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? 

Breast Feeding and Diabetes

For months now I've been saying that I'd write a blog post about breast feeding as a diabetic.  I'd skipped the topic while still pregnant since it wasn't quite relevant at the time and for the past 11 weeks since GV was born I just haven't made a priority of writing about it since doing it seemed more important.  But seeing as she's happily asleep in her swing chair and GW is at least pretending to nap in his room, I'm going to take this opportunity to tell you about it since I know you all must have been anxiously loosing sleep over it since I first mentioned I'd write about the topic back in 2012.

No? Just me? Ah well, c'est la vie.

According to the American Diabetes Association, the best thing that a diabetic mother can do for her new born child is to breast feed.  Citing multiple research studies, the ADA explains that babies that are exposed to diabetes in utero and are breast fed for upwards of six months after delivery have a decreased incidence of respiratory infections, a lower risk of asthma and atopy, tend to have lower blood pressure and are less likely to develop childhood obesity.   All great things, right?  Well, combining these medical benefits with the fact that the disease is not transmittable, that there have been research studies connecting certain types of baby formula containing bovine protein to the development of autoimmune diseases like diabetes and that I thoroughly enjoyed breast feeding GW, the choice was easy for me.  The practice of breast feeding with diabetes, however, is not so easy.

Blood sugar affects everything we do in our daily lives because it provides us with energy, so it seems only logical that there be some relationship between blood glucose and the natural formation of breast milk.  While you've probably heard that breast feeding burns calories, you may not have taken the next mental step to connect that with blood sugar... Essentially, in a similar way to how our bodies burn both calories and glucose when we exercise, a mother's body burns both fuels to create milk for her infant. So while a non-diabetic mother can singularly reap the weight loss benefits of nursing her little one due to her self-regulation of glucagon and insulin, a diabetic mother needs to monitor her blood sugar with extreme caution so as to not put herself (and by extension her baby) in danger of hypoglycemia.

To prevent this and to keep blood sugar stable, it's important that I eat before, during and sometimes after feeding GV.  But that brings me to the next topic of difficulty: weight gain and nursing.  Because of my sugars I need to eat more to keep my blood sugar up to be able to safely nurse -- but then that means that although I am burning calories while nursing I am required to ingest more calories to nurse which means any weight loss I should have with breast feeding is replaced with weight maintenance, if not additional weight gain.  Obviously this creates a source of stress for someone as physically self-conscious as me, but to take it to a less superficial level, weight gain can change a diabetic's chemistry enough to change the body's response to glucose and therefore its artificial insulin requirements.  So... to keep this complicated... that means that I need to eat more to nurse more and that I must exercise more to compensate for not only remaining pregnancy weight (15 lbs to go) but the extra calories necessary to nurse (and exercise) all in order to keep my sugars stable enough to nurse in the first place.

Furthermore (because why, really, would it end there?) not only should my blood sugar be kept from going low while breast feeding, but they should not be permitted to go high either.  While the majority of perinatologists, pediatricians, obstetricians and diabetes organizations insist that there is no connection between a mother's in-the-moment blood sugar and the quality of her breast milk, there is a school of thought out of the Sansum Diabetes Research Institute in Santa Barbara, CA that believes the value of a mother's breast milk decreases when her bg is over 150 mg/dL.  According to these researchers, such deficient breast milk can cause infants to have "reactive hyperglycemia" which causes them to vomit, be excessively irritable and require more milk to satisfy their nutritional needs.  While there aren't additional studies to backup these claims and I've never seen such negative effects in GV's behavior when I have nursed her while high, a lack of evidence doesn't necessarily refute the possibility and I've decided to play it safe rather than sorry.  Admittedly it voluntarily adds another level of complication to breast feeding, but what does it really cost me?  If it is no big deal, then oh well.  If it actually matters, then it's worth the effort.

The bottom line is, I am thrilled to be nursing; it's a very personal choice and I find it completely satisfying. But breast feeding and diabetes take a lot of conscientious thought -- and at 3 o'clock in the morning when GV wants to nurse that is a lot to ask for.  Don't get me wrong, glucose control is definitely less critical and requires far less attention to minutia now than in pregnancy, but it's still exhausting to continuously consider.  I could let it go and give myself an easy DKA-sponsored trip back to my skinny jeans, but I cannot justify cutting myself any self-satisfying slack on my sugar control since a lax take on it would imply irresponsible parenting at best.

Seeing as I take my vocation as wife and mother extremely seriously, I guess this is just another one of those necessary "diabetes says this is how it is going to be" horse pills to swallow and get over it... now if only they made that in a gummy I'd be happier.

Why take a horse pill when you can have a gummy?  

2 miles down, 22 lbs to go

I CANNOT TAKE IT ANY MORE.

I made it four, almost five, weeks without exercising, but waiting another two will drive me absolutely mad.  Between the beckoning my running shoes are incessantly doing, the taunting the scale does each morning and my mental stream of expletives each time I have to put on maternity pants rather than normal jeans I'm just about at the end of my post-bed rest couch potato rope.  So, to quote Rafiki, "it is time."

Godiva exercise fuel...
 quick carbs or extra calories?

After a much needed trip to the local Target to pick up running pants that fit (ug, how mortifying!), HB and I laced up our dusty sneakers, packed the kids into our new Bob Dullie (thank you CraigsList) and hit up one of our old running loops for a "test run."  Between his ACL reconstruction this past August and my involuntary pregnancy induced running hiatus, it's been months since either of us have put one foot after the other for more than a gimpy shuffle or waddle.  Clearly we weren't going for much in the way of distance or speed and, considering this was only day one, I must admit that our one goal was to prove to ourselves that neither of us are either too old, too out of shape or too broken to do it... which I am tickled pink (maybe it's just my asthma?) to report we accomplished! Granted tomorrow we might be a bit sore, but by jove, such mental exercise was well worth it. 

With my starting blood sugar reading at 177 mg/dL, we ran five minutes on one minute off for four sets around the local YMCA sports fields.  The high wind was an additional challenge and I over bundled myself for the weather something fierce, but we kept it mutually positive and pushed at an average ten minute mile pace (okay, HB pushed the pace and I tried to keep up... BUT I'LL FIX THAT!).  By the end of our second mile, my legs were exhausted, my blood sugar had dropped to 84 mg/dL and my body was soundly expressing it's disproval for my bra selection.  It's normal to have glucose ranges drop that far when exercising, but seeing that this was my first time running while breast feeding and diabetic I am thrilled to see that my sugars are acting like they did when I was running and simply diabetic.  Obviously I'll monitor it each time we go out, but hopefully the numbers I saw today will be a trend (and how about next time I nurse GV before we go, rather than after... ouch).  I'll keep you posted.

So with two weeks remaining before I'm officially cleared to exercise at my six week check up, I'm taking my life back and saying screw it.  HB and I both have about 22 pounds to lose before we get back down to our pre-pregnancy weight - and, for me at least, this is after losing 20 lbs in child birth! I definitely gained more this go around than with the first baby (only 26 lbs gained with GW), but hey, I was allowed to exercise in the first pregnancy and I didn't have to scarf simple sugar to keep myself going.  I don't think it'll be all that hard to drop the baby weight with the right amount of effort, the real challenge will be seeing how much time it takes to get back into competitive running... I'm thinking maybe going for a full marathon this year, so hopefully the pounds will shed right off and I can start training to step up into the big leagues of diabetic endurance athletes! I mean, really, half marathons are so last year... 

TOF: The new PTO

Yesterday morning, while doing my daily pre-preeclampsia routine, I weighed myself and just about had a panic attack.  From the last time I weighed myself before going to the hospital my weight is down a total of eight lbs! That is an additional three lbs from Tuesday morning... While I'd normally be throwing a party about the scale showing a lower number, it's not exactly a trend a pregnant woman wants to see during the third trimester of pregnancy when multiple pounds should be added!

So I called and left a message for my doctors wanting to make sure that they weren't terribly concerned by such a dramatic drop.  After several hours I eventually got a call back with the nonchalant guidance that "don't worry, sweetie, such changes day to day are just water weight."

Okay, fine, I know that water weight can cause a few pound swing one way or another on any given day, but eight pounds over one week? The doctor then went on to explain that what I'm probably seeing is my body evening out after a week of full bed rest and hydration and that my body is finally showing the real numbers of atrophy induced weight loss... Sigh.  Eight.  Pounds.

Accepting that at face value (after all atrophy isn't a danger to the baby, only an annoyance to me), I asked him for further clarification about what kind of activity I am allowed to do post-hospital.  Initially confused by why I was in the hospital and thinking that it was because of a complication with placenta previa (which as you remember, has cleared up entirely) he said "just don't do heavy lifting or vigorous exercise."  Correcting him and explaining what happened at the hospital the doctor got quiet and asked:

"We didn't put you on anti-contraction medication?"

"No.  But I am having contractions when standing for long periods and after short stints of walking."

"Hmm."

Comforting, right?

Well, he explained that the fellow who discharged me made a mistake and should have at the very least told me to stay off of my feet for an additional two hours in the morning and two hours in the afternoon.  BUT that if my body was showing signs of exhaustion (aka contractions or physical weakness - both of which I'm experiencing) that I should listen to my body and do more bed rest than the minimum he would require.  He seemed comfortable with my next appointment being next Tuesday, but asked me to keep him posted if there were other problems that came up between now and then.

AS IF I WOULDN'T!

So... considering walking to the pharmacy from the car caused contractions, standing cooking dinner caused contractions, putting GW down to bed caused contractions... yeah... bed rest is definitely what the doctor ordered.  As HB and I have been joking lately that he's going to need another bonus of Paid Time Off (PTO) from the office for his spectacular work (yes, this is ANOTHER shout out for you - enjoy it!) given the high maintenance this pregnancy is requiring, he decided to give me a raise in my hourly acquisition of "Time Off Feet" (TOF).   Very generous, dear, thanks.

That said, I am going back to my comfy pillow and another episode of Dinosaur Train with GW.  We've recently been learning about the fact that all dinosaurs poop and that only some of them are nocturnal...  GW seems to think that they are all called "bigosaurus" and that the pretend, invisible dinosaurs in our house need to constantly be put in time out in the back yard because they can't use their indoor voices.

Too funny.

My diagnosis

In December 2010, amid finals for graduate school and extensive family drama I began to loose weight uncontrollably.  I'd been doing Sean T's Insanity work out program for about five weeks and thought that it was going exceptionally well, but the changes happening with my body started to seem like more than pure cardio...  I was drinking water by the gallon, using the bathroom every twenty minutes, eating whatever I could get my hands on and, quite literally, wasting away into thin nothingness.  

Let's get the embarrassment over with and
on my terms.  Me Summer 2002.


Don't get me wrong, I am constantly fighting to rid-myself of the fat-girl mindset that has gripped me ever since my overweight high school days.  Back then I weighted in around 200 lbs and for the past several years I have been - medically speaking - in range of my ideal weight and perhaps a bit low on the body mass index.  But when the scale began to read three to five pounds lower every day and my weight sank down to 115 lbs (ideal weight calculators say I shouldn't weigh less than 135 lbs) I knew something had to be wrong.   My husband and I even experimented to see if I could gain weight one Saturday night and I ate an extra large supreme pizza, half of a sheet cake and three pints of ice cream with ease... the next morning my weight was down four pounds.  So I put a call into the doctor Monday morning fearing the worst but wanting an answer.  

After the lab work was done and xrays were completed, my husband and I anxiously waited for a prognosis.  Eventually we heard back that my labs conclusively showed that I have diabetes.  Unfortunately, the initial doctor we saw wasn't well versed in the intricacies of the pancreas and he made the assumption that because of my age (24 at the time) I must be a type 2 diabetic.  He sent me home with a prescription for medication that would cause weight gain, a basic test kit (without showing me what to do with it) and a recommendation I take diabetes education classes the following month.  Ignorantly feeling relieved I didn't have anything "serious," I accepted the general diagnosis and went home. 

It wasn't until the next day that the pieces of information the doctor gave me seemed to ill-fit my situation. I'd been left completely clueless as to what being diabetic meant and questions began to overwhelm me...  My lifestyle is very active, I eat well and I am otherwise healthy, so how the heck can I be type 2? How do I use this test kit and what the heck do the results mean? What is it that I am not supposed to eat?  You want me to spend how much on 30-days worth of weight gain pills?!   Um, no. 

Instead of waiting the five weeks for the class I was told to take, I decided to call my God Mother in Colorado who - thank God - is a diabetes nurse educator and the mother of a type 1 diabetic.  Gingerly she walked me through, step by step, the process of checking my blood sugar... I pricked my finger, held the test strip to the blood and waited for the reading to appear on the screen.  But my first reading didn't come back as a number.  I told her I must have done it wrong and tried again.  It said the same thing.  

"What does it say, sweetie?" She asked. 

"It just says the letters 'HI'," I responded. 

"Honey, that means your sugars are high.  Find the instruction manual and tell me what ranges the kit reads to."

Not knowing what it meant to have her say that my sugars were "high" (yes, the doctor skipped over all of that information), I dug through the book until I found what she requested.  

"It says that it reads up to 460 mg/dl,"  I said. 

"Jaime, I don't mean to scare you, but you need to go to the hospital right away.  Don't eat anything, take your test kit and go there now.  Blood sugars that high are very dangerous and it sounds like they have been this high for a while, you need to get to the emergency room."

"Uh, okay..." 

Advising me to go to Georgetown University Hospital in Washington DC because of their national reputation in endocrinology, my husband and I packed up our son, cancelled our evening plans and went on our way.   

At the hospital I felt like I'd walked in with a gushing gun shot wound based on how quickly the staff responded to me saying "newly diagnosed diabetic" and "blood sugar over 460 mg/dl."  Within a few short minutes I was on a gurney, getting new labs, attached to an IV drip and officially diagnosed as a type 1 - NOT TYPE 2 - diabetic.  

Using unfamiliar phrases like "hemoglobin A1C of 11.6," "ketones," "hyperkalemia" and "diabetic ketoacidosis" to describe my situation, the doctors explained in no uncertain terms the severity of my situation and the probability my pending admission to the hospital would be to the ICU.  I quickly found out that if I hadn't come to the ER for treatment, I likely would have gone into multi-system organ failure within weeks and very possibly could have died as a result of the damage.  

Well that explains why my God Mother told me to go to the ER, eh?  

My stay at GTU Hospital lasted four days and it was in those 96 hours that I got a crash course on the impact diabetes would have on my life:   I learned that the islet cells in my pancreas were attacked by my immune system, but there is no way to know why... I learned I would be dependent on artificial insulin via injection or pump for the rest of my life...  I learned that I must count carbs to stay healthy and that nothing should enter my body without knowing its carb content...  I learned what it meant to test my blood sugars and that I'd need to do it at least 5 times a day, preferably more...  I learned what consequences my body may face if I don't take care of my diabetes...  needless to say, overwhelming and scary. 

It's been a year and a half now since I left the hospital and started to actually live life as a diabetic.  I'm on an insulin pump now and that makes life much easier than four-five injections a day, but even with the convenience of automated insulin-delivery I am still amazed by the pervasiveness of diabetes in my general existence.  It affects so much more than what and when I can eat... it impacts when, how and if I can exercise, what clothes I can wear and how I wear them, whether or not I can do simple tasks like drive a car or take a shower, and - most disheartening to me -  it impacts the safety of future pregnancies.   

For a die-hard foodie who loves to run and wants several many kids, talk about a one two punch to the pancreas!  

But such is life and, hypothetically, God only gives us what we can handle so I must trudge on and work on acceptance.  It's definitely not the end of the world, but life with diabetes is hard, it is complicated and it is often very misunderstood.  In the following blog posts I will be focusing on the challenges I face as a diabetic as they arise and we'll see where this takes us.  I'm hopeful that my rambling will help the people in my life understand my situation and help dispel the erroneous assumptions associated with this unavoidable, incurable disease. 

Thanks for reading!