therapy is to mimic normal physiology. Basal insulin is provided by administration of NPH, Lente, or Ultralente at bedtime and sometimes before breakfast as well. Insulin also is given before meals (0 to 15 minutes before for lispro, or 30 to 45 minutes before for regular insulin). This algorithm is the foundation of intensive therapy, which involves multiple injections daily versus 1 or 2 injections for conventional therapy.

Insulin dosage requires frequent adjustment

To determine the insulin dose needed to achieve glycemic control in pregnant gravidas, multiple blood glucose measurements are needed because insulin requirements steadily increase throughout pregnancy in women with pregestational diabetes.^13-16 Jovanovic and Peterson¹³ quantified these increases as 0.7, 0.8, 0.9, and 1.0 U/kg per day in the first trimester and at weeks 18, 26, and 36, respectively.

Using memory-based reflectance meters to monitor blood glucose, my colleagues and I observed that insulin requirements during pregnancy in women with pregestational diabetes are triphasic (TABLE) and require frequent assessment with individualized adjustment of the insulin dose in each trimester.¹⁶ Women with type 2 diabetes require significantly higher doses of insulin each trimester, compared with women with type 1 diabetes.

In women with gestational diabetes, we observed a biphasic increase in insulin requirements¹⁷:

Insulin requirements increased up to the 30th week of gestation, necessitating frequent dose adjustments.
After 30 weeks, insulin requirements stabilized, requiring minimal or no dose adjustments. Insulin requirements for obese subjects were 0.9 U/kg per day, compared with 0.8 U/kg per day for nonobese women.

The actual insulin dose varied more for obese than for nonobese women.

TABLE

Insulin requirements during pregnancy for women with pregestational diabetes

	INSULIN REQUIREMENT (UNITS/KG/DAY)
TRIMESTER	TYPE 1 DIABETES	TYPE 2 DIABETES
1	0.86	0.86
2	0.95	1.18
3	1.19	1.62
Insulin requirements vary with gestational diabetes

When to start drugs

Most women with pregestational diabetes are treated with insulin prior to pregnancy. Thus, the main task during pregnancy is maintaining or improving glycemic control. In gestational diabetes, pharmacologic therapy (insulin or glyburide) is initiated only when regulation of the diet fails to achieve the desired level of glycemic control or when the disease is severe enough to mandate therapy.

Authorities disagree on the threshold of severity that necessitates pharmacologic intervention (glyburide or insulin). Some suggest a threshold of fasting plasma glucose of at least 95 mg/dL,^18-20 which will decrease the rate of macrosomic and large-for-gestational-age infants,^19,21 while others suggest at least 105 mg/dL.^19,22

All authorities agree that drug therapy should be started when postprandial glucose levels are 120 mg/dL or higher at 2 hours or 140 mg/dL or higher at 1 hour.

Using these standards, 30% to 50% of women with gestational diabetes require pharmacologic therapy when diet alone fails to reduce glucose levels.

Determining insulin requirements

The insulin algorithm for women with gestational diabetes is based on prepregnancy BMI:

For women with a BMI of 25 and less, the insulin dose is 0.8 U/kg.
For women with a BMI of more than 25 (overweight and obese), it is 1.0 U/kg.

For example, a woman at 28 weeks’ gestation who currently weighs 85 kg and who is classified as overweight or obese on the basis of her prepregnancy BMI, would be given an insulin dose of 85 U (85 kg×1 U).

Once the total insulin dose is calculated, it is divided so that two thirds is administered in the morning and one third in the afternoon or evening. The morning dose is further divided in a ratio of 2 to 1 (intermediate and rapid-acting) and the evening dose into a ratio of 1-to-1 (rapid-acting and intermediate). The rapid-acting dose is administered with the evening meal, while the intermediate dose is given just before bedtime.

If the patient with gestational diabetes has not achieved the desired level of glycemic control after 3 to 7 days, increase the total dose by 10% to 20% and thereafter adjust it when needed.

Fine points of insulin therapy

The actual total insulin dose in women with gestational diabetes is 40% higher than the calculated dose¹⁶; this provides a margin of safety and avoids severe hypoglycemic episodes. As a rule of thumb, self-monitoring of blood glucose is necessary before every administration of insulin.

The failure to introduce insulin therapy in a timely fashion may lead to fetal hyperinsulinemia and associated complications. Conversely, premature initiation of insulin in women who could have achieved glycemic control with diet alone leads to unnecessary drug treatment.

When gestational diabetes is diagnosed after 30 to 33 weeks’ gestation and there is little time left to gain the desired level of control, pharmacologic intervention is recommended. There is greater flexibility when gestational diabetes is diagnosed early in the third trimester.

Which form of insulin is best?

Human insulin is recommended when insulin is prescribed during pregnancy, and the same type of insulin is used for pregestational and gestational diabetes. The main differences:

use of the insulin pump in type 1 diabetes and
the insulin dose, which is based on insulin requirements for each type of diabetes.

The most common form of insulin today is biosynthetic human insulin. Short- or rapid-acting insulin is administered before meals to reduce glucose elevations associated with eating. Longer-acting forms are used to contain hepatic glucose production between meals and during fasting.

Regular insulin and insulin lispro are the 2 most common rapid-acting forms of insulin in use.

Pros and cons of insulin lispro

Mounting evidence of the benefits of insulin lispro for type 1 and type 2 diabetes in nonpregnant individuals includes:

fewer episodes of severe hypoglycemia,
limited postprandial glucose excursions, and
a possible decrease in glycosylated hemoglobin when the drug is administered by continuous subcutaneous infusion.²³

Insulin lispro also offers greater convenience in the timing of administration: Analogs can be administered up to 15 minutes after the start of a meal, in contrast to soluble insulin, which must be taken 30 minutes before the meal.

Neither the American Diabetes Association²² nor the American College of Obstetricians and Gynecologists¹⁹ endorses the use of insulin analogs. The reason: these drugs have not been adequately tested in pregnancy, although insulin lispro is categorized as a class B drug.

Data on insulin lispro are limited and abstracted from studies with relatively small sample sizes (only 244 gravidas reported thus far in the literature). Most case reports describe improved glycemic control, increased patient satisfaction, and fewer hypoglycemic episodes, but lack sufficient data on maternal and neonatal outcomes. Even so, many obstetricians have administered the drug with no adverse outcome.

In my opinion, insulin lispro can and should be used in pregnancy because of its ability to produce more physiologic insulin patterns and because the data against it are anecdotal. In contrast, insulin aspart and glargine should be avoided in pregnancy because data on their effects are limited.^24-40

Individualizing the insulin regimen

A relatively high dose of insulin (about 50–90 U) is needed to achieve glycemic control in gestational diabetes. In contrast, in type 1 diabetes, a lower dose is necessary (50–60 U). Because of the different glycemic profile of women with type 1 diabetes, individualizing the insulin regimen is accepted practice.

The carbohydrate algorithm. For every 15 g of carbohydrates ingested at mealtime, 1 U of rapid-acting insulin analog (insulin lispro or insulin aspart) is required.

If postprandial glucose is continuously elevated (>120 mg/dL) at 2 hours, an increase in rapid-acting insulin is required. Thus, the carbohydrate algorithm may change to 1 U of insulin for every 12 g of carbohydrates until the appropriate ratio is achieved.

If hypoglycemia or relative hypoglycemia occurs, the amount of carbohydrates should increase for each unit of insulin. For example, the adjusted dose would be 1 U of insulin for every 18 g of carbohydrates.

The range of these algorithms is influenced by prepregnancy BMI, disease severity, type of diabetes, and type of carbohydrate (ie, complex versus simple).⁴¹

Recognizing patterns of severity. The second algorithm involves identifying the glucose severity pattern (ie, hyperglycemia, hypoglycemia). For example, the total dose of insulin required (0.8–1.0 U/kg) is divided into a ratio of 60% for intermediate or long-acting insulin (basal dose) and 40% for the premeal dose. If the glucose level falls above the targeted level, a single unit of insulin lispro or insulin aspart is added for every 30 mg/dL, but not exceeding 3 U at one time. If glucose levels remain high, redistribute the calculated insulin dose to obtain an improved actual dose (ie, reconfigure the new calculated dose throughout the day based on patient need).

2 destructive complications

Retinopathy

Poor glucose control may contribute to or worsen diabetic retinopathy—the leading cause of blindness in diabetic patients 24 to 64 years of age—by increasing intracellular accumulation of glucose and its metabolic products. This damages the tiny blood vessels inside the retina, beginning with the formation of microaneurysms and progressing to blockage and, potentially, proliferation of fragile, abnormal, new blood vessels. If vessels leak blood, vision can be severely impaired or obliterated.

Patients at risk should achieve glycemic control gradually. Rapid initiation of stringent glycemic control can cause short-term progression of retinopathy, especially in hypertensive patients, although there are no apparent long-term effects.

Diabetic nephropathy

This complication increases the risk of preeclampsia, chronic hypertension, and fetal growth restriction, and is the most common cause of end-stage renal disease. Proteinuria often increases during pregnancy in diabetic women, but renal function generally remains stable. Nevertheless, advanced diabetic nephropathy (serum creatinine >1.5 mg/dL or creatinine clearance of ≤90 mL/min) can cause further deterioration.

Also pay attention to the lag effect (time from administration of the drug to the start of action), and to stacking, especially in patients with type 1 disease.⁴² Insulin stacking occurs when the residual insulin dose (after NPH or regular insulin peak of action) from a prior injection during a meal or between meals is combined with a later dose. This later dose—when added to the residual insulin—may cause hypoglycemia.

The stacking effect explains why most women with gestational diabetes need no regular or rapid-acting insulin at lunchtime yet are still able to maintain the desired level of glucose control.

Special needs in type 1 disease

Because glucose levels in women with type 1 diabetes typically vary widely on a daily or even hourly basis, the insulin dose should be flexible. For example, the patient may need 1 U of rapid-acting insulin for every 25 mg/dL of blood glucose above 125 mg/dL, or 1 U for every 20 mg/dL above 120 mg/dL, and so on. I encourage patients to titrate based on half-unit increments, which can be measured in an insulin syringe.

Insulin pumps. Insulin lispro and insulin aspart are approved for administration as a continuous subcutaneous infusion. However, use of the pump in pregnancy has been limited—as has its research.

Improved metabolic control is a potential advantage of the pump. When the patient is motivated and alert, use of the pump can reduce nocturnal hypoglycemia and morning hyperglycemia caused by the “dawn phenomenon” (an abrupt rise in glucose level in the early morning).

Disadvantages of the pump include cost, diabetic ketoacidosis, and hypoglycemia (caused by malfunction or infection at the infusion site). Maternal and fetal outcomes are comparable whether the insulin pump or intensive therapy is used. However, improvements in lifestyle and metabolic control may justify use of the pump in women who have trouble achieving glycemic control.⁴³

The many advantages of glyburide

Oral agents can be a pragmatic alternative to insulin in pregnancy because they are easy to administer and noninvasive. Many experts and authoritative bodies in the US recommend glyburide (sulfonylurea) as an alternative pharmacologic therapy during pregnancy.^20,44-48 Others recommend further evaluation.^19,22,49,50

Although some oral agents cross the placenta, they do not necessarily cause a toxic or teratogenic effect on the fetus. Glyburide, a class B drug, does not cross the placenta.^51-53 It increases insulin secretion and diminishes insulin resistance by lowering glucose toxicity. Its onset of action is about 4 hours, and the duration of action is about 10 hours. Thus, after achieving the targeted therapeutic level, glyburide covers the basal requirement as well as postprandial glucose excursions.

The starting dose is 2.5 mg orally in the morning. If the targeted level of glycemia is not attained, add 2.5 mg to the morning dose. If indicated (after 3 to 7 days), add 5 mg in the evening. Thereafter, increase the dose in 5-mg increments, up to a total of 20 mg per day. If the patient does not achieve acceptable glycemic control, add long-acting insulin.

Evidence on oral agents. Several retrospective and randomized studies evaluated oral agents in pregnancy. Most demonstrated that these agents are comparable to insulin in glycemic control and pregnancy outcome.^54-61

In a randomized study, my colleagues and I found comparable pregnancy outcomes for glyburide and insulin.⁵⁶ Recently we reconfirmed our original observation⁶² that hypoglycemic episodes are more common in insulin-treated patients than in those taking glyburide. In this study, we used continuous glucose monitoring and found hypoglycemic episodes in 63% of the insulin-treated women with gestational diabetes, but only in 28% of those taking glyburide.

We further analyzed the association between glyburide dose, gestational diabetes severity, and selected maternal and neonatal factors.⁶³ Not surprisingly, we found that the glyburide dose increased with the severity of gestational diabetes. The success rate (ie, achievement of glycemic control) decreased as disease severity increased. However, there was no difference between glyburide- and insulin-treated patients at each level of severity. Thus, achieving glycemic control—not any particular mode of pharmacologic therapy—is the key to improving pregnancy outcome in gestational diabetes.

When costs of insulin therapy and glyburide treatment are compared, the latter is considerably less expensive.⁶⁴

Ensuring fetal health and a safe delivery

Three principles form the basis of obstetric care for women with diabetes:

fetal testing to prevent stillbirth and compromised fetal states at delivery,
lung-maturity testing to prevent hyaline membrane disease, and
determining the best time and method of delivery to prevent fetal compromise, macrosomia, and shoulder dystocia.

Fetal testing

At our institution, we begin fetal testing at 32 weeks’ gestation in all women regardless of diabetes type—even earlier in women with vascular/hypertensive disorders. This includes assessing fetal movements 3 times daily and nonstress testing weekly. This approach has led to a stillbirth rate of 2.5 per 1,000, compared with 4 per 1,000 in the general population.⁴

Is amniocentesis warranted to determine lung maturity?

A major goal of fetal surveillance in gestational diabetes is preventing lung disease. Inadequately controlled gestational diabetes can increase the risk of respiratory distress syndrome or delay lung maturity. Thus, assessing fetal pulmonary status by confirming gestational age or fetal size can be misleading.^65,66

The delay in lung maturity among infants of diabetic mothers is 1 to 2 weeks.⁶⁷ This delay was associated with poorly controlled diabetes in several studies. Thus, this subgroup of patients stands to benefit most from amniocentesis.

At our institution, the common practice is to test for lung maturity before any elective delivery at less than 38 weeks’ gestation. However, when the clinician determines that delivery would be beneficial, as in cases of poorly controlled diabetes, noncompliance, or other obstetric indications, we deliver the infant regardless of lung maturity. These fetuses experience minimal lung morbidity after 37 weeks’ gestation.

The bottom line: Compromised lung maturity in a live infant is preferable to a deceased infant with healthy lungs.

Timing of delivery

Most experts agree that women with diabetes should be delivered at term—though the definition of “term” ranges from 38 to 42 weeks’ gestation.

At our institution, in addition to the established routine obstetric indications for delivery, 4 additional indications mandate elective delivery for women with diabetes:

Fetal macrosomia (weight >4,000 g). For large-for-gestational-age fetuses (>90th percentile), induction of labor may be appropriate when fetal weight ranges from 3,800 to 4,000 g and the gestational age is at least 38 weeks. Delivering these fetuses reduces the risk for shoulder dystocia, an ominous complication of diabetes in pregnancy.
History of previous stillbirth—often the result of poorly controlled diabetes—also warrants induction of labor.
Poor compliance or glycemic control. This includes the failure to test blood glucose enough to determine glycemic control; inability or unwillingness to adhere to the diabetic protocol, such as fetal testing; and missed appointments.
Presence of vasculopathy-related hypertension.

Using this approach, we had a labor induction rate of approximately 20% and an overall cesarean section rate of about 15% to 20%—not significantly higher than rates among the nondiabetic population.⁴

The road ahead

More pharmacologic alternatives are on the horizon and may include metformin and other oral antidiabetic drugs, insulin glargine and oral insulin, and a technologically improved insulin pump that can interact directly with blood glucose levels.

The author reports no financial relationships relevant to this article.

References

1. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977-986.

2. American Diabetes Association. Implications of the United Kingdom Prospective Diabetes Study. Diabetes Care. 2000;23(suppl 2):S27-S31.

3. Intensive blood-glucose control with sulfonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS33). Lancet. 1998;352:837-853.

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Oded Langer, MD, PhD
Chairman, Department of Obstetrics and Gynecology, St. Luke’s-Roosevelt Hospital Center, University Hospital of Columbia University, New York City

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