Last Pre-Baby Endocrinology Exam

Going into day four with my CGM down and no estimated delivery time for my new transmitter battery, I went to my endocrinologist's office today for yet another pregnancy check-up with very little confidence that my sugars have been as tight as they ought to be this week.  Knowing full well that these few days won't have a huge effect on my HgA1C as it's a three month average of my blood glucose readings and since I'm getting measured more frequently than is typical, I could somewhat safely estimate that today's A1C reading would be relatively close to last month's of 5.5.  

Sans kids, Grandmama or HB (aka taunting the traffic Gods to let me get home from NOVA in anything resembling a reasonable amount of time), all of my attention was focused on the appointment and I cannot even begin to tell you how mystified I was by the ignorance of my nurse as she asked me questions about my diabetes. 

"Are you still taking Dexcom G4?"  she inquires.

"Yes, I still use it,"  I respond patiently. 

"How many units of that do you take a day?"

My internal monolog: "Seriously, are you freaking kidding me? It's my continuous glucose monitor, woman! It doesn't use or even measure units! And come on, there are only so many of them available on the market and used by this office! Are you seriously asking me this as if it were a prescription drug?!"

My answer: "It's my glucose monitor."

"Oh.  Are you still taking Medtronic Minimed?"

"Yes..." I said in attempts to mask my skepticism of what was to come next. 

"Is that a pill or something?"

My internal monolog:  "O. M. G.  You have got to be kidding me!"

My answer: "It's my insulin pump.  I use it with humalog." 

"Oh.  I'm new to this diabetes thing."

My answer:  "You're lucky."

Scurrying out of the room after checking my blood pressure (98/80 - um, shouldn't that have been of concern?) and taking a sample of blood for my A1C, she skips several of the typically routine pregnant-diabetic questions and leaves me to wait for the significantly more competent and well trained Doctor.  

Surprised to see me without entourage, Dr. Rogacz dives right into my chart and the CGM trends I've provided for her covering the previous week.  Reporting that my HgA1C is up to 5.9, she theorized that this increase - while in the wrong direction - is likely as a result of less prevalent overnight hypoglycemia and an apparent growing trend in mid-afternoon highs.  Merely suggesting that I add Symlin to my late-morning coffee or adjust my bolus settings for my mid-day meals, she snaps my chart shut and announces that as far as she's concerned I'm doing beautifully.

"The next time I need to see you is two weeks after delivery.  Otherwise, make sure that you set your pump to your lowest basal setting for delivery and that your husband knows to turn off or disconnect your pump at the infusion site if you need to have an emergency c-section.  If he doesn't do that, anesthesia will just rip it out and you'll need it after the procedure is complete." 

Finding it terribly ironic that she didn't really feel like she needed to see me today and that the more serious conversation she planned to cover was intended for HB instead of myself, I appreciated the vote of confidence from my go-to diabetes expert that I'm doing everything motherly-possible for Baby #3 and that on her scale of patients - both pregnant and not - I'm one of the few she's not slightly concerned about.  Wishing she could send those exact words over to the perinatologist for their diabetes-rant days where I come away feeling like I'm the biggest diabetic screw up on the planet, it was nice to know that at just shy of 34 weeks of gestation that I'm off the hook for additional "you need to be monitored" appointments until the end of February.  

Again: go me. 

And to top it all off, there wasn't a bit of traffic on the way home and door-to-door my typical 2.5 hour Friday afternoon commute took me 52 minutes.  Now that's a good way to end the week on a medical high note! 

Week 29 Endo Appt

While the changes with Baby over the next two months transition my perinatal appointments from every four weeks to every two weeks and soon to be twice per week, I take comfort in the clockwork predictability of my pancreas and the resulting routine schedule I have for my endocrinology appointments: when pregnant, I see my doctor every four weeks and when not, every three months.   Seeing as there are still at least eight weeks to go with this pregnancy in the best case scenario, I find myself regularly annoying the receptionists at NOVA Endocrinology with my requests for non-existent appointments in my doctor's overly-booked schedule.  Always tacking me on to the tail end of my doctor's Friday afternoon schedule, I have plenty of time to mull over her suggestions and feedback as we fight our way through the I-95 traffic leaving Washington DC at rush hour - which, thank God, wasn't too bad today. 

 

After the last three weeks of vitamins and omelets, I anticipated that my HgA1C, like my weight, would be lower today than it'd been at my last appointment on November 12.  But while the scale did indicate that my weight is down, my HgA1C remained stagnant at 5.5 despite my drastic reduction of insulin from roughly 55 units per day down to between 30-35 units daily.  Inquiring about my glucose trends, I then presented the doctor with my latest CGM logs...

 

 

Finding my post-breakfast hyperglycemia to be still of concern, she asked if I'd continued the 30 unit injections of symlin with my breakfasts since swapping over to my monotonous diet.  Given that my omelets sometimes include a skosh of milk and sometimes not, I told her no, but seeing as I continue to struggle with post-prandial highs and insulin resistance kicks in to full swing during the third trimester of pregnancy due to the wonderful world of hormones she instructed me to start back up on my morning needle to the stomach routine for better numbers.  Moving on to inquire about my basal rates, I rattled off the nine (yes, you read that correctly: NINE) settings I have programmed throughout the day:

 

1)  12:00 AM to 1:30 AM:  0.450 Units

2)  1:30 AM to 4:30 AM: 0.625 Units

3)  4:30 AM to 6:00 AM: 0.950 Units

4)  6:00 AM to 7:00 AM: 2.50 Units

5)  7:00 AM to 8:30 AM: 0.875 Units

6)  8:30 AM to 4:00 PM: 1.45 Units

7)  4:00 PM to 7:30 PM: 1.75 Units

8)  7:30 PM to 9:00 PM: 1.25 Units

9)  9:00 PM to 12:00 AM: 0.475 Units

Grand total: 28.075 Units

 

Recording this with some annoyance (apparently this kind of nuancing of basal rates isn't terribly common at her office), she honed in on the one number that stood out in it's oddity: 2.5 units from 6:00 AM to 7:00 AM.  Otherwise surrounded by practically negligent doses, this "high" dose demonstrates my sensitivity to the body's natural rhythm of hormone production that happens between 2:00 AM and 8:00 AM that is commonly referred to as the dawn phenomenon.  As the knock on effects of this phenomenon haven't been something I've necessarily struggled with previously (maybe I did and just didn't notice), my doctor explained that at some point my honeymoon phase as a new type one diabetic will end and my insulin requirements will plateau to some degree of predictability.  As I've only been a diabetic for three (almost four... golly...) years, she doubts that my pancreas has fully given up the ghost and she thinks this new found requirement for additional insulin for one specific hour each morning may actually be a step closer to life post-honeymoon with my ball-and-chain pancreas.  

In coming out of today's appointment and having the traffic jam to think about it, I'm torn in to two emotions: frustration with my HgA1C remaining stagnant despite my concerted efforts and shock, I guess, that something may be progressing with my diabetes separately from the pregnancy.  I've become so accustomed to think of my medical situation as a high risk pregnancy due to diabetes that my diabetes just being my diabetes is odd... I'm probably putting too much thought into it and overanalyzing the whole thing, but being diabetic is so... normal... for me now that the thought of being considered as "newly diagnosed" floors me.  I understand that there are men and women out there who have had type 1 diabetes since their childhoods and at my age they are likely settled into their insulin routines with a decade or two of experience under their belt, but I feel so settled and so diabetic in my own skin that the comparison takes active consideration rather than passing acknowledgement to register.  

Well, for better or for worse, my diagnosis anniversary is just around the corner on January 25 and, if we're going with traditional gift choices, that means my pancreas and I should exchange either flowers or fruit to mark the date... we'll see how my next endocrinology appointment goes on January 9th, but I have a feeling we'll be skipping the carbs and going straight for the floral arrangements since that, at least, wont mess with me and Baby ;)

Actively Passively Aggressive.

With HB starting a new job and our switching insurance providers (thank you US Congress for removing pre-existing conditions clauses!), the bureaucratic flaming hoops pushed my three month endocrinology check-up back from June to July and I must admit I am feeling anxious about my next A1C.  I'd been slacking back in December with a general apathy toward the world of diabetes and let my A1C increase into the abnormal range with a reading of 6.5.  Feeling self-depricating and flat out pissy about my inability to be under 6.0 without constant focus on my blood sugar readings, I remember Dr. Rogacz looking at me and plainly saying "get over it, perfection just isn't gong to happen."  You can imagine the dismissive internal monolog my brain launched into at this...

Obviously this particular "get over it" method of diabetes management is beyond my scope of comprehension, so I decided to implement a more passive-aggressive approach toward my pancreas by starting on the Dexcom G4 Continuous Glucose Monitor (CGM).  Instead of making me prick my finger or forearm several many times a day to check my glucose levels, my CGM enables me to weekly insert a (rather bulky) sensor into my abdomen and then passively glance at the number and trend line displayed on my i-pod sized display screen.  Letting the CGM do the active work of testing every four minutes (yes, essentially constant), I can pretend I'm non-diabetic all I want without having to endure bruised and sore fingertips.   Granted, I have to calibrate the sensor daily (+) so I am not test kit free, but at least there is some emotional distance between me and my pancreas that didn't exist when my apathy shot my A1C up to 6.5.  

In a circular logic kind of way, my creative interpretation of "passive diabetes management" with the CGM is actually much more actively aggressive than it was before -- even when I was testing 10+ times per day during the pregnancy with GV.  By rarely testing my blood sugar but regularly monitoring the constant sensor information about my glucose levels and trend patterns, I lowered my A1C from December to March all the way down to 5.9!  It seems that despite my continued annoyance with the reality there's no "getting over" being diabetic, I owe all credit for my sanity and overall health to the technology that I'd previously been avoiding...  ironic.

Perhaps in being curious about what another three months of CGM usage will do to my next A1C I am actually starting to take Dr. Rogacz's advice to some degree and I'm finally curbing my apathy towards my diseases.   I definitely have my hopes up that I'll have an even better reading than 5.9 this go around and, as much as I may try to pretend otherwise, that shoots my "don't give a dang" facade straight in the foot.

My July 3rd appointment can't get here soon enough.

Endo Check Up

I am so beyond frustrated with myself for having thoroughly dropped the ball on my blog posts recently... with the best of intentions I keep logging on to start writing and then immediately get distracted by something shinny and wind up hitting save after typing the most basic reference note to come back to in my "free time."  What with unpacking the new house, GW starting pre-school, GV being just moments away from walking and trying to really sink my teeth into my work with Team RWB, I've hardly had time for sleep let alone a coherently written sentence.  Fortunately for tonight, however, I told myself that I am not allowed to unpack another box until I put on background noise and, in order to do that, I decided I need to publish at least one timely blog update first.

So here it is.  

I went in for my every three month check up with the Endocrinologist this past Wednesday, Sept 11.  Beyond the issue that I couldn't provide recent blood glucose logs to her because I've lost my pump download USB in the move, I knew going into the appointment that it wouldn't be a stellar one.  The last couple months have been beyond difficult for me and not because of stress from running, Vermont or any of the other drama that has magically appeared, but because of the gosh darn fact that I'm diabetic.  I'm just done with it and I don't want to play any more.

I am sick of checking my blood sugar so often that my forearms get bruised and my finger tips are painful to touch.  I am sick of needing to count every dang tortilla chip I eat to make sure my carb counting is right.  I am tired of shopping for clothes with an eye to where to put/hide my pump rather than what actually looks good.  I'm frustrated that people glare at me in mass because my "pager" is going off.  I'm annoyed that my training runs resemble more of a staccato sprint than a crescendo of distance because of carb stops.  And, dagnabbit, I am jealous that HB gets a milkshake with his meal and doesn't bat an eye at the massive amount carbs he's inhaling absentmindedly.  It's just not fair.

Yeah, yeah, yeah, I know - life isn't fair.  And, yeah, I got it - God gives us what we can handle.  But that doesn't diminish the acrid reality that chronic is as chronic does and I don't want to "is" or "does" any more.  And, going into my appointment today, I knew that this attitude would come back to bite me  in the butt with my HgA1C reading.

Back at the beginning of June, my A1C was a 5.8  - which as you recall is within the limits of "normal." Today, it's up to 6.1, which in all reality is pretty tight for most diabetics, but is wildly loose for this one.  Between my current (hopefully ephemeral) apathy for the disease and an increasing difficulty with hypo- and hyperglycemic awareness it was no surprise to me that the numbers were up into the abnormal range, however marginal. I rationally understand that I need to do better and that it's just a matter of exerting a bit more effort into self-care, but, seriously, what stay at home Mom has time for self-care? Maybe some have figured it out, but I certainly haven't.

Of course, Dr. Rogacz was generally encouraging as usual and, knowing me far too well, she went out of her way to merely make a gentle nudge on the CGM topic rather than hit me over the head with my own bad attitude.   The latter would probably have been far more effective and appropriate, but I think she knew that I'm ready to give in to her this time anyway and give a CGM a chance since I'm already blowing off active participation in my disease... and since HB wont let me do that (however super model skinny that'd enable me to be) and our NFP requires better of me, I'm planting a white flag of general diabetes resignation and forfeiting the other half of my abdomen to Dexcom.

Sigh...

I don't know what my deal is... perhaps I'm just overextended?  I'm trying my hardest to be the best parent, wife, catholic and veteran advocate I can be, but I know I need to seriously step up my game at writing, home decorating and (oh yeah, supposedly doing a marathon) running -- maybe if I drop out of diabetes 101 the rest of life's course work wouldn't seem so heavy?  Figures, the one thing I don't want, is the absolute one thing I can't get rid of...

Diabetes, I seriously don't like you.

Endo Check Up

It seems funny to me how our perception of time changes based on whatever it is that makes up "normal" every day life.   Last fall, when I was pregnant with GV, I had so many doctors appointments that my days, perhaps even my hours, seemed to be measured in trips up and down the I-95 corridor to Fairfax INOVA Hospital.  But now that I'm back to "normal," fireman rain coats and matching wellies accent my routine far more than white coats, which are soooo last season.  Doctors appointments now merely indicate the passing of yet another three months -- either in the form of a well baby visit for GV or a routine endocrinology check up for me.

The latter is what I did today. 

The past couple months have been ROUGH diabetes wise and, to be completely honest, I've been dreading this appointment for fear of the criticism I feel is entirely appropriate for my self care.  It isn't that I have been slacking on the job or purposefully blowing off my blood sugar (although, to be fair, I simply forgot to bolus once... yikes), it's just that I'll be going along just fine and then WHAM! my blood glucose is in the high 200s and there is no simple explanation for it.  My pump will indicate that I have enough active insulin in my system to cover the correction, but my glucose will have shot up like the insulin wasn't even there and, quite similiarly to when I was pregnant, come crashing down an hour or two later.  Without understandable rhyme or logical reason for this, I've just been rage bolusing and enjoying a few extra doses of whatever something sweet I'd happen to be craving at the time (currently pecan pralines).

Thus expecting an abnormal HgA1C, which if you remember is anything above 6.0, I brought my support group along for the telling finger prick that would inevitably quantify the amount of flack I'd justifiably be given.  Dispensing with the "oh what an adorable baby" and "you must be such a good big brother" comments and getting down to it, I held my breath and gritted my teeth as I waited for the results in the same manor I did while checking the mail box for my college acceptance letters...

Doctor Rogacz entered the room.  We exchanged our pleasantries and, with little ado, got down to my diabetic trials and tribulations.  Explaining that some things have changed - I'm running more, I've been under more stress and that I'd been sick without singular cause - but that most of my lifestyle factors remain the same, I blushed in embarrassment as I handed her my blood glucose logs for the last two weeks which included daily ventures into the 200s.

"Hmm, I don't know what to tell you," she said. "The timing of these highs are inconsistent and you've got a number of lows as well.  But your HgA1C is good at 5.8 - so you're doing something right even with these numbers."

SHOCK.

Reading my face and plainly hearing HB's comments of "I told you so" (he relishes those opportunities), she then not only didn't give me a hard time about my hyperglycemic excursions she was incredibly encouraging of my dedication.

"You're never going to have perfect blood sugars, no matter how hard you try, so try to relax.  You're doing a great job!"

Frustrated with the medical recommendation "to relax" I professionally dodged her compliment with a question or three about my marathon training to which she merely said "do what you have to do to not pass out" which, in endurance running and diabetes management, I take as excellent advice.

So without jabs about my continuing lack of CGM, lectures about abnormal blood sugar ranges or prescriptions for whatever else might be ailing me, I felt like I dodged a bullet today as we walked back to the car.  I thoroughly expected my HgA1C to be in the high 7 range and I lost significant amounts of sleep last night because of anxious dread of medical criticism... but I guess all that worrying was for not.   My Nana, may she rest in peace, always said that the things you worry about never come to pass and until now I'd figured that was just her way of recommending I "relax" but, hey, perhaps she was right.

We'll see where I'm at in another three months.

3 Month Check Up

So I am having a really hard time believing that it has already been 3 months since my last endocrinology check up, but since GV is already 14 weeks old and time just seems to be flying past I guess I buy it.  Originally, my appointment was scheduled for two days ago, but seeing as this is Northern Virginia and any sign of snow makes the entire region shut down, the "snowquester" got it pushed back to this afternoon.

With GW, GV and Grandmama in tow, I met with the wonderful Dr. Rogacz for a routine diabetes check-up for the first time!  Pleased with my weight loss and new HgA1C number of 5.8 (that is down from 6.2 mind you), she announced she wasn't concerned about my diabetes care in the slightest and that I am doing remarkably well.

Inquiring about my longer term plans for additional pregnancies and care planning purposes, I told Dr. Rogacz I intend to spend the next 12+ months training for and running in endurance races.  Since pregnancies, diabetes and running don't work together in the slightest, she seemed a bit relieved to know we wouldn't be putting my body through more of that any time soon, but it did cause her to use a term that I dread from endocrinologists: CGM.

Pump with infusion site on right; CGM on left.

CGM, Continuous Glucose Monitoring, is a technology that works with insulin therapy to keep a diabetics blood sugar as tight as possible.  As an additional attachment to the body, the CGM tests blood sugar every four minutes and logs the results so as to indicate the trending direction of your blood sugar and therefore making it easier to catch it as it goes up or as it goes down.  It'd be incredibly helpful for me on my training runs, it'd ensure my safety overnight by alerting me to lows before they happen, it'd help me keep my A1C lower by giving me constant readings and I'd generally be armed with much more information than I currently get with just my Free Style Lite test strips.  Essentially it is an extraordinarily handy tool and wonderful technology to have... I just don't want it.

Here's my logic:

Because I wear an insulin pump and have an infusion site adhered to my body 24/7/365, I constantly carry a 2" by 3" by 1" visual reminder in my pocket that I'm diseased.  Granted it is an extremely helpful piece of plastic to have and I'd be worse off with out it (multiple injections are so not my thing), but I resent the fact that I LOOK diabetic because I wear this tubed device everywhere I go.  Now, if I were to add a CGM, not only would I be attached to the insulin port that is necessary for my pump to operate, I'd have this transmitting device inserted into my subcutaneous jiggle that would make it all the more difficult to hide my disease under my clothes.

I understand that it is incredibly superficial of me to be concerned about "looking diabetic" and how this beneficial technology would impact the fit of my sweaters, especially since most people don't know what they're looking at anyway, but hasn't diabetes already consumed enough of my life?  I mean I can't even have a cup of coffee in the morning without needing to compose my little grey cells enough to test my blood sugar and calculate my bolus, why should I give another portion of my abdomen over to yet another accessory for my broken pancreas?

Don't get me wrong, that was an entirely rhetorical question and I understand the benefits of it.  I mean, okay, there is something to be said for having an HgA1C estimate whenever I want and, hypothetically, it'd protect me from severe hypoglycemia by averting it's onset in the first place, but I'm incredibly sensitive to lows as is and assuming my daily readings stay within a certain range I know my A1C is where I want it to be without knowing exactly where it is.  Perhaps I am being stupidly stubborn on this, but STILL.  I'm just not ready for that.  I feel diabetic enough as it is.

Maybe sometime down the line I'll come around and will willingly participate in the next level of self-care, but for the time being my answer is HELL NO.    Sorry to disappoint you, Dr Rogacz, I'd love to be your shining star patient with all the bells and whistles, but I'll take my low-tech stellar A1C and go on my way.  See you in June.

Week 36, part two

For the third night in a row, I woke up in hell this morning with my blood sugar much lower than it ought to be.  Wednesday I was 34, Thursday I was 32 and today at 2:45 AM I was 43 -- what the heck?!  I mean I love the excuse to wantonly eat simple, quick acting carbohydrates like I am a care free non-diabetic child again, but within the context of the last few weeks of a class B diabetic pregnancy I'm not thrilled in the slightest to need to open my bed side table drawer and raid the stash of sweets HB and I have stock piled for moments like this.  It'd be nice to want a piece of candy for once!!

Any way, I've been going back and forth with my new endo via the phone practically every day this week and I lowered my basal rates by 0.05 each night in an attempt to curb my plummeting blood sugars. Heck, I've practically cut the rate from 12 AM to 3 AM in half over the past three days -- but unfortunately to no avail.  Needless to say my Friday appointments with the perinatologist and endocrinologist couldn't have been better timed this week...

Still gawd-awfully sick with this respiratory infection (I'm now on a new uffdah-uffdah prescription of antibiotics and still coughing like day one), we went back to the Antenatal Testing Center this morning for yet another round of non-stress tests and my 17th sonogram.   The NST was enough reactive to pass and the AFI was much higher than last time (19 on Tuesday, 24.6 today), which the sonographer and resident (ug) dismissed as "symptomatic of being a diabetic."  However, given the smorgasbord of health complications I've had this week - an optical migraine on Sunday, the coughing and vomiting of this infection and contractions - on top of my seriously unstable blood glucose, the resident kicked my case back to Doctor Bronsky who felt it was worth a cervix exam and blood panel to make sure I didn't necessitate immediate hospitalization for preeclampsia or placenta failure.  

Fortunately the blood panel came back showing normal liver function (thank God) so immediate hospitalization wasn't necessary, however Dr Bronsky placed orders for me to have an amnioenteses done on Tuesday (day one of week 37) to evaluate Baby's lung maturity so that he can move the delivery date up from November 27 to as soon as possible.  Soooo, essentially things with my blood sugar aren't stable enough for her to make it another 10 days in utero but the doctors cannot risk her coming out too soon since diabetic babies are notorious for having immature lungs (even at "full term") and you throw in my respiratory infection in on top of that and they've got a very delicate line to walk between letting her stay in and getting her out safely.

Furthermore, from talking with Dr. Bronsky about the possible use of additional steroids as a fail-safe to help her along, HB and I found out that subsequent injections of steroids to mature a premie baby's lungs for delivery is highly controversial after the first dose and there is mixed evidence regarding not only its efficacy, but the safety of it.  So while the doctors back at Stafford Hospital on Sept 25 made the right emergency choice to administer the steroids to me for a possible pre-term delivery, the reality at this point is that my docs aren't sure what they're going to do if a) I go into spontaneous labor sooner than induced or b) if the amnio shows her lungs to be less developed than ideal for a before Nov 27 delivery.

Generally we're feeling like deer in the headlights and overwhelmed by the delicacy of the entire situation.  Having lost the mucus plug and had some show already, I'm feeling like a passenger in a uncontrollable rail car with no clear, straight forward escape plan... thank God HB is the one who has to drive the truck to NOVA, thank God the Perinatal Associates are the best of the best high risk pregnancy docs Virginia has to offer and thank God that Fairfax INOVA has one of the top 5 NICU in the country!

After leaving the testing center, we went straight to my appointment with Dr Rogacz in Fairfax.   Taking a sharpened pencil to my chart, she slashed my basal and bolus rates with the finesse of a Michelin Star Chef at the cutting board.  She then brought up the ever present topic of "when labor begins" ... to which I must say, as a pregnant woman you're constantly thinking about what's this sensation and even as a second timer I find myself worrying about whether I'll know when my water breaks, but adding diabetes management to something I'm already stressed to the gills about is simply exhausting.  It's really no wonder I'm so sick.

Any way, she walked us through what she wants me to do with my pump settings for active labor.  Similar to an endurance athletic event, which let's face it, labor is, the whole physical process of pushing a baby out of your womb causes blood glucose to fall sharply in diabetics because of expended energy... That being said, she's asked me to cut my rates from what they are "normally" (ha, as if they are stable and normal now) to my lowest setting and keeping them at that low 0.2 unit setting until the baby is out.  Of course if my blood glucose continues to drop even at that low basal rate, we'll need to decrease it further and have me put on a glucose drip to make sure I don't go into hypoglycemic shock while in active labor.  Fun stuff.

So after Baby and the placenta are out, I'll need to reprogram my pump again since I'll be back to pre-pregnancy (actually probably lower) insulin needs because the placenta will no longer be present to create an insulin-resistant environment in my body.  For this Dr. Rogacz has instructed me to initially cut all of my basal rates in half, suspend use of the symlin injections and go from there.  Being naturally so hyper-sensitive to insulin will likely make the postpartum diabetes dance a difficult one, but I've been rightly warned that any non-diabetic symptoms I may display -- in other words maybe not even needing artificial insulin -- will be temporary as my body recovers and returns to a new normal.

I only have one word to describe all of this: over-frlcking-whelming.

I wish I was in the blissful period of enjoying the last few days of pregnancy with out a care and an extra foot rub or two, but the reality is that this pregnancy will be medically complicated start to finish.  I knew what I was signing myself up for, but conceptively rationalizing risk and tangibly feeling fear are completely different things.  Honestly, I'd like to just get this show on the road already so that I can know it how things turn out, but it's out of my hands.

Hallelujah for Hypoglycemia! Wait, what?

So at 1:50 AM last night I woke up with a start -- something, unfortunately, that isn't uncommon any more.  Between the trips to the bathroom to vomit, the horrendous coughing episodes that violently shake our bed and the occassional contraction that reminds me that no, seriously, labor really is just around the corner I've found myself spending many an early morning wide awake for one reason or another.  But last night, in an ironic sense, was a nice change from the ordinary -- I woke up sweating, over heating and shaking in another state of hypoglycemia.

I managed to get my light on, sit up and, granted I had to stab myself twice to get enough blood for the meter, I tested my blood sugar.   The meter read 34 mg/dL.  With difficulty I managed to wake HB up and he helped me get some orange juice into my system (I also took the excuse to grab 4 pieces of candy corn - life and death situation after all).  So I sit up waiting for my blood sugar to return to normal ranges for an hour or so and by 3 AM my meter finally read a solid over night number of 94 and I was able to go back to sleep.

The funny thing about all of this is that it felt wonderful to wake up without the other symptoms I've been experiencing the last couple nights.  My hypoglycemia was so bad that I couldn't feel my throat hurting or my chest aching, I didn't notice the congestion in my nose or lungs and I felt - ironically - normal again.  Course when I woke up this morning to HB's alarm clock it was with the same coughing, gagging and contracting as yesterday so the escapade back to "normal diabetes land" was short lived and fleeting in the night. 

I called my new endocrinologist to let her know about the low and - get this she calls you back personally - she said that unless I begin to have more hypoglycemic readings during the day that the baby is likely burning through too much of my glucose over night and that is causing the severe lows at that point.  However, she continued, if the lows continue during the day then we need to worry more about the integrity of the placenta - and given that she knows what she is talking about and my perinatologists trust that she knows what she is talking about, then those are the honest to God options for explanations.

So all morning I watched my bgs stay in normal ranges as I tried to decrease my body weight by at least one lung, but this afternoon has been a different story.  My blood sugar post nap #4 was 39 mg/dL... I had juice... I checked again and it was 38 mg/dL... I corrected again... I checked again and it was back up to 39 mg/dL... I waited... I checked again and it was down to 37 mg/dL... and as of about five minutes ago it finally got up to 47 mg/dL.  Needless to say, something is wrong and the grams upon grams upon grams of carbs I've ingested to correct this low aren't going very far.  I've left a message with Dr Rogacz and I'll fax her my logs tomorrow, but seriously this is ridiculous.

Just what I needed - to be excessively sick and having more diabetes complications. If I was a betting person I'd wager that my water breaks sometime soon... because, really, why wouldn't it?

Week 35, part two: Beta Cells are Complicated!

Okay, so this post is coming a couple days later than it ought to have been put up - but with good reason.  It's been gorgeous here and I've been trying to soak up all of the warm sunny vibes from the world around me to balance the completely diabetes-world rocking appointment I had on Friday with my new (and might I add fabulous) Endocrinologist.  But before we get into the nitty-gritty details of what happened there, indulge me with a quick recap of the the second week 35 Baby check up...

As of Friday morning, Baby was incredibly active in her non-stress test (I credit HB for that since he sang to her) and her amniotic fluid index reading was slightly elevated but still within normal limits at just over 19.  "My doctor" was the only one of the four from the practice to be at the office rather than at the hospital testing center, so he had me see the nurse practitioner, Laura, for my check up.  With nothing earth shattering to report she ran the group-B strep test and checked for any effacement -- I hear back about the strep Tuesday at my first week 36 appointment and once again I've received compliments on my solid cervix (which I have to admit, I'm getting kind of tired of).  So she patted me on my head and sent me on my way... by far the least eventful and non-dramatic perinatal check up I've had in ages. 

So we go get lunch in Old Fairfax City while waiting for my endocrinology appointment to start, but when we eventually got there... oh my goodness, people... it was the nicest doctors office I've been in in ages AND they have the good sense to decorate with gorgeous photos of mountains (I'm a native Rocky Mountains girl, so mountains are a quick quick way to my heart).   With a 72 page chart faxed over from my old doc at UMW and a stack of freshly filled out new patient forms, the receptionist warmly welcomed me to their practice as if they'd been waiting for me for to grace them with my (albiet sickly) presence. Considering my first endo kinda dropped me on my head when we moved (we hadn't planned to change providers, but she insisted because of the "distance" ) and my second one was seriously incompetent, I think the look on my face at this woman's kindness must have been one of a deer in the head lights. What a pleasure.

Within minutes, a nurse was checking my vitals, taking blood for a HgA1C test and running through a basic history of my current diabetes status.  A few minutes later the door to the exam room opened and in walked this glowing angel of diabetes know how, Dr. Suzanne Rogacz.

Taking her time to look through my chart, to get a detailed verbal history of my life with diabetes and to talk through my current blood sugar roller coaster ride, she listened to what I said and responded to how I feel better than any specialist I've ever seen.  She didn't reprogram my pump - at all - or even ask me to take it off to verify it's settings.  She didn't ask for justification of my blood sugar logs and she confirmed that while the lows are concerning, the post-meal highs are more critical for this point in pregnancy because of the impact they have on Baby.  HALLELUJAH! After the ambivelance my last endocrinologist showed to those post prandial numbers, this was amazing to hear a licensed medical professional say something I expected!!

I'm seriously in love with her.

But, what is a good story without a twist right?  So we're going along through this appointment without surprises when WHAM! Out of the clear blue, Dr. Rogacz turns the tables and suggests that I reintroduce amylin to system ... In the two years that I've been an aggressive type 1 diabetic, I have never heard of it, I have never read about it, and I most certainly have never been told that I am missing it!!

Reading the look of confusion on my face, Dr. Rogacz explained that amylin is a hormone that is co-secreted with insulin by the beta cells of the pancreas to help regulate blood glucose.  Since my body destroyed those beta cells and made me externally dependent on synthetic resources, I'm not only naturally lacking insulin, I am also failing to self-produce amylin as well. She explained that it's not essential to "healthy living" like insulin is and that very few diabetic patients are selected to be put on amylin supplementation because it's a sensitive hormone that requires acute self-care to deal with the nuances of taking it (sever hypoglycemia becomes far more likely on amylin than just insulin by itself) and aggressive diabetes goals that are (unfortunately) uncommon with most diabetics, regardless of type.  But seeing as the hormone, which is only available in "Symlin" pen injection form, would smooth out my blood sugar patterns - making the peaks less high and the lows less low - she thinks that it could take me to the next level of blood glucose control that I am currently unable to do with an agressive insulin regimine alone.   Which, hypothetically speaking, is exactly what I need right now and what I want out of life in general --  the closer I can make my blood sugar resemble a non-diabetic's the healthier I can be for my husband and my kids.

 

Sooooooo... with little persuasion and a vote of confidence from a doctor I trust, we called the shot (haha) and I'm now injecting amylin at least three times a day in addition to wearing my 24/7/365 pocket-buddy of an insulin pump.  I'll admit that it's hard to get back into the routine of doing an injection whenever I want to eat anything more than 250 calories or 30 grams of carbs, but I'll fall into a routine one of these days and it'll eventually be old hat:  sit down evaluate the meal, input carbs into the pump and bolus insulin.  Pull out an alcohol wipe, clean off the symlin pen tip and abdominal injection site, attach the needle, set and stab. 

Simple enough, right?

We'll see how this goes.  I go back to see her again next Friday for another prenatal+endo check up.  I'm relieved to be working with someone who gets my goals and the factors that play in my individual case... she's supportive of my family planning, she's understanding of my physical goals and my running addiction, she is eager to help balance breast feeding and blood sugars... she's everything I could have asked for in an endocrinologist all wrapped up with a pretty bow. 

Merry early Christmas to me!