Week 30

All I can say about my week 30 appointment is that I am beyond grateful that I am already a parent, because if it weren't for GW and GV I'd be a furious, incoherent mess as I sit here typing at the computer.  Having spent the last two weeks fretting about my weight, my amniotic fluid index (AFI) levels, and Baby's rapid weight gain I hardly slept a wink last night as I tossed and turned in anticipation of my perinatal appointment this afternoon.   Waking up twenty minutes after the alarm clock went off and finding an abnormally high weight on my home scale (up two pounds from yesterday... guess I shouldn't have had that banana) didn't start the day off well.  Attempting to look at least partially decent for the first time in a week, I threw on some clothes, quickly did my hair and make-up and went into the kid's room to find both GW and GV awake but still lounging in their beds.  Happy to not continue the morning battle with our usual "but, Mooooom, I'm still tired..." argument, the kids easily slipped into their laid out outfits and went downstairs to the kitchen to begin our breakfast routine - which, again, went surprisingly well. 

So off to school we go and as I'm dropping GW off in his class room, I pull his teacher aside to let her know that I'd need to pick my son up early today to accommodate our perinatal appointment that is scheduled for just after lunch in NOVA.  Informing me that, "well, we're not going to be here today and we won't be back by that time," I was a) shocked to learn of the field trip that the parents weren't informed about (seriously?!), and b) dreading the dream crushing "you can't go" conversation that I was about to have with GW.  As this would have been the first time he would have been able to ride the school's bus, something he's been begging to do since September, you can imagine the near tear confusion and anger that seized his face... I explained the issue and apologized for his disappointment (to which he countered with several suggestions about his walking home from school alone, sleeping at school so we could just pick him up tomorrow and even running to the appointment on the side of the highway so he wouldn't get lost) and we finally came to a calm, albeit not happy, understanding.  We then attended morning mass and began to run some errands. 

And then my phone rings... "Mrs. Cammack?  It's Perinatal Associates.  We have you down for a 1:30 appointment this afternoon, but we're going to need you to come in at 12:45 instead." 

No problem... if you live in NOVA.   Big problem if your husband works 45 minutes away, isn't answering his work phone, cell phone, texts, email, instant messages or my ESP and, in best case scenario traffic, the doctors office is one hour away.  While I had an hour and forty-five minutes before we no-sh*t needed to be on the road, I spent the next 55 minutes trying to reach HB before he finally answered and had exactly 50 minutes remaining to pack up and get home before we were officially late.  Shockingly enough, his little commuter car got him home exactly on time and we hit the road. Thanks to construction and accidents, we wound up only being slightly late to my (considerably earlier than we were prepared for) appointment. 

Then guess what happened... 

For the first time in our experience at this doctor's office, HB, the kids and I were left to wait.  Usually prompt and punctual, we waited for an hour and twenty minutes before my appointment officially began.  So, for those of you who are parents and know the agony of cooping kids for an excessive amount of time in a non-child friendly environment like a business or office, you recognize that had we kept our originally scheduled appointment for 1:30 we would have only fought 45 minutes of "place of business" behavior without lunch, toys or books rather than the doubled length of frustration.  

Enter miracle number one:  those kids were complete angels.  Granted GV didn't want me to read my book and she insisted on climbing to the adjsent chairs exclusively from my significantly smaller lap (at least something is smaller about me!) than from the floor, but they whispered "psst I love you" to one another and to each of us, they snuggled us individually and in turn, and they even managed to let the other two couples in the waiting room wait in what could almost have passed as a child-free sense of peace. 

During that wait time I was called back briefly to the nurse's station for my typical vitals check. My BP was great at 114 over 69 and, thank goodness she measured that first, because the minute I saw the number on their ruddy scale I flushed with anger.  Eight bloody pounds up from yesterday on the home scale and right back to the number I was advised would cause a c-section four weeks ago.   Yeah, yeah, yeah, I know you can't compare results between two different scales and in one instance I weighed myself sans clothes before breakfast and in the other I was fully dressed (a seasonally appropriate sleeveless shirt and flip-flops for today's gorgeously frozen tundra weather, mind you) and it was post 1 cup of greek yogurt, but STILL! Are you freaking kidding me?!

Enter miracle number two:  upon slumping back into my waiting room chair, GV climbs up into my lap and, taking my cheeks between the palms of her hands, she looks deeply into my eyes and says with the most sincere concern "you okay, Mama?" Forcing the deep breath I wouldn't have found anywhere else, I was able to tell her "yes, I'm okay, GV" before giving her a hug and feeling at least some of the world's weight fall from my shoulders.  Too bad I couldn't have been weighed again...

Finally, finally, finally the nurse comes out, calls my name and leads our troop to the sonogram room. Having discussed with GW that he'd be able to help with the sonogram if he asked the sonographer  very nicely, my heart sank when Dr. Bronsky walked in to the room in place of our normal nurse.  Knowing full well the answer to GW's question would be either silence or "no," when he approached the table to inquire "may I try?" I spoke as kindly as I could to him "no, not now GW." Automatically lead to the "but you said I could!" face of anger and tears that I'd already seen that morning regarding the bus, I briefly explained that we'd talk about it after the appointment before shifting my attention back to the sonogram.  I found the doctor ever so casually checking Baby's position (head down, good), heart rate (132 bpm, good) and ... yeah, that's it. 

"What are the AFI levels?" inquired HB, trying to prod for additional data. 

"They looked fine," was the brief response. 

"Oh, well those numbers and his weight have been of concern at the last few appointments..." HB said suggestively. 

Taking the wand back up, Dr. Bronsky then began to actively measure the amniotic fluid pockets around Baby.  Correcting himself, he then stated, "yeah, your fluid level is definitely high.  It's up to 27 cm.  But that's almost the same as it was last time."

Percentile wise, perhaps 23 cm and 27 cm are somewhat comparable for their respective
gestational weeks, but they're both at 99th percentile and not where I ought to be

Upon collecting the two pictures he'd printed for my chart (none for us today - boo), wiping off my belly and instructing us to follow him to his office, HB and I were stunned but the limited information collected and the dismissive statement that equated 27 cm to 23 cm... neither of which is considered a good number.  

Enter miracle number three: every time we've brought the kids to these appointments and it comes time to sit down with the doctor for the last five to ten minutes before their sweet freedom is realized, they've flat out lost their minds. They roll on the floor, flop on the couch, grab things from the desks... anything distracting and disruptive they could do, they've probably done it.  But today, they sat by our feet in relative stillness as they watched a movie on mute for the duration of the appointment.  Feeling rewarded by the access to the iPad (a very rare treat at our house), they didn't interrupt, they were polite and they gave no-reason to illicit the "and you're having another one?" face and/or comment we've unfortunately received from particularly judgmental people previously.  

Sitting board straight out of anxiety, I watched the doctor as he rapidly typed the data he'd collected into my chart and answered the random questions he asked regarding symptoms I'm experiencing and my previous deliveries.  Providing very little council on my and Baby's condition or the red-flag concerns we've been fretting upon since our appointment on HB's birthday at the beginning of November, Dr Bronsky - my go-to guy and ally during GV's pregnancy - practically brushed me aside and shooed us out the door with his paltry information: he noncommittally indicated that a vaginal delivery is still possible; he distinctly commented that I can't do anything more than I already am; he passively dropped that a c-section would be required at "4200 grams or more"  for any diabetic (had to look that up, gee thanks doc, meaning 9 lbs 4 oz); and, to finish things up, he concluded that my weekly appointments and non-stress tests will begin on December 30.  

Leaving the office with my blood pressure soaring from frustration and unassuaged concern, HB and I both felt like today's visit was a waste of time and a full drain of our emotional energy.  I know I should be grateful that a professional looked things over and that he didn't feel comment was required, but less is not more with me and simply dropping off some biometric data on me and Baby surely didn't need to take the four hours - and that's before the drive home! - to accomplish.  I needed reassurance today.  I need hard facts to concentrate on for the next two weeks.  I need to know what progress, be it good or bad, we're making and how things are shaping up just in case I'm hospitalized (God forbid) anywhere except the one place my chart is electronically stored.  Walking away empty handed, empty stomached and cranky is not ideal for anyone leaving a doctors office - let alone for a woman who is 30 weeks pregnant. However...

Enter miracle number four:  those darn kids couldn't have been better behaved, more compassionate or more encouraging than they were today.  On any normal day their actions would have been ten times above and beyond the norm, but given how challenging the day was and how HB and I were seething unhappiness from our every pore, GW and GV rose a whole new level of my esteem that I didn't know I even had.  I've always loved them more than anything, but actively appreciate them? That's something I need to do more often. 

To be honest, I've found myself much more cognizant of the little things with them over the past few weeks that I simply feel I was blind to previously.  I have been so wrapped up in the drama of life and the worries of what if that I haven't given them the benefit of blossoming in my consciousness in the way that they've been doing entirely on their own.   The appointment today was, in my estimation, a complete disaster and something I would gladly take a time machine to, but in the grand scheme of things it's only one afternoon in one week of one pregnancy that will lead to a lifetime of family moments and memories with all three of my wonderful kids.   GW and GV kept my feet grounded today where my temperament alone would have taken me sky high in vexation.  While I hope to come back from my next appointment on December 30 with solid facts, answers and some semblance of comfort, I am clinging to the awareness they gifted me today that appreciating them, our time and our family in spite of the darkness that can cloud around can leave a wake of happiness where otherwise there would be none. 

Thanks, guys.

Good behavior ice cream and Santa all in one swoop?
Yeah, they're that good. 

Week 28 Update

So for the past three weeks I've been on carb-lock down.  Knowing that increased insulin usage has a direct relationship with increased consumption of calories (chasing lows) and fat storage (gee wiz, thanks diabetes), my endocrinologist and I agreed that I would try to cut my insulin use down to the lowest possible rate so as to curb my pregnancy weight gain. Attempting to operate on exclusively my basal dose without bolusing additional insulin to cover food intake, I've pretty much cut carbohydrates completely from my diet with the exception of my guilty pleasure of daily gummy vitamins and one, much needed and nonnegotiable, cup of coffee.  So eating three three-egg and cheese omelets a day for the past three weeks, you can imagine both the success and the frustration I've had with this "diet." 

On one hand, my insulin use is way down and not only has my weight gain stopped, but I've managed to drop several pounds.  At first I was surprised when my pump began to initiate its "auto off" function during the day (this happens only when I haven't actively programmed it for ten hours), but in looking at my how my daily usage averages have dropped over the last month it's not so surprising -- I've gone from a minimum of 55 units daily to a maximum of 32 units daily!  While the numbers on the scale aren't quite so dramatic, which is a good thing, I am also pleased that the home scale is now reading five pounds less than it did at my week 25 check up and that, thank goodness, puts me back under the 35 pound weight gain maximum that I've been advised to maintain.  The unfortunate other hand of this equation, however, is that I am beyond sick of eggs.  Come February and Baby's arrival, I don't know if I even want there to be eggs in the refrigerator as merely an ingredient let alone as a ptotential food source... ug!

Anyway, hovering at right about 30 pounds of maternal weight gain (which is still about ten pounds more than what I ought to be at this point in the pregnancy), I was feeling a bit more confident headed into the week 28 follow up we had today with the perinatologist.  Knowing that my weight and baby's weight are not necessarily linked,  however, I held my breath out of sheer anxiety as the sonographer measured and clicked, measured and clicked, measured... lingered... measured again... clicked.   

"Well, your baby is measuring about two weeks farther along at 3 pounds 4 ounces," she states with an impressed air. 

Thinking back to the beginning of the pregnancy when our dates weren't lining up with the size of the fetal yolk sac causing the MFM to move our due date back from February 8 to February 21, I inquired of the sonographer if that might be why we're seeing him grow much, much more quickly than he should. 

"No," she said with certainty. "Early sonograms are very accurate - within three or four days - for gestational age.  You'll have to talk to Doctor Nies about his weight."  

Finding this information to be far from comforting given our knowledge that the average baby should weigh no more than 2 pounds 2 ounces at 28 weeks, I braced myself for more bad news as HB, GV and I sat down for our consultation. 

"How are you?"  Dr Nies asked.

"Stressed beyond belief," was the only honest answer. 

Being the nicest, most comforting of the practitioners at this particular office, Dr. Nies kept her kiddie gloves on for our conversation as she dove into my chart and looked at the results of the sonogram and compared them to my triage stats.  Upon seeing my decreased weight and confirming that I was in fact still eating, she gently moved on to explain that her primary concern at this point in the pregnancy is not Baby's above average weight, but that my amniotic fluid levels are elevated. So while she simultaneously assuaged my concerns that a c-section for macrosomia may not be necessary (that will be contingent on Baby's weight being above 10, maybe even 9, pounds in several more weeks),  the high amniotic fluid index (AFI) reading of 23.1 requires a diagnoses of mild polyhydramnios.  Stating we'd keep an eye on it but to call immediately if I get "unusually bigger" or experience more contractions (a regular happening of late), we left the appointment with both me and my uterus feeling irritable. 

As polyhydramnios is a brand new complication for the books (oh joy), I promptly began my homework upon reaching the car.  Playing a sick and twisted game of chicken and the egg, the condition could be a result of my diabetes (not likely given my HgA1C) or it could be a bi-product of the macrosomia OR, to keep things interesting, the macrosomia could be a result of the polyhydramnios and exacerbated by structural complications we are currently unaware of in the fetus.  Charming, right? Regardless of cause, however, the presence of even a mild case of polyhydramnios - and let's pray it doesn't elevate itself to a moderate or severe case - on my already high risk case makes the rest of this pregnancy more complicated and more prone to additional issues than before.  Polyhydramnios is associated with: 

• Placental abruption (because I needed to be at more risk for that...)
• Pre-term labor and rupture of membranes
• Umbilical cord-prolaps
• Mandatory C-section
• Still birth
• Post-delivery hemorrhaging due to the excessive size of the uterus during pregnancy

So... that's not good. Unfortunately there isn't anything that I can do above and beyond what I am already doing to prevent either macrosomia or polyhydramnios.  I can keep my diabetes under tight management - check - and I can work to keep my weight gain below 35 pounds for the pregnancy - check, thus far at least.  Beyond that, the outcome is entirely in God's hands and at the whim of my perinatologists when and if things progress one way or another.   In the mean time, I'll just continue to worry and eat my omelets...  someone have pancakes and a couple Christmas cookies for me, will ya? 

Week 25 new complication: Macrosomia

What a way to celebrate HB's 35th birthday - two doctors appointments and a trip to the dealership service shop! With the exception that he wonderfully took the whole day off of work to enable us to be together as a family, it was definitely one of those days that you wish you could be granted a do-over.   Fortunately, he's the best sport on the planet and, hands down, the most amazing supportive husband and daddy ever so while I would have been mortified by the days events effects on my birthday, he stood unwaveringly by to make the most of the day's misadventures.

About two weeks ago we purchased a new car to accommodate the growing family and to replace the truck HB purchased just a few weeks after we began dating in 2006.  Having purchased used, our new Yukon has a couple parts that the dealership needed to order before replacing - which we were under the impression would be installed today.  So getting up extra early to fight the commuter traffic along I-95 North, we started the day with an hour and a half of sitting in what I can only describe as the quietest waiting room I've ever been in at a dealership... there were several many serious looking business suits sitting about the room focused on books or laptops and, of course, because I'm that Mom, I stressed the entire time about GW and GV's behavior so as to be courteous to these other patrons.  For the most part the kids did a good job of keeping the ruckus to a dull roar by looking out the windows at the various cars on lifts, but if HB hadn't been there to help me wrangle at those particularly loud moments I am quite sure my head might have exploded.   Anyway, we eventually had to approach the front desk reiterating that we were on a schedule with doctors appointments and couldn't afford to wait longer for our vehicle to be returned only to learn they hadn't done a single fix to the car in that time frame and the parts that were needed had to be ordered.   Oui.

So frustrated with the morning, we proceeded to the Perinatalogist's office for our 25 week appointment.  It's the first appointment in weeks that we've brought GW to as his school schedule and the baby's appointment schedule haven't been compatible, but knowing how much he enjoys the sonograms and how excited he is for his new baby brother it only made sense to include him in the day's "festivities."  We had just piled into the waiting room where the kids promptly fought over a few magazines and a specific chair next to Dada when I was called back into the triage area for my vitals check.   Pulse - check! Blood pressure - check! Weight - WTH!?!

"Okay, you'll be called back for the sonogram shortly."

Reporting to HB that my weight registered as five pounds heavier than the scale at home did just a few hours prior, I tried to shake off my weight-consciousness and focus what positive attention I could on the kids as they leafed through the various baby and parenting magazines.  Shortly there after, we were called back as a family to the sonographer's room.

"Can I help you?" GW asked of the sonographer as she squirted the warm goo on my growing belly.

"Sure, can you hold the wand steady?" the sonographer asked.

Taking the wand and prodding the baby bump with a bit too much enthusiasm, GW willingly accepted assistance from the pro and images of Baby #3 began to appear on the screen.   Things looked fine from what I could tell - the heart beat sounded right, the parts were in the right place and there weren't any particular spots on which the sonographer abnormally lingered.  Handing me a towel to clean up and GV the pictures to carry - "carefully!!" - we packed up and went back to the waiting room for some more, you guessed it, sitting.

Fortunately this doctors office is spot on with their scheduling and it wasn't too long before we were called back to talk with Dr. Khoury, the MFM at the office who appears to be taking point on my case this go around.  Upon inviting our tribe in, GV promptly walked to his knee requested up and sat quietly through out the appointment.  GW on the other hand seemed to think that the sofa in his office resembled a tumbling mat - which, as you can imagine, did nothing positive to assist the appointment along in my eyes.  Dr. Khoury, who is apparently ready to have grandkids, didn't seem to mind terribly, but still...

"So, correct me if I am wrong, but have you gained 42 pounds this pregnancy?" he asked bluntly.

"Well, the scale at home says 37, but yes, I've struggled much more with quick weight gain this go around." I responded.

Going on to inquire about my blood sugar control ("are you chasing lows?"), my exercise routine ("are you able to exercise?") and a smattering of other weight-relevant questions, he launched into a new diagnosis as he typed in my electronic chart:

"Well, your baby is macrosomic and, unless you can get this weight gain under control, you're going to have a c-section."

I've known since GV's pregnancy that most diabetic pregnancies result in overly large babies - macrosomic babies - that cannot be delivered safely through vaginal delivery, however, I've also known that tight blood glucose control (which is measured by the HgA1C) can prevent this over padding of fat on the fetus.  What I didn't know was that there may also be a coorrelation between maternal weight gain during pregnancy and macrosomia regardless of diabetes.  Awesome.  So while I've been thoroughly on top of my glucose levels with a recent A1C of 5.5 (well within normal limits), my seemingly uncontrollable weight gain is causing some of the exact problems that I've been trying so hard to avoid.   Granted, my glucose control is helping in other areas like organ formation and an absence of birth defects, but you can imagine my frustration...

I might be considered abnormal for this, but one of the best parts of pregnancy that I have previously enjoyed and that I am actively looking forward to is labor.  The pain is terrible, but the way my body knows what to do and how quickly I progress through active labor (30 minutes with GW and 15 minutes with GV) is a source of pride that I take incredibly personally and even the mention of a c-section makes my heart just crumble with a sense of loss.  I know that in emergency situations it's unavoidable and many women haven't had the option to pursue vaginal delivery, but wrapping my head around Dr. Khoury's words sent me into a self-depraving sense of grief... I've been working so hard to keep Baby and me healthy and now this?!

Maintaining as much composure as possible, we scheduled our follow-up appointment for week 28, walked to the car and I promptly burst into tears.  Consoling me as much as he possibly could, HB held my hand and repeated words of encouragement as I pulled up the Mayo Clinic information pages on fetal macrosomia.  While a c-section will prevent much of the structural damage that could endanger both me and Baby and, at the end of the day, a healthy baby is a healthy baby for which to be thankful, there are several complicating factors as a result of macrosomia that make my mind reel:

For Baby the risks, even with c-section, are immediate as well as having longer term implications:

• Baby faces the likelihood hyperglycemia and impaired glucose tolerance at birth - the exact opposite of concerns for blood sugar levels we faced with GV.  With her, we were concerned with her glucose levels being to low (which they were), which was easily fixed by feeding her.  With Baby, I don't know what the doctors will need to do to address elevated glucose levels or if they can do anything. 
• Baby faces a higher likelihood of suffering from childhood obesity as research indicates some degree of link between higher birth weights and excessive weight gain in school age children. 
• Baby faces a higher probability of suffering from a variety of conditions - such as increased blood pressure, high blood sugar and elevated cholesterol - that, when combined, directly lead to a heightened risk of heart disease, diabetes and stroke. 

For Mama the risk for complications increase if future pregnancies are considered (which, yes, future pregnancies are something for which HB and I are hoping):

• The risk for fetal macrosomia increases with each pregnancy, especially those for male babies.  So Baby #4, should we be able to have another, is not only at a higher risk for a higher birth weight due to birth order, but given that we're struggling with macrosomia with Baby #3 he or she will be at an elevated risk because of my maternal history with the condition. 
• Given my history of placental abruption and the compounding issue of a potential c-section, my risk for uterine rupture with future pregnancies is heightened due to the damage I'd sustain to the anterior wall.  This also decreases my candidacy for a vaginal birth after cesarean (VBAC), for which I emotionally am holding out. 

I can rationalize that a c-section isn't the end of the world and I can also rationalize that I have two, soon to be three, beautiful children that I've been blessed with by God, but the picture I have in my head of what I want and expect out of life versus the rationalization of what options and outcomes are just not in my hands are two irreconcilable things.   I understand how fortunate I am to live in the United States and to have access to the comprehensive medical care that so closely monitors me and Baby.  I understand that it's up to me to curb weight gain for the remainder of the pregnancy and that the chromosomes and genetics involved are beyond my control.  I can understand that my crying in the car today has absolutely no correlation whatsoever to what happens with delivery of Baby come d-day... I get all of that, but for the time being, I'm miserable.  I'm overwhelmed.  I'm scared.   I don't know exactly what I'm going to do or how best to go about it, but so help me God I've fought this hard to have a healthy baby in the way I want to that I'm not about to give that up now.

The only thing I can possibly say about the day that is remotely positive is that HB and the kids were exactly where I needed them and that I couldn't have gotten to this point of writing about all of this without their love and support.  I am beyond grateful for HB's consistency, GW's compassionate hugs and GV's constant attempts to make eye contact with me and inquire about "Mama happy?"  Without them, I'd be in ball somewhere suffering from complete self-loathing rather than actively working to acknowledge the good that exists in my life already.

I wish it could have been a better birthday appointment, HB, but thank you for everything you did today and simply embody in spite of it all.