Week 35, part one

After the abominable doctors appointments I had Friday and the horrific blood glucose readings I had over the weekend, I was in full on pissy mode yesterday morning for my first week 35 perinatal appointment.  Between my baby-doc accusing me of irresponsibility and my pancreas-doc being a full on moron, it was impossible to not anticipate the worst coming into the appointment and to not expect another unnecessary, unwelcome tongue lashing.  I mean I know that these doctors are on my side and that the doc-patient relationship has been fine until now, but Friday's appointments were off putting enough to make me dread the next interaction.  It's almost like when I do an infusion change -- the needle doesn't always hurt, but once in a while I press that button and that needle jams into my skin and smarts like crazy! And, while that particular time stinks and I want nothing to do with the pain I'm in as I'm experiencing it, the next time I go to do an infusion change after the that is always worse because I'm just waiting for the sharp twinge that I just simply have zero interest inflicting upon myself.  So with a facial expression of complete exasperation mixed with anxiety, I give into the inevitable and subject myself to the (sometimes literal and sometimes figurative) jab again.

Oh the psychological stress of diabetes and pregnancy... fun stuff.

So while HB and I are waiting for round two of the verbal one-two combo (your diabetes management sucks and you're a horrible mother) to begin, I scowl my way through the (reactive) NST and (normal) AFI before being told my chart has been singularly assigned to the same doc that came down so hard on me Friday.  I was not happy.  Not only is this non-standard procedure for this practice - you usually get who you get and patients can't request to work with only one practitioner - but, while I thoroughly respect the guy and appreciate his knowledge with regards to the baby, his criticism of my diabetes control hurt like hell and I do not (repeat DO NOT) appreciate him stepping on my toes outside of his respective medical specialty lane.  Of course, this is all on top of the fact that the nurse practitioner I talked with via the phone on Monday said that this doctor is considering hospitalizing me again for the problems I'm having with my sugar control and that I should bring my hospital bag to every appointment... in other words, he's saying don't make plans.

Don't get me wrong, if I need to be monitored more closely for Baby's sake I'm fully willing to do what I need to do, but I'm not thrilled to be put through the stressful wringer of "am I coming home today?" at every single appointment!  I want to be and feel that I need to be home for GW's sake so as to keep his world as normal as possible pre-baby and Lord knows I have very little interest in bonding more with the High Risk Perinatal (HRP) Unit staff if I can avoid it.  No offense.

Clearly I was in a good mood and thrilled about the whole situation -- which of course didn't get much better when we got called back to the doctor's office to watch as he silently juggled my latest blood glucose logs, a due date calculator and flipped through my chart. Eventually looking up, the doctor confirms my gestational age as 35 weeks to the day and that the combination of my abnormal AFP levels and continuing reduction in insulin requirements means that "the placenta is conking out on us early."  Having done the research I already know this isn't a good thing and that the situation poses a bigger issue for Baby's health than anything, so it's no surprise that the doc explains that Baby may need to be delivered sooner than Nov 27 and that he's calling for more detailed sonograms to be done at least twice a week between now and delivery.  He'll be watching to see if her weight gain falls off, her non-stress tests are non-responsive, the amniotic fluid level changes dramatically or if her movements decrease because any of those symptoms will indicate that the placenta has transitioned from "just" extremely delicate and impaired to full on dysfunctional and dangerous. 

Awesome.

Amid all of this lovely news that surely did nothing to reduce my stress levels, the doctor surprised the heck out of me by going out of his way to reassure that none of this is my fault and that I'm doing an excellent job of handling what is going on.  You can imagine the look of confusion on my face...  either he genuinely altered his opinion of the situation from last Friday or he simply wanted to survive what I can only assume were death rays coming from my eye balls.  He encouragingly tells us that he made several calls and has arranged for me to see a better, NOVA based endocrinologist as soon as possible (this Friday).  So while things aren't going well placenta-wise and I am feeling beyond anxious about how the next couple weeks are going to play out, at the very least I can say I came out of yesterday's appointment with a plan for better, more consistent and aggressive medical care for the remainder of this pregnancy and beyond.  No longer having a single health care provider within an hour of our house, I guess it'd be fair to say that the writing is on the wall and it's just a matter of time before we move again... go figure.

The bottom line is that I managed to not get hospitalized yesterday and, God willing, that will stay the case at least until Friday.  My blood sugars are currently "stable" with lows only dipping into the 60s (not the 50s) and highs peaking in the 170s (not the 200s), so we continue the wait and see game that I wish with all of my heart had lower stakes.  It's funny, in a random conversation I had recently, someone assumed that my current existence is simply composed of "taking it easy at home" rather than actually doing something -- and while I have to laugh at the ignorance of the statement (clearly they'd never been on bed rest), it was beyond frustrating that this person couldn't wrap their head around the implications of what I'm medically facing.  I'm not scared of what child birth could mean to my life or safety, but the risks that go into delivering this baby into the world given the complications she is already fighting are more than enough to cause the insomnia, nausea and muscle knots that I can't shake.  I truly hate the combination of diabetes and pregnancy, the I-95 corridor and NOVA traffic, the distance to the hospital and the complete inability to predict anything with regards to delivery...  

There's nothing easy about this.  Absolutely nothing.

Lows continued...

So after sending my blood sugar logs to both the endocrinologist and perinatologist on Monday, calling both yesterday and again early this morning to ask "what's up doc?" one of them (the perinatologist) finally got around to calling me back five minutes ago.  Yes, that is three business days later and one and a half hours after their offices officially close for the day...  so you can imagine how grumpy I've been as my blood glucose has continued to drop.

According to Dr Khoury there is either one of two things happening.  Given that I'm quite close to delivery (we're considering 32 weeks close? Wow... that's so not comforting), one possibility is that the baby is so busy swiping the nutrients from the food I eat to put on weight herself that my body isn't actually absorbing any of the carbohydrates that I am bolusing for.  Alternatively, the other option (as I've explained previously) is that the placenta is deteriorating and my increased insulin rates aren't necessary because the placenta isn't producing pregnancy hormones at the high rates that are appropriate for its gestational age.  Either way, my blood sugars are continuing to bottom out and Dr. Khoury agrees that hypoglycemia isn't a good position for me to be in at this stage in the pregnancy (this is mostly because of the risk of falling).

I guess it is a good thing that he didn't sound too concerned over the phone about getting me in to see them before my appointment next Tuesday. He did specifically request that I call the office in the morning to make sure that they have me scheduled for a few more tests that they otherwise would have waited to run until the following week.  He said to continue to decrease my bolus and basal rates in my insulin pump as necessary and to fight the lows as aggressively as I can "with the help of my endocrinologist" ... yeah, if she'd bother to call me back.  Hmph.

Well, considering my bg was 53 an hour ago and I "over corrected" with a piece of fudge and 8 pieces of candy corn and I'm still low (a lot of good those carbs did, I'm only up to 65) I think it's time for yet another dose of sugar.  You'd think I'd be thrilled to have the excuse to indulge my sweet tooth, but honestly, I'm pretty ticked off that I'm forcibly eating crap food to satisfy the sick needs of my bleeping pancreas.  I mean come on, if Baby is absconding with all of my nutrients then she shouldn't be gorging her tiny little self with the loads of simple carbs my body needs to balance out her well rounded diet!  And if, Heaven forbid, my placenta is breaking down then Baby needs for what little work it is bothering to put in to be quality rather than mere junk...

On Tuesday we should be able to know a bit more one way or the other by looking at the degree of calcification on the placenta and at Baby's weight.  If her weight is on track or higher than expected for week 33, then she's the cause of my hypoglycemia.  If her weight is below where it should be or if there are visible white patches of calcification, then the placenta is not only sending my blood sugar low but it may be adversely impacting her growth.  In either case they'll do a fetal non-stress test to see if she's okay and we'll go from there.  Obviously the ideal situation is for me to continue to be pregnant for an additional four weeks to make it to term, so we'll see what results those tests show and what options the doctors feel like they have.

I'm generally trying to remain calm and keep the contractions (yes, they're still happening and no, they're not much better) from being too frequent or too long, but I've got to admit that I'm feeling first timer stressed and overwhelmed right now.  I can't control anything when I'm constantly trying to play catch up with my sugars.  I can't plan for anything when the baby could arrive whenever (minus the hour of driving, of course).  I can't do anything or go any where without taking contractions or the physical exertion of simply standing into account.  Perhaps I'm just antsy from hanging out in bed so long or maybe the lows are really getting to my head, but I'm exhausted from anxiety and there is nothing about pregnancy right now that feels familiar.  All I can do is remind myself that there is a sweet little precious angel on the tail end of all this stress and that next time (yes, we still want more kids after this) it might be easier.

I don't think I should hold my breath though.  It'd probably cause hypoglycemia or some other something-or-other that I just don't want to deal with right now.

Again, hmph.

Grumpy, rainy, blah, low day.

HB and I recently started watching the show Once Upon A Time and, for those of you who don't watch it, oh my goodness is it addictive.  The plot is a witty, complex hybrid of fairy tales and (Hollywood) reality that has story book characters fighting for their memories and lives in the fictional small town of Storybrooke, Maine.  The reason I bring this up is that there is a scene in Season One where Snow White is talking with Grumpy and the other dwarves about her intention to take a potion that will cause her to forget all of her pain.  Grumpy, who Snow is specifically trying to convince of the brilliance of her plan, talks her out of her voluntary amnesia by explaining to her that "as wretched as it is, I need my pain.  It makes me who I am.  It makes me grumpy."

Now, if you can't find the humor in that brilliant script writing then I have no further explanation of anything in this post worth reading.  But, in the feeble attempt to throw a grain of salted humor on an otherwise open wound, I have to admit that Grumpy totally has a point: we are a walking, talking portrait of our histories and, to be true to ourselves, we must acknowledge who we are and where we've come from.  So starting as a pregnant diabetic and going from there, I have somehow managed to turn into a crotchety, bearded dwarf in the past couple days. 

Someone really ought to call the tabloids. 

It's a combination of the stress of the last three weeks, the overcast, crumby, dank weather outside and the constant hypoglycemic blood sugars I keep fighting that have caused the change.  If it wasn't for GW's incessant hugs and kisses I'd probably shrink a couple inches and be permanently attached to a pickaxe by now, but seriously, you try to be low all the time and not turn grumpy! It makes me shake, it makes me sweat, it makes me short tempered, it makes me physically and mentally weak, and it makes me worried.  The last of which is by far the worst symptom.

As I've explained previously, at this point in a diabetic pregnancy - regardless of what type of diabetes you're talking about - the mother should be experiencing increasing insulin resistance as a result of the placenta creating copious amounts of pregnancy hormones that cause the body to ineffectively absorb insulin.  In other words, there should be increased insulin requirements, more regular hyperglycemic readings and very few hypoglycemic episodes.  But over the last couple days, I have been struggling to keep my blood sugars out of the 50s and I've been decreasing my basal and bolus rates to fight off the low, grumpy, blah blues... 

I mean, I wake up and my blood sugar is in the mid 60s so I eat breakfast to correct this and it some how manages to drop lower when it ought to even out.  I correct for it again (home made fudge for GW's bday, so good and sooo very full of carbs) and remain low.  I repeat this a couple more times and remain low.  And finally I under bolus at dinner and manage to get up into the 90s-130s for a while - but even at that point, while that is a safe, healthy number it is lower than it typically ought to be for a postprandial with "insufficient insulin." 

HB faxed my logs to the endocrinologist and, when she eventually calls back, I expect her to basically confirm that I should decrease my basal and bolus rates (which I've already done) - but that doesn't explain why my rates are decreasing.  We also contacted the perinatologist to get their take on it and make sure that we're not looking at the issue we were warned about at my infamously "healthy" week 29 appointment of placenta deterioration (aka the old placenta).  Unfortunately, all of my diabetes and pregnancy books and web sources indicate that this is likely the case but until the perinatologist confirms this I'm just not ready to go there. 

Ideally the situation would be entirely my fault due to poor carb counting or manual errors in programming my pump, but I know my pump is dead nuts where the endocrinologist told me have it at my last appointment and Lord help anyone who thinks I can't do the basic arithmetic it takes to do accurate carbohydrate counting.  I'm hard enough on myself about being diabetic and doing things right the first time that slacking or miscalculation just doesn't happen at this consistent rate... not exactly uplifting.    

Hopefully the docs will get back to me shortly, but for the time being I'm going to hide in my bedcover-cave and grumble whenever I have to emerge for yet another quick carb.  Definitely not the lying in bed eating bon-bons situation I'd like to be in. 

Hmph. 

Week 29 Prenatal Appointment

Had my week 29 prenatal appointment this afternoon and I am happy to report that things are looking (mostly) good. The Sonogram shows that Baby is right where she needs to be size wise (a healthy 3 lbs flat) which means my AFP abnormalities are not presenting growth restriction issues and my blood sugar control is tight enough that fetal growth isn't excessive. The sonogram also showed my placenta is securely out of the way of the cervix and it's high enough now that the phrase "what previa?" is completely appropriate to apply to the remainder of the pregnancy. While this is obviously great news, that doesn't necessarily mean I'll get the vaginal delivery I've been hoping for after all – it appears that Baby is extremely content to hang out in a fully breech position and unless she flips over, I'll still require a c-section. For the time being I'm not going to worry about it since there are several many weeks left and I'll just be content to be annoyed with her use of my cervix as a trampoline.

We did receive one new bit of bad news that will require additional monitoring (yes, on top of what they're already doing) - the doctor said that the placenta is beginning to look "old." While I have yet to do my typical extensive research on what this means, it is my basic understanding that toward the end of pregnancy the placenta begins to calcify as it prepares to detach during labor. So when a doctor refers to an "old" placenta that typically means that it looks to be closer to 39 or 40 weeks old, which is not an issue at that point in a pregnancy, but obviously at 29 weeks that's not exactly awesome.

Having read of other diabetic mothers experiencing this complication I was not terribly surprised to have the doc introduce the issue, but I will admit it's frustrating to hear of yet another thing that could/is going wrong with this pregnancy. I asked her if there was anything we could do like an injection of botox or apply a prescription strength anti-wrinkle cream but apparently, much to the dismay of my sense of humor, there really isn't much that is doable about it. She said we need to keep an eye on it more closely by watching amniotic fluid levels for decreases, my blood glucose for unexplainable hypoglycemic episodes or drop offs in fetal growth from possible malnutrition.

So with that "I'm old" announcement, my placenta signed me up for every two week appointments a month earlier than typically necessary. While my life seems to be a revolving door of doctors appointments at least I can say that this little girl will have one very full pregnancy scrapbook with all the hoops they have me (gingerly - come on I'm 29 wks pregnant thank you) jumping through.