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.

2:19 AM

In a pitch black room with little but the sound of HB sleeping next to me I think to myself "it's hot."  I roll over, kick the covers loose and snuggle into my pillow more and assume the excess heat is from HB or the much appreciated heated mattress pad he got for me two years ago.  But before falling back asleep then I have another thought, "I feel low. Open your eyes."

So at 2:19 AM, with shaking hand and groggy cohesive thought I reach out, turn on the bed side lamp and fumble for my test kit.  I manage to stab my arm with the lancet and press it in hard and long enough to get the right amount of blood.  I insert the test strip into the meter with some difficulty and apply the tip to the blood.  The meter beeps and I wait for it to process...

37.

With absolutely no finesse, I wake HB from his typical deep sleep and ask him for "Juice. I need you to get me 8 grams of juice."  Fortunately being a) much better and much more responsive at waking up than he used to and b) able to translate what I meant despite the rude awakening, he got up and went to the kitchen to retrieve an eight ounce glass of orange juice (23 grams carbs).  With his help I sit up and drink about five ounces of it - my correction typically only needs to be about 10-15 extra grams to come back up - and we begin to wait.

Five minutes later my hands go numb.  Eight minutes later my lips and cheeks begin to tingle.  I hate the sensation, but the cruel fact of the matter is that I was just regaining feeling.  It was a complete fluke - maybe miracle is more appropriate - that I managed to feel my body temperature change, wake up and recognize what was happening to me...  At 37 mg/dL, my blood sugar is in a scary low hypoglycemic range - one that I've been in before, but never one I've been in while pregnant.

The last time I was in the 30s was right after I was diagnosed and the doctors were still trying to figure out my insulin dosage needs.  Back then, they had me on Novalog pens for my fast acting insulin (aka bolus), Lantus pens for my slow acting insulin (aka basal) and I was on some sort of sliding scale but I couldn't tell you what that was now even if you paid me to...  all I remember is that HB and I were sitting on the couch watching Victor/Victoria when all of a sudden I began to sweat like I was in a sauna and felt like I was in - literally - hell.  My skin cold to the touch, HB didn't have an answer but we checked my blood sugar and my meter read 32 mg/dL.  I remember my doctor looking at me with some disbelief that I'd maintained consciousness with a bg reading that low and I remember feeling lucky.  As we were fine tuning my needs back then, I'm sure that hypo was because we'd over shot my bolus calculation -- but now? I have no clue what is going on, but my basal rates are still too high and I don't want to take any chances with luck.  This is my baby we're talking about and my hypoglycemic shock isn't something I want to put her through.

When my endocrinologist turned my basal rates across the board down by 0.050 units on Friday, I let her.  Getting yelled at by my perinatologist for poor diabetes care made me feel horrible and I wanted to make it right and prove to him that his criticism was out of line (which I still maintain it was).  I didn't agree with the endo that every basal rate deserved that reduction because I wasn't 100% low all the time, only at certain points during the day - especially over night and first thing in the morning.  But, going with the professional opinion, I reprogrammed my pump in the way I was told to and this weekend has been horrible.

On Saturday, my blood sugar several hours after the bolus for lunch wore off and I didn't have remaining active insulin in my system I checked my blood sugar for the sake of checking and found it comfortably sitting at 202 mg/dL -- MUCH higher than the acceptable range of 140 or below.  Deciding to think for myself, I changed the basal rate for that time of day back to what it was before my endo appt on Friday and - guess what? - I didn't have inappropriate highs or lows at that time on Sunday.  Her method of generic reduction didn't help and, despite the reductions, I've still been seeing lows... I'm completely underwhelmed by her assistance and frustrated by the persistence of numbers in the 50s and 60s!  I've started to take those numbers to almost be normal,  but 37 is a completely different ball game.  Something is definitely wrong.

I've decreased my basal rates from 12 AM to 3 AM from 0.50 units to 0.425 units and dropped my daily basal rate usage even farther to a total of 12.8 units... much less than it was just a few weeks ago when it'd gotten up over 17 units a day! I'm planning to call the perinatologist's office in the morning to make sure they know what's been happening even after I call in an "expert" and that I'm frustrated.  They really had no right to yell at me on Friday when I haven't done anything irresponsible and the source of my decreasing insulin requirements still needs to be identified rather than dismissed as my "human error."  I'm constantly correcting and continuing to fall low -- doing everything I can -- but where ever the leak is, I need the perinatologist to plug it because I'm drowning in insulin.

I'm also planning to ask them for a referral to a more consistent endocrinologist in NOVA and I hope to swap all of my medical care back up that way by the end of the week... The endocrinologist down here has been perfectly nice, but I need someone who is more aggressive and who is responsive to me and my individual needs.  It's not personal, it's medical.  Which, oh by the way, means it's incredibly personal.

It's now 3:21 AM and my blood sugar is finally up to 73 mg/dL.  HB's gone back to sleep and I'm exhausted from continuing contractions (irregular enough to ignore, but none the less uncomfortable), back pain from uterine pressure on my sciatic nerve and a general inability to get sound sleep because I'm too busy worrying.  I'm going to drink some more juice since my bg is still a bit on the low side to fall asleep with confidence and try to catch another couple hours of zzz's.


I wish I could remember what it's like to count sheep, I'm getting sick of counting glucose molecules.

Week 34, part freaking two

Hmph.  Double hmph.  And grump!

It has just been one of those no good, down right horrible, get off my back, leave me alone or give me chocolate kind of days.   I didn't sleep well last night because GW, who is usually the best snuggler in the world, kept trying to head butt me in the chest to make space for his legs to go sideways on the bed and that of course made the fact that the alarm went off extra early so that HB and I could get to the hospital on time for my bi-weekly testing all the more gruesome.  Normally an hour drive, we left an additional 30 minutes early to fight the in-bound morning traffic to NOVA and DC and managed to get to the valet parking at the hospital with a few minutes to spare before my 8:30 appt.  Of course the antenatal testing center was running a bit late and we wound up sitting for an additional 45 minutes, but whose counting? (Oh yeah, me).

So we finally get back to the non-stress testing area and it's beyond freezing -- and for those of you who do not know me personally, I do not do well with any temperature below 70 degrees F.   The nurse, who I'll admit was very nice, squirts the non-heated (gasp!) goo on the paddles and hooks it up to my belly.  About fifteen minutes into the test she grumbles about the sleeping baby, gets me cold ice water to drink (again, gasp!) hoping to wake up the baby.  After the next fifteen minutes she decided to shut off the monitor and get the doc's take on my NST since the accelerations were borderline to where they ought to be (ideally they should rise by 15 beats per minute over the course of 15 seconds or more, Baby's were going up for like 13 seconds).  Leaving me sitting there in frigid goo under an air conditioning vent for another while, she eventually came back to announce that the results were acceptable and she sends HB and I back to the waiting room for the next available sonographer.

Waddling down the hall back to the waiting room, we turn the corner and find that the formerly sparsely filled room is now as packed as it possibly can be with pregnant women and significant others.  We found ourselves a corner and, to fill the dragging time, I started counting...  at any given moment there were between 11 and 16 pregnant women in that dang room.  Some closer to popping than me, others barely showing -- but all obvious with their hospital band bracelets.  It's funny how pregnant women take on different shapes and how differently we all carry... at 8.5 months I look like the typical woman does at six months and one woman's jaw actually dropped when she learned my due date is only two weeks after hers since we look so drastically different.  Course she'll probably get lucky and meet her baby sooner than I will, so size - ladies and gentlemen - really doesn't matter.

Anyway, the sonographer finally calls me back and does the quickest sonogram of my pregnancy yet.  She absolutely knew what she was looking at and clearly took speed clicking classes because bang bang bang and "you can go sit down and the doctor will call you back shortly."  I think if I had been a normal pregnant woman and that this was one of the very few times I could see my baby on the monitor I'd have been annoyed, but since this was sonogram #15 and I wanted part two of breakfast asap it was perfectly fine with me.

So back out to the waiting room we march and waited among the collection of mamas.  We watched the third interview with Sarah Silverman on morning television, we cringed at a 3 year old little girl with horrible manners boss her mother around and we joked about our lapse in judgement at leaving our entertainment (GW) back at home.  Some time later, this random doctor comes out and calls my name and I have no freaking clue who this guy is.  His jacket says that he's a "MFM MD" which is at least one step in the right direction, but seeing as I'd never heard of him, he looked like he is 12 years old with facial hair and I admittedly have little to no faith in medical fellows I was not exactly thrilled to see a non-familiar face behind the desk.  After pulling out a phone book to sit on and figuring out which way is up on my several inches thick chart, Dougie Howser then reviews my tests says that things with the baby were fine with the exception that the AFI was a bit high (even though it was lower than Wednesday).   Understanding that it was in normal limits, I moved on from that comment and handed him a print out of my blood glucose charts from the last three days and that - my friends - began the worst part of my day...

Not understanding the charts or what information I was trying to explain to him, Dougie decides to take my print out down the hall to my normal doctor (why couldn't I just see him in the first place?) for his take on things.  The next thing I know is that we're being called into the principal's office for a serious parent-doctor sit down...  Thoroughly disappointed in my asking him for "input" (which I did not), the normal doc began a lecture about insulin care during pregnancy and how off my blood glucose numbers are and how poorly programmed my pump must be.  Looking specifically at my pump settings and seeing that my basal rate is no where close to 50% of my daily insulin usage (which it ought to be), he said that I needed to stop self-managing and start working more closely with my endocrinologist or that he'd need to take me off the pump and put me back on injections so that he could manage my glucose.

ONLY OUT OF MY COLD DEAD FINGERS WILL 

A DOCTOR PRY MY PUMP AWAY FROM ME. 
(Adapted from a Charlton Heston quote)

I attempted to explain that I've tried to work with my endocrinologist's office and that they typically aren't responsive or they just tell me to do what I'd otherwise do for myself, but that just seemed to result in more frustration on my doctor's part than understanding.  He then said that I needed to get into see my endocrinologist today for an emergency reprogramming of my pump or that I'd at the very least need to begin seeing a different NOVA based endocrinologist next week.  I tried to explain that my concern in bringing up my blood sugar with him isn't that I need external input in how to decrease my settings (that's straight forward and I've done it successfully for the last 34+ weeks without problem), but the cause of the lows -- to which he pretty much left me with no answer except "see you Tuesday."

Thus leaving the hospital in near-tears from the feeling of being completely misunderstood and the "you're a horrible mother" treatment, I immediately called the endocrinologist to pass the buck along.  Fortunately having space for me in the schedule once we got back from NOVA, I was able to get in and sit down with my endocrinologist to go through my logs with a fine tooth comb.  Agreeing with me - and the NOVA doctor - that my logs show far too many lows, she did exactly what I would have done on my own and lowered my basal rates even farther.  Cutting every single basal setting by 0.050 units, my total daily basal rates are down to 12.875 units!!  I asked her about the randomly high postprandial readings, but she said they weren't of concern to her because of the extreme prevalence of hypoglycemic lows and she lectured that those 40s and 50s should be my only concern as well.  When asked about how I should address the chastisement I received for the 50-50% ratio of daily bolus to basal insulin usage, she essentially told me that my perinatologist would just have to get over it since that's just how things are going.

So... my perinatologist yells at me for horrible diabetes care and my endocrinologist barely does anything to "solve" the problem AND neither have an explanation for why my sugars continue to drop but rather they each individually want to point the finger at the other and say, "well, that's their job."

AGH!

I don't know... I feel like my blood sugar control has been pretty good for the pregnancy all things considered.  These lows are definitely concerning to me and they make me frustrated and scared, but I can recognize them and treat them as they happen so it's not the worst case scenario of hypoglycemia I could face (knock on wood).  I'm angry that my doctor up north would blame me for the problem I am only trying to fix and I'm annoyed that my doctor down south is being so passive...   All I can say is that I am hella happy that the baby is due in 25 days or less (less, please God, let it be less) and that I can put this excessively hands on medical care out of my life for a while.  I'm looking forward to working with our pediatrician (aka a doctor for someone else, not me) for regular well-baby appointments and I cannot wait to get back into running.  Any outlet for frustration besides chocolate would be fantastic right about now, but hey, I'm a hypoglycemic, post-placenta abruption, 8.5 month pregnant woman on modified bed rest so that just isn't going to happen.

Pass the chocolate.

Hmph.

Week 34, part one

As an exciting post-Hurricane Sandy and Halloween outing, the whole family came along with me to the perinatologist office today for my week 34 non-stress test (NST), amniotic fluid index (AFI) reading and check up.  HB, who is the most wonderful, involved father I know, always comes but today was a bit of a treat because my Mom came along totting a very sharply dressed snowman.  I was quite flattered that GW received as many compliments on his home made costume as he did, but given the fact he is such a dang cute kid in the first place I give him all the credit for wearing the outfit with such success... course wearing a jumpsuit of 100% polar fleece inside a warm doctors office for two hours turned out to be a bit tricky (especially since he skipped his nap today), but he managed just fine and put smiles on several many faces.  Particularly mine.  

 

 

So... the appointment.    Tam, the sonographer, did a partial sonogram for a basic biophysical profile (BPP) reading since they comprehensively looked at the baby's weight and my cervix thickness last week.  It is my general understanding that the doctors only do a full sonogram examination of the baby every three weeks because so many things can vary from one week to the next that it's not worth the extra stress if something may be a simple "water weight" change.   Any way, Tam spent the sonogram focusing on Baby's heart rate, her breathing patterns, her muscle tone, her movement and amniotic fluid levels (22.3) - to which I am happy to report Baby got the perfect score of 8/8.  She also did another 3D ultrasound and, for the third time this pregnancy, we got to see our little angel's face... granted she stuck her tongue out at the camera today, but hey she's supposed to be practicing that - she's got a big brother to contend with after all!
 

After the sonogram, the nurses had me do my second weekly NST.  Since she was more active after I downed Starburst last week to correct for a low, I checked my blood sugar before starting, noted I was trending low and did the same this week to try to save time.  Unfortunately Baby was set and determined to sleep through the Mommy-provided stimulus and after sitting there strapped by a belly band to a loud "wubba-wubba" machine for 45 minutes the nurse came in and gave her a vibroacoustic prod... Having never experienced this before, I must say it's kind of startled me when the nurse first pulled out this wand thing because I didn't know if I should expect a shock or what.  But essentially a vibroacoustic stimulator is a hand held machine that sends vibrating sound stimulus into the uterus to invoke a fetal heart rate acceleration - which is the whole point of the NST in the first place. After that the baby responded within the limits they look for at this stage in the game and I was taken off the machine after another 15 minutes.  

Bored out of his mind, GW requested to go read a toy book (pregnancy magazine) in the lobby with Grandma and so HB and I went back just the two of us for our meeting with the one and only Dr. Bronsky.  I gave him my blood sugar logs and for a matter of several minutes (which felt like several hours) he was dead silent as he looked at my numbers and began strategically flipping through my chart.   As I've previously shared here and outwardly complained about at all of my recent appointments, my blood sugar has been continuing to drop into hypoglycemic ranges that aren't normal or ideal for this point in the pregnancy. Since my last blog post where I indicated that my basal rate was decreased to the "low" daily total of 15.3 units I've had to further decrease it to 13.9 units - and I am still seeing numbers in the 40s and 50s! So, finally, he spoke up and said with a voice of mixed relief and concern that the results of my AFI and NST today are fantastic but that the lows in my blood sugar logs likely indicates a problem they're not seeing with the placenta.  As the implications of this can be dangerous and my diabetes is "very serious" (his words, not mine), these numbers warrant the doctors to be even more cautious as we finish out the pregnancy and Dr. Bronksy requested that I come in twice a week to the hospital for my testing so that they can monitor Baby more closely and "retrieve" her immediately as necessary.  

So as of this Friday morning at 8:30 AM, I begin my new routine of every Tuesday and Friday doctors appointments for the next several weeks of third trimester fun.  With any luck there wont be reason to justify more frequent appointments than that between now and delivery, but we'll see if we actually make it to the induction date - which YES we did set today. 

Drum roll please... 

If for whatever reason I do not go into spontaneous labor before week 38, the doctors have scheduled Baby to be born on Tuesday, November 27!  Dr. Bronsky explained that he'll have me come in the night before to be put on Cervidil and, depending on how things went with that, the morning of Nov 27 he'd would start Pitocin and artificially rupture the amniotic sac.  If things progress slowly, he said that we could expect to have Baby mid afternoon that day; but when HB mentioned how quick active labor was for my first birth, Dr. Bronsky said it could be much quicker than that.  

As I'd rather go into labor spontaneously than wait for this little whumpus to come out on a specifically circled date on the calendar (yes, I think that is weird), I am somewhat hopeful that she'll decide to pleasantly surprise me between now and then with an awkward gush and sharp twinge of pain.  Regardless, even if I don't go into labor on my own before then, it sounds like the docs are confident that I'll be able to have the vaginal birth that I've been hoping for and for that I thank God!  With how complicated things have been it's at least nice to know that Plan A is what I wanted all along and that Plan B is there as needed... 

Since my hands are shaking and my bg is probably low that is all for now. I'll be back again on Friday with another update from the land of the overly poked and prodded.  

Love, 

Diabetic Mommy of One, soon to be Two

Diabetes and Pregnancy

So back when I was first diagnosed with diabetes one of the most difficult things for me to hear the doctors say was that I couldn't have any more children for an extended period of time (several many years) because of the difficulty women have managing diabetes and pregnancy.  As HB and I had previously been hoping to begin trying for baby #2 around that time, the doctors took their time to explain the complicating factors my new disease has on the creation of fragile little embryos and maintenance of a healthy fetus. The white coats used big, scary medical terminology to indicate that abnormal blood sugars cause significant birth defects, that babies of diabetics are HUGE, that I'd likely wind up more sick because of the strenuous nature of pregnancy on my already damaged body and that there was no way a freshly diagnosed diabetic could understand the nuances of either the disease or the combo of the disease & pregnancy without several many years of diabetes management under the belt.

I remember feeling emotionally crushed.  I had been so looking forward to the feeling of a baby in the womb again, to holding another sweet little angel in my arms and to adding to the completeness my life newly feels because of my kid(s).  Having spent so much of my life prior to GW searching for a true form of self-expression and the key to my passion, I whole heartedly embraced the gift he gave me by honoring me in being my son... nothing replaces or ever could replace what he - and my future children - give me by simply being who they are.  So when the doctors pushed the "stop" button and placed my entire dream of a large family on hold, it hurt and I resented the failure of my pancreas all the more.

But now that the two year anniversary of my diagnosis (1/24/2011) is within counting distance and that I am close to finishing a difficult, but successful pregnancy with diabetes I understand what the doctors were saying back then.  Managing a pregnancy with pre-existing diabetes is tough and not something to be entered into lightly without serious preparation or comprehensive disease understanding.  I mean the consequences of diabetes alone on the health of a diabetic are serious enough, but adding the responsibility for another person - especially a little person - to the mix has a lifetime's worth of impact... indulge me with a quick explain:

With diabetes, by itself, there is a basic level of disease maintenance that is necessary to be considered healthy.  In the medical community, unfortunately, that is measured by the "low" bar of a HgA1C of 7% - which although it is better than the average diabetic (8% or higher) it is still considerably higher than a normal, non-diabetic's A1C (between 4% - 6%).  Whether on multiple daily injections of insulin or on an insulin pump, a diabetic must actively work to maintain some degree of glucose control to be a functioning person with limited knock on issues (such as blindness, amputation, heart disease, stroke - you get the point).  And - to speak generically on behalf of insulin dependent diabetics - that control can be extremely tough in even the most basic situation.

But when you throw pregnancy in on top of that (in all fairness, probably any other medical complication), diabetes gets more complicated and that's not a good thing.  Unexplainable changes, sharp spikes and dips in bg readings and larger than me implications for the baby make the juggling act of insulin, carbs and hormones all the more sensitive and important.  If I didn't know how to handle low blood sugars, how to prevent DKA, how to calculate a bolus or understand what a bolus rate is, I wouldn't know how to do what the fetus NEEDS me to do to keep it safe.  And since the placenta is constantly throwing in changing variables it's frustrating enough to be fine tuning my insulin needs without the overwhelming feeling that inevitably would result if I didn't "get it."  Especially since my bgs drop overnight (I've been in the 40s and 50s the last couple times I've checked at 3 AM), I need to literally know what to do with my eyes closed and in my sleep because the reality is that is life with diabetes and there is no down time!

Long story short, I was fortunate that my doctors had enough confidence in my self-care to grant me the "go-ahead" on this pregnancy as soon as they did.  But in retrospect I must admit that those doctors at Georgetown University Hospital had a point when they said that it isn't wise to mix the two until really ready.  I mean, I wouldn't forgive myself if something happened to my baby because I failed to take care of my disease or didn't understand it enough to be a good mother before birth.

Even now, at eight and a half months, diabetes and pregnancy is a scary mixture to me, but I'm grateful that there are materials available that helped prepare me for what my body would going through.  For those of you who are diabetic and thinking about becoming pregnant, or if you know and love someone who is, these are some great paperback (I like what I can hold rather than surf) resources worth checking out:

- Balancing Pregnancy with Pre-Existing Diabetes: Healthy Mom, Healthy Baby by Cheryl Alkon (click here) ** Most helpful to me **

- Diabetes and Pregnancy: A Guide to a Healthy Pregnancy for Women with Type 1, Type 2 or Gestational Diabetes by David A. Sacks, MD (click here)

- Diabetes Pregnancy: What to Expect by the American Diabetes Association (click here)

Recognition of Reality

I don't remember what it was exactly that tripped the thought in my head yesterday, but it flat out struck me square between the eyes and almost bowled me over that I'm going to be "normal" again soon.  With Tuesday marking the start of week 34 in the pregnancy, I have less than six weeks (take a few for reality's sake) of pregnancy left before Baby arrives and the complications of the last eight and a half months will disappear into my past.  I will no longer have to worry about the plausible existence of placenta previa, the horrifically real possibility of placenta abruption, the worrisome implications of abnormal alpha fetoprotein levels or the plan-changing results of non-stress tests.  I'll be able to cut the umbilical cord with the perinatologist's office and be a free woman... I'll be free to drink wine, free to exercise, free to pick up my son, free to vacuum the house -- free to be the regular, normal ol' me.

Kinda.

The thing is, I completely forgot that "normal" means being diabetic.  D-I-A-B-E-T-I-C.  Do you have any idea how weird that word sounds?  Ever since my diagnosis I've referred to myself as someone with "type 1 diabetes" as if it was purely something clinical and, by doing so, I've emotionally distanced myself from incorporating the reality of the autoimmune disease into my identity.  But when GW asked me about my medical ID bracelet (again) and why the symbol on it means "ambulance" (ah! That's what it was that started this train of thought!), I explained to him that "Mommy's got blood sugar problems because Mommy is a di-a-be-tic."  It was in teaching him to annunciate the word that reality hit me like a ton of bricks that my new normal isn't the normal I was anticipating.

For whatever reason it slipped my mind that all the medical issues of the right here, right now aren't purely solved by labor and delivery.  I think part of it is that, lately, a lot of people have assumed that I have gestational diabetes (GD) and in attempting to explain that this isn't the case I've some how managed to appropriate a degree of emotional detachment from my situation with the "comfort" GD offers pregnant women - a light at the end of the tunnel.  But as my insulin issues aren't purely pregnancy related and they aren't due to any form of basic insulin resistance, the rose colored glasses of wishful thinking come off and I am forced to acknowledge the reality that I'm chronically ill and not just knocked up.

While I may get a break from being pregnant (yes, we are planning for more kids and no, we aren't crazy) once Baby is delivered, nothing else changes.  I have to continue to check my blood sugar, to count carbohydrates, to wear my insulin pump, and to visit the endocrinologist's office.  I still have to wear a medical bracelet - even if I get to swap out my "PREGNANT Type 1 Diabetic" one for the more simple, straight forward "Type 1 Diabetic" version.  I still have to work to take care of me so as to take care of my family, even if they're all physically separate from me and my choices...  Baby will need me to maintain high enough blood sugars to avoid hypoglycemic shock from breast feeding (I'll get to that topic soon, I promise) and HB/GW will need me to continue keeping my blood sugars low enough to prevent other adverse side effects of diabetes from setting in. I'll have to continue checking my feet for sores and neuropathy, checking my eyes for retina degeneration, maintain a low-sodium, active life style to stave off the onset of hypertension and heart disease, and ...  unfortunately the list keeps going.

There is nothing funny about being a diabetic. It's awful and down right unwanted.  I couldn't do anything to prevent my body from destroying my islet cells and, believe me, if I'd had a say in the matter I would have fought like hell to protect those little suckers.  I guess that's why I've taken this pregnancy thing so incredibly serious from day one (well, more like D-90 since I started pregnancy self-care months before conception) -- I have influence in how things go.  I cannot idly sit by and let whatever medical benefits I can provide for myself slip away when everything else seems so completely out of my hands.  But as the pregnancy is winding down, the understanding that I am still sick is setting in... and while I'd love to alter the definition of "autoimmune" to mean that I'm automatically immune to stupid things like pancreas failure, I'm permanently weighted down by the rigidity of my new "normal" existence.  No amount of painful labor or delivery can save me from it.

I'm sure I'll be just fine - Lord knows I'm stubborn enough to deal with this disease and keep things on the road - but it'll probably take a while for me to really wrap my head around what all this actually means.  For so long my identity has been centered around the people I love most and the career choices I've made that I haven't really altered it to fully recognize the implications of my medical situation... no matter what role I fill or hat I wear, I am and will always be a diabetic.

Dang it.

January 2011 - The last family photo taken
before I was diagnosed with type 1 diabetes. 

Week 33

It's hard to believe it was a month ago today that I went to the hospital for the placenta abruption.  That day seems like it was just a couple days past and yet it also seems like eons ago... on one hand the stress of the experience and the nerves of it happening again make me feel just as scared as I did in the truck driving to the Stafford Hospital ER, but the boredom and anxiousness brought on by modified bed rest and limited activity make the action of it all seem like a completely different lifetime.  Overall I'd venture to say I'm far more agitated about the progression of things than I'd like to admit, but I'm sure if you were in my shoes you'd be just as concerned and anxious to have a healthy baby to hold and this pregnancy behind you.

Apparently NST go a lot faster after downing
Starburst to fight off blood sugar lows...
Go figure, sugar makes Baby active.

We had our first weekly appointment with the Perinatologist on Tuesday and that officially kicks off the routine non-stress tests and fetal weight screenings.  They did the 13th sonogram of this pregnancy and, much to my relief, it showed that Baby is looking pretty good.  The amniotic fluid levels are normal, the placenta seems to be as stable as it can be given its injury (and does not show signs of advanced calcification), her weight is a bit high at 4 lbs 12 oz but more or less on track for her gestational age and she fortunately remains vertex.  The sonographer was a bit concerned about Baby's leg growth and repetitively measured her femur to ensure her readings were accurate... but her worried expression vanished when she looked at HB and announced "oh, you're the source of stumpy legs" (no, I did not stifle my laugh).   Unfortunately for our daughter, she wont have my long legs, but I think it's actually safe to say that HB is quite relieved and happy about that.

Looking over things, Dr. Bronsky was generally happy with the progression (or lack there of with particular regards to my cervix) of things and recommended that I "continue doing what you're doing" (ug).  He agreed that my recent blood sugar logs are of concern and asked me to keep them posted if hypoglycemic episodes persist because while it looks like the cause may be Baby's appetite (trend estimates for her birth weight were I to make to to 40 weeks are currently in the mid 9 lb range), my placenta has been a persistent concern of theirs and they don't want to take chances.

So I'll head back in again next week for another round of flaming hoops to waddle through and we'll go from there.  If things continue as is, we'll be scheduling an induction (or c-section, depending on how things look at that point) for the week of Thanksgiving or the week after.  While I am glad things are stabilized enough for the doctors to make such statements, I'd be lying if I didn't admit that I hope Baby arrives a bit sooner than that... the persistent concern for her safety, the continuation of increasingly painful contractions and the heart wrenchingly painful look of disappointment on my son's face when I tell him that no, I still cannot pick him up is just a lot to emotionally handle for another four or five weeks.  Obviously I want her to be at a gestational age that is healthy for her to come out and I want to avoid the use of the NICU if we can, but as soon as those boxes are checked lets get this baby girl out and move on from pregnancy complications to new baby bliss.

In additional news, I also had an appointment yesterday with the Endocrinologist since the whole plan to fax in my logs completely fell flat.  The nurse practitioner thoroughly reprogrammed my pump and decreased my insulin rates almost across the board.  Two weeks ago my total daily basal rate amounted to 17.5 units and now it's back to 15.3 -- while that might not seem like a lot to those of you who are diabetic or understand insulin usage, it's a huge amount for someone like me who is so extremely insulin sensitive.  She also adjusted my target blood glucose ranges to be slightly higher to ensure that I'm not dropping lower than I really need to -- so even if the 70s are "safe" to be in, why not shoot for the 80s or 90s and hope for better bg averages?   Fair enough.  I'll go back and see her in three weeks if my blood sugar stabilizes and maintains safe ranges, otherwise I'll see her sooner as necessary.

So... where does that leave me?

Well, at 33.5 weeks, it leaves me waiting for what's next and prepping the nursery, house and family for the arrival of Baby.  I've been doing a bunch of research on diabetes and infant mothering (remember, I'm brand new to this combination) and it's amazing how intertwined the pancreas is to each of the choices I make and, since that little baby is entirely dependent on external care for quite some time,  her overall well being.  As this post is long enough as is, I'll save it for another day, but let it suffice to say that I'm generally overwhelmed by information overflow, physically uncomfortable, anxious for safe delivery and ready to get this show on the road... Granted ready for Baby and ready for Hurricane Sandy are two very different things, but let's just hope that Baby understands that things have been complicated enough as is without being born during the - to quote the Washington Post - most "unprecedented and bizarre" storm that "may be unlike anything the region has ever experienced."  We'll see how that goes.

Things that make me nauseous...

The past couple days I've been so ridiculously nauseous that even the thought of the most bland food makes me queasy.  Course it's not just food that has been making my stomach churn:

1. HB is off in VT.  We closed on our property up there at the beginning of the month and so he's been up there the past several days moving furniture into the place for our first tenant.  I can rationalize that I am of no help to him in my current state and that going with him was completely out of the question, but I don't think reason is necessarily relevant when it comes to the simple fact that I miss him and don't like him being gone.

Built in the 1860s, this is our "new" farm house on
Green Mountain near Middlebury, Vermont. 

2.  My little, baby boy is not so little any more.  I've known for several weeks that he is in the 90th percentile for his age group height and weight, but it didn't actually hit me that he is huge until yesterday when I picked out a new pair of shoes for him.  Admittedly his new shoes are slightly on the big side so he doesn't grow out of them tomorrow - so that is a minimal comfort - but still, his feet are almost as big as mine and he's only 3!

GW's new shoes next to mine.  

Sickening, right? 

Well, I don't know if my nausea is pregnancy related, the virus that is going around town or a deeply visceral reaction to the emotional stress of things going on right now, but as it didn't set in until later in the evening on Thursday when HB left I'd hypothesize (GW's latest favorite word) that it's probably the last of these three options, in which case I hope for it to be at least partially alleviated around 9 PM tonight when he gets back...  Then again since HB has been sick all week with that weird, random virus, option two is also a possibility (please, Baby, don't arrive until after he is healthy).  I'm going to pretend like the option of additional pregnancy-boohockey doesn't exist because being 8 months pregnant with complications is hard enough as is without additional nausea.  

Maybe a(nother?) nap is in order? Ug. 

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. 

The Little Man.

Taking a gigantic step away from diabetes and another step away from pregnancy concerns, I want to write this blog post about something, actually someone, who is ten times more influential and important in my life than my insulin pump.  GW.

Three years ago at 9:43 PM he was born and my life was turned completely upside down.  I was terrified to become a Mother - I didn't know if I had it in me to be what a child needed me to be (I hate - HATE - babysitting) and I didn't think that he'd be all that thrilled to have me as his Mom.  But, with the grace of God, the mommy-genes kicked in while I lay in my hospital bed that night holding him...  he was this tiny bundle who filled my arms like the missing piece I didn't know I was previously without.  I remember thinking "this is my baby" and that I had been completely ridiculous to even worry about my ability to attach.

Within the following days and months, it gradually hit me just how irrelevant everything else in my life was.  My feminist views, no matter how relevant to my younger self or how important similar opinions are for others, just compiled an incomplete self-perspective.  My job, no matter how cool it seemed, was just a job.  My career aspirations, no matter how high they reached or how within my grasp they came, were only about me and not inclusive of my family.  I know it's controversial to some (and to you I make no apologies or excuses), but making the choice to stay home with GW and be a full time Mom was simple.  I didn't - and still don't - find him to be something I can compromise over and by making him and my family my priority I know I'm doing what my heart says is right for me and I am enjoying every moment of it.

Of course it's not all rainbows and pop tarts - there are tantrums, potty training tales (HB is teaching him to stand at the toilet - Lord help me!) and I have found that there is absolutely no such thing as a day off.   But all of those frustrating moments balance out with wonderful little things like the adorable way he says "oh my gosh" when he's excited, how his tickle pocket makes him belly laugh and how he has an unending interest in classic musicals (he's perfected Dick Van Dykes performance of "Me Ol' Bamboo" from Chitty Chitty Bang Bang and he's practiced his auditioned to be the eighth brother in Seven Brides for Seven Brothers several times).  I love how he covers his ears when he's scared, how he insists I need him to hold my knees so I don't fall into the toilet, how he always behaves well when he sees Santa Claus at Mass and how he still thinks that knocking on the refrigerator is the required secret code to get a glass of milk.   He's just adorable.

What can I say? I'm the typical gushing parent and while the stereotypical shoe might fit I will unreservedly shout from the roof tops that I am proud of who he is and that I am grateful for the person he is helping me become.  Someday he might read this post and be embarrassed by what I have to say, but you know what, kid, I love you, you make me happy and that wont ever change.

So happy 3rd birthday, angel, and may you have many, many many more.

XO



October 2011 and October 2012 birthday portraits
- my goodness he is growing up quick!

Blah A1C

After four weeks of no appointments (I missed my last appointment when I was at the hospital), I went into the endocrinologist this morning for a regular diabetes and pregnancy check up.   Seeing as my blood glucose numbers have been all over the chart for the past several weeks, I wasn't surprised to have Dr P report my HgA1C has gone up.  At my appointment in August my number was fantastic at 5.3 which is completely within "normal people" range, but this go around my number is 6.2 which although it is still "healthy" for a diabetic, it is higher than I ought to be while pregnant.  The perinatologists don't want my HgA1C over 6.0 for fetal growth purposes, but given the steroids they injected to mature Baby's lungs if she needed to be delivered it's not at all surprising that my numbers are inflated.  As long as the number is heading back down the right direction for my next endocrinology blood panel this number should be no big deal, but if it's still high or continues to go higher, then we'll need to start worrying a bit more about the impact diabetes (on top of all the other complications) may have on delivery and Baby's health.

To give me a better shot at a lower HgA1C in a few weeks, Dr P helped me fine tune several of my carb ratios (the lowest is now 7.5 carbs:1 unit insulin) and a few of my basal rates to reflect trending dips and peaks my logs illuminated.  Given that I haven't been eating much since I've been home it's much easier to see where my respective basal and bolus rates are off; for example, my postprandial after dinner has been high several nights in a row indicating that my bolus rate after 5 PM is too low, but my afternoon blood sugars consistently dip into the 50s and 60s after several hours without food so that means my after 3 PM basal rate is too high.

I'm sure all of this will be out of date and need to be changed tomorrow (hoping and assuming my placenta is still working it's "magic"), but for the time being I should be on the right track.  Seeing as the best performance of my placenta is hell for my blood sugars and that I'm supposed to be on more bed rest rather than less, Dr P suggested that I fax her my blood sugar logs twice a week starting Monday rather than coming in to the office once a week for further insulin adjustments.  While I'm admittedly stubborn about dealing with my disease on my own, I'm actually really grateful to her for this flexibility and for her willingness to provide whatever support and assistance she can given the complexity of my situation.  I expect that if my non-existent appetite continues that she'll be mostly monitoring my basal rates for accuracy...

I honestly don't know what to make of my weight or my appetite at this point in the pregnancy, but the perinatologist on Tuesday didn't seem concerned so I'll take my cue from her.  The nurse I had today, however, was the most concerned I've seen any medical professional be about my weight. In fact, she ironically (given the number of Type 2 patients they see) encouraged me to go straight out to get a cheeseburger "or better yet, a double cheeseburger and fries" to pack on a few more pounds.  I'm still six pounds down from when I went to the hospital and I'm at the bottom end of "acceptable weight gain" for week 31 at 17 lbs, but even if my weight is a problem I highly doubt that high-fat, high-sodium fast food is the solution for me or for Baby.  Super indulgent chocolate cake with fudge, maybe, but I have yet to hear a doctor of mine prescribe that.  Perhaps that'll be a point of conversation next week?

Or maybe I'll just go for it with extra cherries and insulin on top since tomorrow is, after all, GW's 3rd birthday :)

Week 31 Perinatal Appointment

Well, I had my first perinatal appointment this morning since returning home from the hospital just over a week ago.  And while I'd love to say that the doctors announced that I'm perfectly healthy and ready to go back to pregnant life per-normal, they, unfortunately, did not. 

It was an odd appointment - not like any of the others that I've had before.  Instead of getting another sonogram and then seeing one of the doctor in one of their cushy offices, we were taken into an exam room (I'd almost forgot what those look like) and asked how I was feeling rather than told what has new.  I explained to the doctor that I am continuing to get contractions, that they're worse and more frequent when I stand, that Baby's been moving about less than before and that I've generally been feeling like absolute blah.  Listening with an increasingly concerned face (never what you want to see), the doctor stepped out of the exam room and asked the sonographer to do the previously unplanned sonogram. And off to get sonogram #12 we went... 

Checking only the crucial bits and not doing a full examination of the baby, the sonographer admitted she was sad to see me on a week where she otherwise wouldn't have.  Reassuring me that she's there whenever I need her to be (and decreased fetal movement is a good reason to need her), she checked to see if I was effaced from the contractions (which I am not, thank God), she checked the amniotic fluid level (down from 28 to 17, so back to normal ranges) and she checked the injured portion of the placenta.  She showed us where the blood clot has formed under the membrane next to the placenta edge AND she found the source of the bleed... an undeniable partial placenta abruption.

At the hospital we'd been told they couldn't identify anything except a "dark portion" of the placenta edge where blood flow was no longer occurring (the clotted area) and that the hemorrhaging must have been from an injury to that edge.  Today, however, the sonogram clearly showed another dark spot a little ways in from the known clot that medically confirms a degree of detachment and bleeding between the placenta and the uterine wall.   While there is a bit of comfort provided by the fact that we have an answer for what exactly happened, it's definitely a more concerning complication than an abstract injury to the edge of the placenta because once you've had an abruption, they're more likely to occur again.  So that continues to be scary. 

Here's a visual for a couple of the complications with the placenta that
I have had with this pregnancy. The partial previa has fortunately cleared
itself up, but the abruption will stay "as is" due to my gestational age
(assuming it's not further injured that is).

The last thing that the sonographer checked was Baby's biophysical profile - which I am pleased to report Baby scored a perfect 8 out of 8 on.  Seeing as she only got a 6 out of 8 at the hospital on Sept 29 due to her limited practice of breathing, this was a comfort to learn because it means her lungs are continuing to mature for delivery.  Which, by the way, she apparently has decided to get ready for by flipping over (yay! vaginal delivery is a serious possibility!) and no longer firmly planting her head under my rib cage.  From what the sonographer could tell, it's this new position that Baby is in that is causing the decrease in the fetal movement I feel because she's not only behind the anterior placenta, she's also facing backward.  So any movements she makes either need to be quite large or lateral to translate into more perceptible kicks... though I must say her hiccups are far more obvious now than ever!

Reviewing all of this, the doctor was glad to see that Baby is still the resilient little toughie that she's been and that the contractions haven't been causing distress to her or further damage to the placenta.  She instructed me to continue to stay on modified bed rest and to call them immediately if the contractions increase to four or more an hour that last over a minute.  But seeing as I'm "only" (ha, that word is used oh so loosely) getting them every 15 minutes for 30 seconds when I stand or sit up, that's "just" (again, ha) a sign of significant uterine irritability caused by the abruption.  Because blood remains behind the placenta and in the clot, she said to expect the contractions to continue... lovely.    Beyond that, the doctor requested that I start weekly appointments the week after next and she expressed hope that I'll only need to do weekly non-stress tests rather than biweekly or more.  We'll see how that goes.

All in all, I guess you could say that it was an uneventful appointment in that we didn't learn of some new complication or problem we need to address. Baby and I are looking stable on bed rest and there is still a fair shot that I could make it into November before she is born.   I guess my bond with the couch will continue to grow and my slower weight gain will sustain (still five pounds down from before the hospital) - for better or for worse. I'll keep you posted.

Maximum Bolus

I had to reprogram my pump this morning.  Given my recent blog posts about new basal rates and new carb:insulin ratios, I'm sure that many of you are thinking "so what?"  And while I have to hand it to you that reprogramming my pump is definitely becoming old news, this particular change in set up is a big deal to me and an official diabetes first... I had to increase my max bolus rate.

I've probably explained this before and I know it's off to the right side here in the diabetes vocab column, but a bolus of insulin is what I inject via the pump to cover the number of carbohydrates that I eat during any given meal or snack.  Back before I was pregnant, I would typically bolus 1 unit of insulin for every 22 to 25 grams of carbohydrates depending on the time of day (it's not a stagnant ratio, our bodies aren't that simple).  So for an extremely large, carb heavy meal - say 100 grams for mashed potatoes, a dinner roll, a glass of wine and 1/3 a dessert (gotta share with HB and GW) - before pregnancy I might inject a total of 4 to 5 units of insulin.

Well, as I've perviously explained is due to dear old Mrs. Placenta, my current carb:insulin ratios are much lower than they were and now three out of four of them are actually below 10 grams per unit.  So to have a heavier carb meal (as I did this morning with GW's early-bday pancake breakfast) I am bolusing what I consider to be exorbitant amounts of insulin to cover what would have previously been "just" four or five units.  This morning I needed to bolus for 100 grams (three of HB's large pancakes with sugar free syrup) and my pump started beeping at me something fierce and the screen read "MAXIMUM BOLUS EXCEEDED."

I've never seen this screen before.

I went back into my pump and looked more closely at the numbers -- 100 grams of carbs at a ratio of 8.5:1 came to 11.75 units of insulin.  ELEVEN POINT SEVEN FIVE UNITS. Do you have any idea how crazy that is?!  Since 2011 I've been notorious with my endocrinologists for being truly insulin sensitive as a little goes a looooooong way.  But now, at just under 31 weeks pregnant, insulin sensitivity is a thing of the past and my 11.7 units now covers less than half of what it used to!  No longer is a maximum bolus of 10 units appropriate when I require more than that for a singular meal.

Sigh...

The whole point of a maximum bolus rate is to protect insulin pump wearers from accidentally injecting too much insulin at any given point.  Like when your toddler grabs your pump while you're sleeping and pushes the buttons to play the beeping noise and all of a sudden you've got 35 units of active insulin in your system to eat your way out of (happened to the type 1 medtronic employee who trained me to use my pump; scary).   Just to give you an idea, at my current ratio 35 units is just about 300 grams of carbs which is equivalent to: 5 slices of apple pie, 4.5 blueberry scones, 8 cups of Kemps Old Fashioned Chocolate Chip ice cream or 12 of HB's large pancakes.  I don't know about you, but I can't eat that much and that's exactly the point of the max bolus.

Long story short, I had to go into the bolus settings and increase the max bolus allotment - something I've never done before.  I only increased it from 10 units to 12 out of mere passive aggression toward my pancreas and placenta (what's up with me and malfunctioning "p" letter body parts?)... I'm guessing they'll retaliate sooner rather than later, but for the time being I'm relishing my effective, minor counter measure.

Take that.

A whole bunch of pregnancy firsts.

As many of you already know, I wasn't a diabetic when I was pregnant with GW back in 2009.  I didn't even have a hint of gestational diabetes let alone a full on type 1 dependence on artificial insulin.  It was a normal pregnancy in many regards with no complications and only a few quirks - namely I didn't realize I was pregnant until week 12 (nuva ring, baby!) and GW arrived "pre-term" by being two days short of 37 weeks.  But all in all, the pregnancy with him was smooth sailing and what I'd typically refer to as "all pop-tarts and rainbows."

Obviously this go round is quite a bit different.  I've got type 1 now, I'm having loads of non-diabetes pregnancy complications and I don't even want to attempt to go there with pop-tarts or rainbows because (lets face it) those probably have more carbs per serving than I have insulin -- especially if the rainbows we're talking about here are made of skittles.   But seeing as this is round two for me, I know what a little bundle of joy I'll get at the end of this and I'm grateful to my pancreas for at least providing me a degree of perspective by sparing my first pregnancy from it's wrath.

The thing is, though, despite my almost three years of hands on parenting experience, there are so many new and different things with this pregnancy that I feel in many ways I'm a brand-new mom all over again:

• My medical care is different and more complicated - leaving many new tests to research and understand.  
• My diet is more restricted and calculated - requiring more attention and proactive tracking.  
• My to go bag is ready to go much earlier (okay, it's been ready for several weeks and is actually re-packed after last week) - making me more anxious and nervous for labor to begin.  
• My expectations for delivery are more grey - causing me to unavoidably "what if" about before, during and after labor. 

So although I'm some how managing to keep calm and accept that the only thing I can really DO to help Baby is put my feet up, I find my experiences with this pregnancy far more resemble that of a first-timer than typical of a pregnancy-vet.  Don't get me wrong, I'm not back to absolute square one of trying to figure out which way the diaper goes on or what the heck a Manhattan Whoozit is, but there is something to be said about the difference between a straight forward, non-diabetic delivery of a baby and the complicated, ultra-sensitive (I mean you're even allowed to eat - yes, more than ice chips) delivery of a diabetic. Wrapping my head around the changes to my experience-based-expectations is turning into quite the task and emotional challenge.

On a completely unexpected note, one of the biggest differences that I've noticed this past week between this pregnancy and the last is contractions.  I know this probably sounds weird, but bear with me... When I went into labor with GW the only sensation I experienced was this sharp, unbelievable point pain that I quickly learned was caused by dilation.  The pain I felt with that was more than I expected and - as a firm believer in modern medicine - very much the reason I opted for the epidural.

Oct 12, 2009 - post epidural and much, much happier.
Hallelujah!

The past two weeks, however, I've had my first taste for what a contraction feels like and I previously had no flippin' clue there was a difference between "contractions" and what I felt in Oct 2009.  Contractions, unlike dilation, feel more like a solid, crescendo-decrescendo of pressure spread across your entire uterus that cause it to go entirely rigid.  I would not describe it as painful, it's just rather unpleasant -- and actually, if labor and delivery were confined to only contractions and not dilation I'd venture to say that natural childbirth would be quite within the non-medicated pain threshold I personally have.   But seeing as dilation is the bleepity-bleep-bleep that it is, I have no shame whatsoever in saying "yes, please" (or something to that effect) to a gigantic needle being rammed in my spine.

Perhaps I've developed too much of an immunity to needles?

Honestly, the biggest change I am scared of (well beyond any possible necessary use of the NICU) is the challenge maintaining healthy-range blood sugar creates with breast feeding.   As with any calorie burning activity, breast feeding requires a mother's body to burn energy - aka glucose - to the point that many diabetic-mommy's report that it is excessively easy to experience their worst episodes of hypoglycemia ever (click here for an example).   Not that these other changes or complications have been a walk in the park, but it's scary to think that the "high risk" of being a diabetic mother doesn't necessarily go away once Baby is born.

When I was expecting GW the only intimidating part about breast feeding was that I'd never done it before.  In trying to sooth my nerves, HB and I experimented with the Medela pump we bought and it made such an audible suction sound that I insisted he try it before I did.  As an extremely supportive husband and incredible good sport, he did and within the first weeks of GW's life I took to that sucker (ha, literally) with far more confidence because of his gallant courage.  But this go around, I can't just ask HB to test drive for me... it's my pancreas and my second baby after all and not some odd electronic that in any non-internet based forum would otherwise make me blush.  Obviously, I need to do some more research on this topic so as to understand the implications of my disease better and hopefully dissuade some of the fears that go along with it.  I'll let you know what I come up with.

Without wanting to jinx myself, I really must admit that I'm looking forward to baby #3 whenever he or she comes around.  Maybe by then I'll have wrapped my head around not only pregnancy, but pregnancy and motherhood with diabetes that I can finally go into the experience with the luxury of fewer questions and concerns than before.  Course, knowing me, there will be some other nuance that will change the situation and give me yet another run at pregnancy with an amateur status... but, by the grace of God, I've got HB and two amazing children that will help me get through whatever that challenge is when it arrises.  All I ask, Lord, is that if I'm allowed my druthers that next time the complication is something as straight forward and "easy" as twins!