Diabetes & Pregnancy: The 3rd Trimester

NOTE:
This post is a continuation of a series about managing my diabetes while trying to get pregnant and being pregnant. For more, you can check out these previous posts:

Diabetes Type 1.5/LADA
Diabetes & Miscarriage
Diabetes & Pregnancy: The 1st Trimester
Diabetes & Pregnancy: The 2nd Trimester

As always, these posts are not meant to be taken as medical advice, and merely discuss my personal experience with my specific diabetes. Everybody's experiences are different, and I am only speaking about mine.

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My baby girl was born on 1/1/2020 (a New Year's baby!), weighing 8 lbs 10 oz and measuring 20.5 inches long. Being pregnant and giving birth as a diabetic is not easy - I knew that going into this pregnancy, and I know it even more acutely now that I've experienced it personally - but of course, all that insanity was worth it in the end, when I got the chance to hold my baby girl... And yet, this is a blog post about that insanity, not about the end result, so bear with me as I talk at length about all the hard work I put into managing my diabetes at the end of my pregnancy. :)

During the 10 weeks that I was in my 3rd trimester (from 28 weeks until I was induced at 38 weeks), I had 18 appointments. I had my annual physical at 28 weeks, as well as a growth ultrasound and doctor's appointment with MFM (maternal fetal medicine). At 29 weeks, I had an appointment with my regular OB and received the Tdap vaccine; at 30 weeks, I had a doctor's appointment with MFM without an ultrasound. I got a short week-long reprieve at 31 weeks... and then, starting at 32 weeks, I had appointments scheduled twice a week - an NST (non-stress test) and appointment with my OB on either Monday or Tuesday every week, followed by a BPP (bio-physical profile) ultrasound with either my OB office or MFM in the second half of the week, which (if it happened at MFM), also included appointments with MFM doctors and nutritionists, and perhaps another growth ultrasound as well. All told, by the end of my pregnancy I'd had 15 ultrasounds.

The non-stress tests were simple. I'd go to the doctor's office, where they would take my weight and blood pressure and have me pee in a cup. I would talk to a doctor, often (but not always) getting my fundal height measured and the baby's heartbeat found on doppler. And then I would be ushered into another room with a reclining chair, given a glass of ice water to sip, and told to stay put for 20 minutes with two monitors wrapped around my belly - one to measure my baby's heartbeat, and the other to measure any contractions I might be having. As I'd already experienced this at the hospital when I was 27 weeks pregnant and had some mildly concerning symptoms which my OB wanted to check out, I already knew the drill. They were looking for proof that my baby's heartbeat was doing well - but they were also looking for signs of "reactivity," which apparently means at least two momentary accelerations in heartbeat over the course of 20 minutes. They also didn't want to see any decelerations in heartbeat - or they would worry that my baby was in distress. Over the course of 7 NSTs, I only ever saw decelerations once. Usually everything was fine, and me and my baby "passed" with flying colors, being sent home once our 20 minutes of relaxation were up.

The one time I had an issue was at 35 weeks pregnant. I wanted to know what my A1C was (since it hadn't been tested in ten weeks, and I was curious), and my doctors needed to get another CBC (complete blood count) before I went into labor anyway, so before I sat in the NST reclining chair I was given a blood draw. I felt fine at the time (and I've never had issues with blood draws in the past), but ten minutes later, when I was sitting in the chair, I suddenly started feeling very faint. I worried it was my blood sugar dipping low, but my continuous glucose monitor (CGM) said I was fine. Before I had a chance to prick my finger to double check with my glucometer, my OB returned to the room and assured me that it likely wasn't my blood sugar at all, but a drop in blood pressure, caused by my blood draw and then sitting in a reclining chair. They moved me so I wasn't reclined as far, and they gave me a cold compress for my forehead, and after a few minutes I started feeling like myself again. I came close to passing out, but never actually fainted. In the minutes that followed that episode however, my baby showed heartrate decelerations twice. My OB guessed it was just because I'd almost fainted, and that probably my baby was fine, and not actually in distress anymore, now that I was feeling better. But just to be safe, it was recommended that I go to the hospital so they could monitor my baby's heartbeat for another hour.

The hospital was just around the corner, and I drove myself there. I checked in and went up to triage - just as I would a few weeks later, when it was time to be induced. They hooked me up to the same two monitors my OB office had just used, and for more than an hour I sat there, listening to my baby's heartbeat. By then, I felt fine - and so did my baby; I was more concerned with what the extra time I hadn't planned on spending away from home was going to do to my eating schedule. I was told three times that the doctor would "be right in" to see me - to assess what was clearly a normally reactive fetal heartrate and officially discharge me - before she finally came in. By that point, it was about an hour past when I'd wanted to eat lunch, and my CGM said I was at 70. The hospital staff offered to bring me a sandwich, but I didn't have my insulin with me; I didn't want to eat lunch at the hospital and have to use their insulin (which I figured would require more monitoring, and mean even longer before I would be discharged), and I didn't want to eat a sandwich without taking any insulin at all, so instead I accepted their offer of graham crackers, so that I wouldn't go low driving home - and then I ate my lunch once I was back in my own kitchen, with my insulin. (I suspect if my CGM had said 68 or something instead of 70, they might have been less keen to let me go - but as long I was at 70, I wasn't technically going low yet, and they had no reason to keep me.)

The bio-physical profiles were even more routine; during 6 BPPs not once did anything get flagged as a potential problem. Each BPP was an ultrasound where the sonographer looked for my baby's heartbeat, evidence that my baby was "practicing breathing" (moving her chest to exercise her lungs, even though babies can't really "breathe" while surrounded by amniotic fluid), and movement (both subtler movements and larger movements that showed proof of muscle tone, like an arm or leg flinging out). These ultrasounds are scored out of 8, and my baby passed with 8/8 every time, usually not needing anywhere near the allotted 30 minutes to demonstrate her abilities. During these BPPs, they also measured my amniotic fluid, to make sure it was within normal ranges. 

I also had three growth ultrasounds during the 3rd trimester - one at 28 weeks, one at 32 1/2 weeks, and one at 36 1/2 weeks. At 28 weeks, my baby had an estimated weight of 3 lbs 5 oz, putting her in the 95th percentile. I talked a lot about this in my previous post about my 2nd trimester, so I won't get into it much again now, but I was genuinely worried that I was going to have a "big baby" due to my diabetes, and that any health complications she might experience because of that (or any problems I might experience during labor because of that) would be "my fault" for not keeping my blood sugars lower - even though it felt like I was doing everything I could to try to do just that. Because of this worry, I started limiting my carbs a bit whenever I could (so basically - whenever I wasn't struggling with hypoglycemia that required me to eat more to keep my blood sugar in normal ranges). I tried to aim for eating about 45-50 g. of carbs per meal (instead of the 60 g. I had been doing earlier in my pregnancy); I also tried to keep my caloric intake around 2000-2200 a day whenever possible (though it wasn't unusual to hit 2400-2600 calories on days when I was battling low blood sugar). If I'd had my way, I would've been eating only 2000-2200 calories a day all along - on days when I ate more, I felt like I ate so frequently and so much, and was often very full, especially as I got farther into the 3rd trimester and my baby and uterus took up more and more real estate. I ate because my insulin dictated that I needed to, to avoid going low - not because I was hungry, or even felt like I had any room in my crowded stomach.

Thankfully, my growth ultrasound at 32 1/2 weeks started seeing my baby's average percentile go down a little - she was estimated to weigh 5 lbs 5 oz (89th percentile) that day. By my 36 1/2 weeks ultrasound, she was estimated to weigh 7 lbs (76th percentile) - at which point I stopped worrying so much. This was also about when my doctors talked to me about scheduling an induction - because I was battling lots of low blood sugars (more on that a bit further down in this post), and any (slight) high blood sugars I was seeing could not easily be fixed without simply causing even more lows, MFM decided it would be best to induce me around 38 weeks. Initially, they'd warned me they might want to induce as early as 37 weeks, but because my blood sugars were mostly on target (at least on average), there was no need to push for an earlier induction and risk complications due to prematurity. So knowing that I would be induced at 38 weeks, two weeks before my official due date, also helped my worries about my baby's size. Babies tend to gain about 1/2 lb. a week on average during the 3rd trimester; it was estimated that being born at 38 weeks gestation would put my baby at around 8 lbs. at birth - a number I was more comfortable with.

Of course, I still worried a little. Even though my baby's weight estimates were going down, her abdominal circumference stayed in a similar percentile through all three of those growth ultrasounds, ranging from the 94th-96th percentile - and since I'd been told that the belly size was a particular indication of diabetes-related larger babies, I was naturally concerned about those numbers. But MFM didn't make a big deal about it, and continued to congratulate me on how well I was maintaining my blood sugars. In fact, the A1C I had done at 35 weeks (which caused me to nearly faint, and resulted in my one abnormal NST result, as detailed above) came back at 5.1% - slightly higher than the 4.8% I saw during the 2nd trimester, but still well within non-diabetic ranges.

Besides all of these doctor's appointments, I also called in my blood sugars to the MFM nurses twice a week. Each time, they relayed my reports to the doctors and called me back with new recommendations for my insulin. As my placenta became more insulin-resistant (as all 3rd trimester placentas do), I needed ever-increasing doses of insulin to keep my blood sugars within my pregnancy ranges. When my 3rd trimester started, I was taking 27 total units of insulin - 9 units of Levemir in the morning and 5 u. at night, plus 6 u. of Novolog with breakfast, 3 u. with lunch, and 4 u. with dinner. 7 weeks later, by 36 weeks pregnant, I was taking 39 total units - 10 u. of Levemir in the morning and 6 u. at night, plus 12 u. of Novolog with breakfast, 5 u. with lunch, and 6 u. with dinner. At that point, my insulin needs finally leveled out, and I was able to stay under 40 total units for the last 2 weeks of my pregnancy, until I was induced at 38 weeks.

In general, I understood why I needed to keep increasing my insulin, and was usually on board with my doctor's recommendations - with one major exception: the recommendation MFM made around 34 weeks, when I called in my blood sugars just after the Thanksgiving holidays. Based on the readings I gave them, which admittedly included some higher-than-usual numbers, they decided to increase both my breakfast and dinner Novolog doses by 2 units - breakfast from 8 u. to 10 u. (a 25% increase), and dinner from 5 u. to 7 u. (a 40% increase). I was always going to hate that recommendation - because I hated it every time they tried to increase me by 2 u. instead of 1 u. at a time. When they did this, it made me feel like they weren't listening to me, not taking my individual diabetes into account, and refusing to consider that maybe my latent, gradual, adult-onset diabetes required different treatment than they were used to. I was not a gestational diabetic or Type 2 with severe insulin resistance and no danger of experiencing hypoglycemia; nor was I a Type 1 who'd had diabetes for most of their life, had been on insulin for a decade or two, and had let their A1C slowly creep up over the years to the point where it was problematic. I'd been on basal insulin for less than 3 years, and mealtime insulin only since becoming pregnant, I took my diabetes management very seriously, and I was very sensitive to insulin, having hypoglycemia easily with just small adjustments. Yes, being in the third trimester made me less sensitive to insulin than I had been in the past - but that didn't mean I could suddenly handle a 40% increase in insulin for a single meal. I knew that one or both of those 2 u. increases would be a major problem (and I knew that I would be the one dealing with the hypoglycemic consequences, not my doctors) and the fact that MFM didn't seem to realize this (or did realize it, but didn't care) pissed me off. 

But besides this negative gut reaction I always had when MFM tried to sell me on a 2 u. increase, I also hated that they were making any recommendation at all, when I knew my numbers "looked bad" not because my needs had drastically changed over a few days, but because they were my blood sugar logs over the Thanksgiving holidays. Besides the Thanksgiving meal itself, I'd eaten at restaurants more that weekend than I usually do. There had been several meals where I hadn't known exactly how many carbs I was eating, or what ingredients were used in recipes. I was also often eating at a different schedule than I normally ate at, with the result that sometimes I didn't take routine insulin (because I wasn't sure if what I was eating was a snack, or if it would end up being my lunch after all). It hadn't been a typical week, and I hoped that my numbers would go back to what they had been the week before, once I was back on a more regular schedule and diet - but MFM didn't seem to want to give me the chance to see if my blood sugars would even out, and that frustrated me.

I could've pushed back more from the beginning - and maybe I should've. But I haven't yet been diabetic long enough that I was completely confident in my gut reactions, and I often talked myself into giving my doctors the benefit of the doubt. I told myself, "I'll try it their way for a couple days, just to get the data to prove to them that this is too much insulin, and then they'll have to listen to me, because I'll have the data to back it up." Throughout my pregnancy, I took this approach a lot. It's probably why I ended up with so many low blood sugar readings - because I foresaw them but let them happen anyway, just to prove (to myself and to my doctors) what I had suspected all along about my insulin dosing. 

The first night I took 7 u. of Novolog with dinner, I was at 48 by three hours after eating - so low I actually felt hypoglycemia symptoms again (I usually didn't, since I had hypoglycemia so often my body had more or less gotten used to it). The second night, I was at 60 by three hours after dinner - another hypoglycemia episode, albeit not as severe as the previous one. By the third day (when I had also been doing 10 u. with breakfast for the last two days), I was at 69 before eating lunch, and 63 before even eating dinner - so I didn't take my 7 u. of Novolog with dinner, choosing to take only 6 u. instead. I saw MFM for an appointment the next day, showed them what had happened, and told them I wanted to take only 6 u. with dinner instead of 7 u. And they listened to me, and agreed that 6 u. with dinner made more sense.

My breakfast Novolog was also a struggle, but I felt like I had "less data" to back up my opinions there (or to even form my opinions at all). For whatever reason, my two-hours-after-eating-breakfast blood sugar reading often came back above 120 - and not infrequently as high as 150+. I'm not sure why breakfast affected me so much more than lunch or dinner did, when I tried to eat balanced meals for all three. Then, by 2.5 or 3 hours after breakfast, my blood sugar would be crashing, and I'd be scrambling to eat a snack to avoid a serious low - but that was a time of day when I was "supposed" to be eating a snack anyway, followed by lunch not too long after; it seemed less serious to deal with hypoglycemia during the mid-morning hours than it did after dinner, when I was prepared to eat only one more (small) snack at bedtime, and then go to bed. I did bring up my concerns about my mid-morning lows, and I talked to MFM about what I should be eating for breakfast, and for that mid-morning snack, to try to head hypoglycemia off before it hit, but in the end I was much less clear about what I wanted to do regarding my breakfast insulin. I could never get myself to say, "I don't want to take 10 u." (or 12 u., when they raised my breakfast by 2 more units just 1.5 weeks later) - because I didn't like seeing those high 150+ numbers either. I was worried about my baby's exposure to high blood sugar in the womb, and what that was doing to her abdominal circumference, or what it might due to her pancreas's ability to manage her blood sugars when she was born. I didn't want to be responsible for any problems she might have. 

So when they recommended more insulin with breakfast, I listened. For the last few weeks of pregnancy, I was taking 12 u. of Novolog every morning. I was working from home by this point, which made it easier to treat hypoglycemia when I had to (and I often had to), but it was also exhausting and frustrating to deal with it almost every day. I would eat 400-500 calories with breakfast, including protein (usually eggs), fiber, and enough carbs to get me to at least 45 g. Two hours after eating, I'd be anywhere from 70 to 180 - with no rhyme or reason I could tell for why some days were significantly worse or better than others, since most mornings I ate the exact same thing for breakfast several days in a row. My post-meal goal was to be under 120. If I was within that goal (and especially if I was under 100), I started eating my snack right away, knowing that number would only go lower; but if I was above 140 or so, I didn't want to start eating that snack yet - not until my blood sugar was back within target ranges first. I quickly learned this was a mistake, and that I had to start eating my mid-morning snack 2 hours after breakfast regardless of whether I was already closer to 70 or 180; by 3 hours after breakfast my blood sugar was pretty much guaranteed to be low if I hadn't eaten a snack (and sometimes even if I had). For example, on Monday, December 16, my blood sugar went from 81 (fasting/before breakfast), to 138 (2 hours after breakfast), at which point I ate a snack with 15 g. carbs. Despite this snack, an hour and a half later I was at 67, and needed to eat a second snack before lunch. The next day, on Tuesday, December 17, my blood sugar went from 73 (fasting/before breakfast) to 170 (2 hours after breakfast). Because it was already so high, I tried to postpone my snack; but an hour later, I was at 56 and had to drink some juice/eat some candy in addition to my planned healthy snack. 

It was a little ridiculous. I felt like every morning was either a race to have a snack before my numbers dipped low, or a scramble to bring my blood sugar back up if it already had bottomed out. There were a few days when I was so low, I actually felt symptoms. But even if I didn't feel symptoms, I took the readings I saw seriously. I sat at the kitchen table, sometimes for an hour or two, eating more and more candy if needed, waiting for my blood sugars to rise enough to take my dog on a walk or go up a flight of stairs to my computer so I could work from home. When I had doctor's appointments (which were twice a week at that point, and often around mid-morning), I made sure to bring extra snacks with me. I ate candy in the car. Once my husband was done with his graduate school semester, I asked him to come to appointments with me, so he could drive.

MFM stopped making adjustments to my insulin during those last two weeks of my pregnancy. I was still having some highs, and a lot of lows, but it wasn't clear what could be done. Try to account for the lows, and I'd end up having more highs; try to fix the highs, and I'd have even more lows. I already had an induction scheduled for the evening of Monday, December 30 - so those last two weeks were just a waiting game. We did the best we could in the meantime, but really we were just counting down the days. 

I also stopped taking baby aspirin at 36 1/2 weeks. I'd read online that it wasn't a good idea to take aspirin too soon to going into labor, since aspirin is a blood thinner and could cause excessive bleeding during labor and delivery if I was still taking it - so I asked both my regular OB and my MFM doctors about it. My OB said I should continue taking it until delivery; when I saw MFM a couple days later, they said I could stop. The reason they put me on baby aspirin in the first place was to avoid early preeclampsia, which is more common in pregnant diabetics than in the general pregnant population. By 36 weeks, we were already past premature labor, so the risk of early preeclampsia had also already passed - though it was still possible I could get preeclampsia in these last two weeks, my risk was more similar to the general pregnant population, and wouldn't be because of my diabetes. On the other hand, MFM also said that it probably wouldn't hurt to keep taking the aspirin until delivery, if I wanted to. The risk of aspirin-related hemorrhaging during labor/delivery was more of a "theoretical" risk than something actually proven and backed up with studies, and many women do take aspirin right up until they deliver without any problems. But I'd never had any problems with high blood pressure (pregnant or not), didn't see myself as particularly susceptible to preeclampsia, and didn't want to keep taking the baby aspirin if I no longer needed to - so with MFM's blessing, I stopped taking it. At my next appointment at 37 weeks, my blood pressure was slightly higher than my usual (136/74), but I still had no other symptoms of preeclampsia - no changes in vision, no headaches, no swelling - so my OB said, "alright, you're just 37 weeks pregnant - I'll allow it."

All things considered, I think I had a pretty easy pregnancy, and am really grateful that I never experienced any morning sickness, heartburn, or swollen ankles, let alone true complications like preeclampsia. Though myself and my doctors spent a lot of time trying to monitor and prevent potential complications, I didn't really have any actual complications (just false alarms). My A1C was never at dangerous - or even "diabetic" - levels (unlike many patients MFM sees), and while part of that was due to how carefully I was managing my diet and insulin, and how dutifully I was recording all my blood sugars, I also started out at an easier place than many Type 1 diabetics do - as a person with LADA (latent autoimmune diabetes in adults), not juvenile-onset diabetes. 

Still, by 38 weeks, I was ready to be done with my pregnancy. I was large and uncomfortable, moving was difficult, and I was tired of all the doctor's appointments and meticulous diabetes care. I was eager to decrease my insulin closer to my pre-pregnancy levels (which would undoubtedly mean fewer hypoglycemia episodes), and to be "allowed" more generous blood sugar targets. MFM told me that in the weeks after giving birth, while we figured out what insulin doses I should be doing, my goal should be simply to keep my blood sugar below 150. No more fasting below 90, or after-meal targets of below 120; I could relax a little. I was also, of course, eager to meet my baby - but if I'm being perfectly honest, "no longer being pregnant" was the fantasy I thought more about in those last few days leading up to induction. I had gained nearly 35 pounds, and was looking forward to losing at least 10 pounds of that over the course of just a few minutes, as I birthed my baby and placenta. I wanted to breathe and move easier, and start feeling like my body was my body again. I knew my body wouldn't bounce back immediately and that postpartum healing could be difficult, but anything seemed better than continuing to be pregnant. (I don't know how women do it all the way to 40 weeks - or past that. 38 weeks was plenty for me!) I was worried about induction - that my body wouldn't be ready to go into labor, and so the process would either be very painful or take a really long time (or both) as my body was medically forced into something it wasn't prepared to tackle yet - but mostly, I was just excited to have a deadline, a day I could count down to, when my pregnancy would end and my new life as a mother could begin...

I will have another blog post soon with an account of managing my diabetes during the week I ended up staying in the hospital (two days of induction, labor, and delivery, and the my first five postpartum days) so check back for that post within the next couple of weeks!