For my account of managing my diabetes during my first trimester (0-13 weeks of pregnancy), visit this blog post.
*Disclaimer: These posts are not meant to give medical advice. I'm not a doctor. I'm merely recounting my personal experience managing Type 1/LADA during my pregnancy - and everyone's diabetes and everyone's pregnancy is different.
**
I started out the 2nd trimester (14-28 weeks pregnant) with an incredible A1C of 5.1% - likely due, at least in part, to how many low blood sugars I was having at the end of my 1st trimester. Around 14-15 weeks pregnant, I was taking 18 total units of insulin a day: 6 u. of Levemir (my basal insulin) in the morning + 4 u. at bedtime, and 2 u. mealtime insulin with breakfast, 3 u. with lunch, and 3 u. with dinner. This was probably too much, and the beginning of my 2nd trimester still saw several instances hypoglycemia. Even with blood sugars lower than 55, I rarely felt symptoms. If I felt anything, it was only being a bit warm, or feeling irritation at how difficult it was for me to poke a straw into a juice box. Thankfully, my CGM (continuous glucose monitor) continued to be pretty accurate, now that I was wearing it on my arm rather than on my abdomen, and I could (usually) count on it to alert me when I was going low.
Also thankfully, most of my low sugars were now happening during the day instead of overnight. I didn't mind these as much - they were typically 2-4 hours after eating a meal or snack, and about when I would/should be eating another meal or snack anyway. I was also more likely to notice falling blood sugar before it got low enough to trigger the urgent low alert on my CGM, since I was awake and looked at my CGM often. If I saw I was at 72 and still trending downward, I could just adjust when I planned to eat next, or how many carbs I planned to eat, to avoid having to treat with candy or juice.
Still, just because daytime hypoglycemia is easier to deal with doesn't mean it wasn't a nuisance at times - like around 16 weeks, when I saw blood sugars below 65 six times, sometimes more than once in a single day. At 16w3d, I had blood sugar that stayed stubbornly in the 50s-60s for nearly three hours, despite eating candy, yogurt, pasta, and more candy. And the next day, my CGM urgent low alert went off another three times: once overnight (at 4:30 am), once three hours after breakfast (at 10:30 am), and once 1.5 hours after dinner (at 7:30 pm). These were not particularly unbalanced meals either, that might have caused a post-meal sugar crash. I tried not only to eat the recommended 50-60 g. of carbs with every meal, but also to balance those with protein, fiber, and fats.
Like I had done before in the 1st trimester, I started decreasing my mealtime insulin doses without express permission from my doctors, making small adjustments as I needed to in order to get through the day. If I was already below 70 before eating a meal, for example, I might take only 2 u. of insulin with my meal instead of 3 u. But even those adjustments weren't always enough, and MFM (maternal fetal medicine, the doctors and nurses who were helping me manage my blood sugar while pregnant) suggested I decrease my morning Levemir by one unit. A week later (at 17 weeks), they extended that suggestion to my nighttime Levemir as well. For the next several weeks, I took 5 u. in the morning and 3 u. at night. Even with those changes, I still had to occasionally take only 2 u. with lunch or dinner; on such days, my total insulin was therefore down to only 15 u.
During the four weeks from 17-20 weeks pregnant, I had blood sugars under 65 twelve times, for an average of three times a week. However, around 19.5 weeks, something else started to happen - even though I was still having occasional daytime lows, I was also having some daytime highs as well. I saw numbers in the 140s-150s more regularly after breakfast, and occasional blood sugars in the 140s or even as high as 180 after dinner. For a non-pregnant diabetic, those numbers would still be considered pretty good, but pregnancy blood sugar targets are <120 two hours after eating, so at the end of 20 weeks, MFM recommended I increase my breakfast insulin to 3 u. This helped, and between 21 and 22 weeks, I had fewer instances of higher glucose - but even more instances of low blood sugar. During those 2 weeks, there were 8 days when my blood sugar dipped below 65.
20 weeks marks the halfway point of a full-term pregnancy, and about when most pregnant people have their "anatomy scan" to make sure all the organs look normal and the baby is growing appropriately. Because of my diabetes, I was also given a fetal echocardiogram - a more detailed look at the baby's heart, to make sure it was pumping and working as intended, and that all chambers and major vessels were accounted for. My anatomy scan and fetal echo were at 21w2d, so that my husband could also be there.
Everything looked great - it was all good news! But that didn't stop me from starting to worry about what my baby's birth weight might be. One of the most well-known risks of a diabetic pregnancy is the risk of a "big baby," and even though I was trying my best to keep my blood sugar levels on target, there were certainly times (an hour here or there, while I waited for an insulin dose to catch up) when my baby was floating in an amniotic sac with high blood sugar. I would sometimes watch my CGM rise near or above 200 after eating - and even though by two hours after eating the number would be back on target (<120), and MFM only cared about that "two hours after" number, I still worried what that half-hour of high blood sugar might've done, before my mealtime insulin kicked in.
I actually had 3 ultrasounds during my 2nd trimester, and the first was at 16w2d, which showed my baby in the 64th percentile for size/weight. I also saw MFM at 17w4d, and my OB at 20w2d, for general check-ins without ultrasounds. They measured my fundal height for the first time at that 20-week appointment. This is a measurement of how high the top of the uterus is, which apparently correlates in cm to how many weeks along one's pregnancy is. I measured 23 cm - a little larger than expected for 20 weeks. Then at my anatomy scan ultrasound at 21w2d, my baby was measuring in the 85th percentile.
I was also starting to gain weight myself, at a rate of about one pound a week. Even though this is the recommended rate for the 2nd and 3rd trimesters, I worried that it was too much, and I would soon outpace this recommendation. I was averaging 2300-2400 calories a day - which was more than I wanted to eat, but when I was trying to make sure I was eating enough carbs and trying to avoid low blood sugars by balancing those carbs with proteins and fats, that amount of calories felt rather inevitable. (Weeks when I had several days of hypoglycemia saw that average raise even higher, to about 2600 calories/day, as I treated my low blood sugars with candy and snacks.)
My doctors, however, were miraculously not worried - not about my weight gain, and not about my baby's size (at least - not yet). They told me babies grow at different rates and it was still too early to tell if it would be a big baby at birth. I was surprised; I'd heard so many stories about doctors' concerns about the size of babies born to diabetics that I was sure that the "85th percentile" news would prompt lectures about dietary changes or insulin adjustments. Instead, they told me I was doing a good job with my blood sugars and that (barring any other complications), there would likely be no need to induce me before 39 weeks after all. (Originally, they'd told me most diabetics need to be induced between 37-38 weeks). They congratulated me on my blood sugar logs and gave me high-fives.
Then, at 23 weeks, the insulin resistance I'd been warned about finally started to hit. That week, I had zero instances of hypoglycemia under 65. It was the first time that I'd had an entire week without low blood sugar in 14 weeks - since my first appointment with MFM at 8.5 weeks pregnant, when I'd started taking mealtime insulin. More than that, I also saw several higher numbers after eating again: 130s after breakfast, 130s (and even a 161) after lunch, 130s-150s after dinner. Most were only slightly higher (and the 161 was because I'd forgotten to take my insulin at lunch that day), but then at the end of 23 weeks I finally saw a post-meal reading that truly gutted me: 208 two hours after dinner. Before when I'd seen a number that high, it had corrected itself before the two hour mark. Or it was high only on my CGM, and a check with my meter reassured me that my CGM was inaccurate and I wasn't actually that high after all. But this time, it was my meter that showed me at 208 - my CGM was inaccurate in the opposite direction, and thought I was only at 174.
Logically, I knew that one night with blood sugar above 200 wasn't going to hurt. It's not about perfection 100% of the time; it's the pattern of your readings and how often the baby (and your own body) is subject to high blood sugars that truly affects health complications. Still, seeing that number dashed my hopes that maybe having LADA instead of a "true" Type 1 meant I wouldn't see much insulin resistance after all. LADA probably delayed the insulin resistance a bit (the book Pregnancy with Type 1 Diabetes by Ginger Vieira warned that insulin resistance might begin around 16 weeks, which I'd passed 7 weeks earlier) - but in the end, diabetes is still diabetes, and even if my pancreas isn't as malfunctioning as others', it's still not functioning as it should be. It's easy for me to forget that sometimes.
In the last 5 weeks of my 2nd trimester, MFM increased my morning Levemir from 5 u. to 6 u. to 8 u., and my bedtime Levemir from 3 u. to 4 u. to 6 u. (and then, when 6 u. proved a bit too high, back down to 5 u.). My mealtime doses were also tweaked - my breakfast Novolog went from 3 u. to 4 u. to 5 u., lunch went from 3 u. down to 2 u., and dinner went from 3 u. to 4 u. With small adjustments being made nearly every week (or even multiple times a week), it started getting very difficult to keep track of what I was supposed to be taking when.
To put another way, I was taking a total of 17 u. of insulin each day at the start of 23 weeks, and a total of 25 u. of insulin by the end of 27 weeks. This was increased gradually at first - I was steady at 19 u. for two and a half weeks, for instance - but then at 26 weeks, MFM started adding more insulin in greater jumps. I had a week with fasting blood sugars consistently between 90-110 (when they're supposed to be under 90), and after that MFM just started piling on the changes (or so it felt to me).
In the past, they usually adjusted me by 1 unit at a time, and then waited a week or so to see if that would be enough - but on October 8 they had me increase my morning Levemir from 6 u. to 8 u., and on October 10, only two days later, they also asked me to increase my bedtime Levemir from 4 u. to 6 u. It solved my high fasting blood sugars (at 27 weeks I was back down to between 70-82 every day), but it also, unsurprisingly, caused a resurgence of hypoglycemia issues. I had 5 days of low blood sugar in the last two weeks of my 2nd trimester, and on the very last day, my CGM urgent low alert went off overnight (twice!) for the first time in 8 weeks. I had to treat hypoglycemia at 1 am - and again at 5 am - and then for the rest of the morning, I continued to struggle getting my blood sugars to stay up. At 7:30 am, before breakfast, I was at 61; by 10:30 am I was back down to 72 and having to eat a snack; and less than two hours later, I was at 62, requiring me to eat an early lunch. After that day, I convinced MFM to back down a little, scaling my bedtime Levemir back to 5 u.
On the plus side, I was able to eat fewer calories most days (those hypoglycemic days notwithstanding), now that I had more insulin resistance. For a few weeks, I was gloriously not worried about low blood sugars at all. My daily calories averaged between 2100-2200 from 23-27 weeks - which was not only more in line with how hungry I was/how much I actually wanted to eat, but also slowed down my weight gain a bit (and which I hoped might also help prevent my bigger-than-average baby from getting any bigger). Still, by the end of the 2nd trimester, I'd already gained 23 lbs. compared to my pre-pregnancy weight - and I had the entire 3rd trimester still to go.
At 24w2d I had another check-in with my OB. This time, my fundal height measured 24 cm - right on track to where I "should" be for how far along I was. For a few days, I worried less... But then at my third 2nd trimester ultrasound at 25w1d, my baby's estimated size/weight came back as being in the 92nd percentile, and all my anxieties and guilt about having a "big baby" resurfaced.
To be clear, I'm not trying to fat shame here. I have nothing against "big babies" in general. I wasn't even that concerned about the idea of having to deliver a larger-than-average baby, which is probably what most pregnant people are worried about when their baby is measuring large. It was just that I was worried I was responsible for making my baby bigger than they otherwise would be, due to the unavoidable fact of my diabetes. If I hadn't been diabetic, I wouldn't have thought much of it - I would've chalked up my baby's size to genetics or something, and looked forward to seeing all those cute rolls on my baby's arms and legs. But because of my diabetes, I was filled with mommy guilt that my baby's size was my fault. I worried I was giving my baby a difficult start to life, and a childhood potentially riddled with health problems, all because of the glucose they'd been exposed to in utero.
That same day I had my A1C tested for the first time since the end of the 1st trimester. Given how big my baby was measuring, how much weight it felt like I'd gained, and my recent insulin resistance, I thought it might be higher than my previous 5.1% result - but hopefully not too much higher. (After all, I was trying so hard to control everything and keep my blood sugars as low as was safely possible for me to do!)... So imagine my surprise when the result came back as 4.8%! All those hypoglycemic episodes had outweighed the few 200+ blood sugars I'd had after all, and my average blood sugars remained solidly in the standard non-diabetic range of 4.0-5.6%. It confused me, frankly. With an A1C like that, what more could I do than what I was already doing? And how could my baby's size be because of my diabetes? Maybe I wasn't at fault after all!
I had another ultrasound at the very beginning of my 3rd trimester (28w1d), which showed my baby now in the 96th percentile.
My doctors seemed divided in opinion. On the one hand, they still congratulated me on my (mostly) excellent blood sugars (though they also seemed a bit more keen to point out the couple of times I'd gone high); on the other hand, they were non-committal about if my diabetes was influencing the size of my baby. One told me, "Whether it's because of your diabetes or not, making changes to your insulin probably won't make it better at this point. You're just going to have a big baby."
They also started talking about the possibility of an induction earlier than 39 weeks again, and how I wouldn't be able to manage my own diabetes during labor and delivery - I would have to be on an insulin drip so the doctors could control my blood sugars themselves. When I started to question whether I would really need to cede all control over my insulin to doctors who didn't even know me or my diabetes, I was told that if I wasn't on an insulin drip it would make the doctors "irritated" and "uncomfortable." As if my priority when I'm in the middle of childbirth should be being a model patient and doing whatever they tell me, instead of advocating for what I want and need based on what I know of my body and my diabetes. Uh, NO. I don't think so. If that's the person they're expecting me to be, they're about five years too late.
In fact, here's how much I'm NOT that person anymore: about halfway through my 2nd trimester, I decided to hire a doula - a childbirth coach/companion. I worried that doctors and nurses would see the word "diabetes" on my chart, make assumptions about my risk factors, and then make decision about how my labor and delivery would go based on those assumptions, without consulting me first. There were a lot of things I was concerned about - whether or not I'd be induced or require a c-section, whether I'd be allowed to move around or if I'd be connected to too many wires and machines (IVs, fetal monitors, etc.) to leave a hospital bed, and how much I would be allowed to manage my diabetes while in the hospital. I worried that if I was given insulin through an IV, I'd be given way more than I needed, and/or that if hospital staff were in charge of treating any hypoglycemia episodes that may occur, they would over-treat me and make my blood sugar skyrocket (like they did after my D&C last year, when the post-op nurse saw that my blood sugar was slightly below 70 and gave me a huge cup of apple juice to drink, which resulted in me having to deal with 300+ blood sugars for the rest of the day after I was discharged).
I knew I would feel more comfortable with someone in the room (besides my husband) who will help me advocate for myself, ask the questions I want to ask, make sure doctors explain their recommendations to me and keep lines of communication open, remind me what my options are, and emotionally support me through the whole process - whether I end up having a relatively normal labor and delivery, an emergency c-section, or somewhere in between. Based on several articles and books I read, it seemed like a doula was exactly what I wanted - and now that I'm already getting pushback from doctors when I bring up my preferences for and concerns about labor and delivery, I'm so happy that I made this decision to have a doula on my team.
In the end, I realize I probably won't have much of a choice on the insulin IV during labor and delivery - but if I agree to it, it won't be because it's what will make the doctors comfortable; it'll be because it's what makes me comfortable. My priorities are figuring out what's best for myself and for my baby - not what's best for my doctors. For them this is their day to day job; for me, it's an experience of a lifetime, one of the most important days of my life, which I'll remember forever. And when I look back on this experience, I want to remember feeling empowered - not coerced into medical procedures or protocols I wasn't comfortable with and didn't need to do.
There's one last thing I want to talk about regarding my diabetes during this trimester - and that's to talk about the effort it takes to manage a chronic illness. I did already explain this in my last post about diabetes, but I don't complain often (except in blog posts I create specifically to complain, like this one), so please bear with me if I repeat myself a bit. :)
Near the beginning of my 2nd trimester, I switched from using Fiasp brand mealtime insulin (the last of the free sample pens my endocrinologist gave me before I was pregnant) to Novolog (the brand my insurance covered with my new mealtime insulin prescription, which now cost me $40/month). I also got a prescription for meter test strips for the first time; before I was pregnant I was not going through my insurance for test strips at all, and was simply buying them on Amazon. Without a prescription, I was using the Contour Next glucose meter, and paying $34 for 100 strips. With a prescription, I switched to True Metrix (the brand covered by my insurance), and ended up paying only about $4 for 150 strips.
Obviously I was glad to save some money (especially now that I was paying for mealtime insulin)... but those savings didn't come without a price. Getting my test strips through the hospital has proven to be a much greater hassle than just placing an Amazon order. First, I had to pick them up in person because my signature wasn't yet in the system for them to auto-bill my insurance. I was assured it would be smoother in the future, and that next month I could just call, ask for a reorder, and they'd be shipped directly to my house. But by the next month the hospital's medical supply distribution center had changed hands (and names), requiring all prescriptions to be resubmitted. This resulted in three back-and-forth phone calls before I was able to relay this message to my doctor's office and get this problem solved, and then another few days before the request went through, by which time I was down to my last couple of test strips. (Good thing I have a CGM as a backup way of checking my blood sugars!)
And the third month I went to reorder supplies? I had to go through the whole process of resubmitting my prescription again, because somehow they had "no record" of my prescription ever being resubmitted the previous month - or the package of test strips they'd sent me. Then, when that third month's supply finally arrived, it was the completely wrong thing. Instead of getting True Metrix test strips, I was sent AccuCheck lancets (which aren't even lancets I can use, because they require an AccuCheck brand lancing device which I don't have). I had to call them back (again) and ask them to send the test strips I needed.
Refilling my insulin is also often a chore, this time requiring arguments with my insurance. For much of the 2nd trimester I was not taking enough Novolog every day to finish an entire insulin pen before it expired (which, due to the nature of insulin, is 4 weeks after the pen is removed from the refrigerator and used for the first time). This meant that my insurance wouldn't let me refill my prescription when I needed to, since according to them I "hadn't used up" my last refill yet. I had to argue that it didn't matter how much of the pen I used - if I was following the instructions from the medicine's manufacturer, I would need a new pen every 4 weeks regardless. (And I had to make this same argument every 4 weeks, because the solution was always just a one-time override, and not changing whatever needed to be changed so that it wouldn't happen again.)
During my 2nd trimester, I really started to notice how much time and energy I was putting into managing my diabetes every day - and how much harder it was to keep track of everything for so long. I spend a lot of time:
*Disclaimer: These posts are not meant to give medical advice. I'm not a doctor. I'm merely recounting my personal experience managing Type 1/LADA during my pregnancy - and everyone's diabetes and everyone's pregnancy is different.
**
I started out the 2nd trimester (14-28 weeks pregnant) with an incredible A1C of 5.1% - likely due, at least in part, to how many low blood sugars I was having at the end of my 1st trimester. Around 14-15 weeks pregnant, I was taking 18 total units of insulin a day: 6 u. of Levemir (my basal insulin) in the morning + 4 u. at bedtime, and 2 u. mealtime insulin with breakfast, 3 u. with lunch, and 3 u. with dinner. This was probably too much, and the beginning of my 2nd trimester still saw several instances hypoglycemia. Even with blood sugars lower than 55, I rarely felt symptoms. If I felt anything, it was only being a bit warm, or feeling irritation at how difficult it was for me to poke a straw into a juice box. Thankfully, my CGM (continuous glucose monitor) continued to be pretty accurate, now that I was wearing it on my arm rather than on my abdomen, and I could (usually) count on it to alert me when I was going low.
Also thankfully, most of my low sugars were now happening during the day instead of overnight. I didn't mind these as much - they were typically 2-4 hours after eating a meal or snack, and about when I would/should be eating another meal or snack anyway. I was also more likely to notice falling blood sugar before it got low enough to trigger the urgent low alert on my CGM, since I was awake and looked at my CGM often. If I saw I was at 72 and still trending downward, I could just adjust when I planned to eat next, or how many carbs I planned to eat, to avoid having to treat with candy or juice.
Still, just because daytime hypoglycemia is easier to deal with doesn't mean it wasn't a nuisance at times - like around 16 weeks, when I saw blood sugars below 65 six times, sometimes more than once in a single day. At 16w3d, I had blood sugar that stayed stubbornly in the 50s-60s for nearly three hours, despite eating candy, yogurt, pasta, and more candy. And the next day, my CGM urgent low alert went off another three times: once overnight (at 4:30 am), once three hours after breakfast (at 10:30 am), and once 1.5 hours after dinner (at 7:30 pm). These were not particularly unbalanced meals either, that might have caused a post-meal sugar crash. I tried not only to eat the recommended 50-60 g. of carbs with every meal, but also to balance those with protein, fiber, and fats.
Like I had done before in the 1st trimester, I started decreasing my mealtime insulin doses without express permission from my doctors, making small adjustments as I needed to in order to get through the day. If I was already below 70 before eating a meal, for example, I might take only 2 u. of insulin with my meal instead of 3 u. But even those adjustments weren't always enough, and MFM (maternal fetal medicine, the doctors and nurses who were helping me manage my blood sugar while pregnant) suggested I decrease my morning Levemir by one unit. A week later (at 17 weeks), they extended that suggestion to my nighttime Levemir as well. For the next several weeks, I took 5 u. in the morning and 3 u. at night. Even with those changes, I still had to occasionally take only 2 u. with lunch or dinner; on such days, my total insulin was therefore down to only 15 u.
During the four weeks from 17-20 weeks pregnant, I had blood sugars under 65 twelve times, for an average of three times a week. However, around 19.5 weeks, something else started to happen - even though I was still having occasional daytime lows, I was also having some daytime highs as well. I saw numbers in the 140s-150s more regularly after breakfast, and occasional blood sugars in the 140s or even as high as 180 after dinner. For a non-pregnant diabetic, those numbers would still be considered pretty good, but pregnancy blood sugar targets are <120 two hours after eating, so at the end of 20 weeks, MFM recommended I increase my breakfast insulin to 3 u. This helped, and between 21 and 22 weeks, I had fewer instances of higher glucose - but even more instances of low blood sugar. During those 2 weeks, there were 8 days when my blood sugar dipped below 65.
20 weeks marks the halfway point of a full-term pregnancy, and about when most pregnant people have their "anatomy scan" to make sure all the organs look normal and the baby is growing appropriately. Because of my diabetes, I was also given a fetal echocardiogram - a more detailed look at the baby's heart, to make sure it was pumping and working as intended, and that all chambers and major vessels were accounted for. My anatomy scan and fetal echo were at 21w2d, so that my husband could also be there.
 |
| A sonogram from my anatomy scan on September 3, 2019, when I was 21w2d pregnant. |
Everything looked great - it was all good news! But that didn't stop me from starting to worry about what my baby's birth weight might be. One of the most well-known risks of a diabetic pregnancy is the risk of a "big baby," and even though I was trying my best to keep my blood sugar levels on target, there were certainly times (an hour here or there, while I waited for an insulin dose to catch up) when my baby was floating in an amniotic sac with high blood sugar. I would sometimes watch my CGM rise near or above 200 after eating - and even though by two hours after eating the number would be back on target (<120), and MFM only cared about that "two hours after" number, I still worried what that half-hour of high blood sugar might've done, before my mealtime insulin kicked in.
I actually had 3 ultrasounds during my 2nd trimester, and the first was at 16w2d, which showed my baby in the 64th percentile for size/weight. I also saw MFM at 17w4d, and my OB at 20w2d, for general check-ins without ultrasounds. They measured my fundal height for the first time at that 20-week appointment. This is a measurement of how high the top of the uterus is, which apparently correlates in cm to how many weeks along one's pregnancy is. I measured 23 cm - a little larger than expected for 20 weeks. Then at my anatomy scan ultrasound at 21w2d, my baby was measuring in the 85th percentile.
I was also starting to gain weight myself, at a rate of about one pound a week. Even though this is the recommended rate for the 2nd and 3rd trimesters, I worried that it was too much, and I would soon outpace this recommendation. I was averaging 2300-2400 calories a day - which was more than I wanted to eat, but when I was trying to make sure I was eating enough carbs and trying to avoid low blood sugars by balancing those carbs with proteins and fats, that amount of calories felt rather inevitable. (Weeks when I had several days of hypoglycemia saw that average raise even higher, to about 2600 calories/day, as I treated my low blood sugars with candy and snacks.)
My doctors, however, were miraculously not worried - not about my weight gain, and not about my baby's size (at least - not yet). They told me babies grow at different rates and it was still too early to tell if it would be a big baby at birth. I was surprised; I'd heard so many stories about doctors' concerns about the size of babies born to diabetics that I was sure that the "85th percentile" news would prompt lectures about dietary changes or insulin adjustments. Instead, they told me I was doing a good job with my blood sugars and that (barring any other complications), there would likely be no need to induce me before 39 weeks after all. (Originally, they'd told me most diabetics need to be induced between 37-38 weeks). They congratulated me on my blood sugar logs and gave me high-fives.
Then, at 23 weeks, the insulin resistance I'd been warned about finally started to hit. That week, I had zero instances of hypoglycemia under 65. It was the first time that I'd had an entire week without low blood sugar in 14 weeks - since my first appointment with MFM at 8.5 weeks pregnant, when I'd started taking mealtime insulin. More than that, I also saw several higher numbers after eating again: 130s after breakfast, 130s (and even a 161) after lunch, 130s-150s after dinner. Most were only slightly higher (and the 161 was because I'd forgotten to take my insulin at lunch that day), but then at the end of 23 weeks I finally saw a post-meal reading that truly gutted me: 208 two hours after dinner. Before when I'd seen a number that high, it had corrected itself before the two hour mark. Or it was high only on my CGM, and a check with my meter reassured me that my CGM was inaccurate and I wasn't actually that high after all. But this time, it was my meter that showed me at 208 - my CGM was inaccurate in the opposite direction, and thought I was only at 174.
Logically, I knew that one night with blood sugar above 200 wasn't going to hurt. It's not about perfection 100% of the time; it's the pattern of your readings and how often the baby (and your own body) is subject to high blood sugars that truly affects health complications. Still, seeing that number dashed my hopes that maybe having LADA instead of a "true" Type 1 meant I wouldn't see much insulin resistance after all. LADA probably delayed the insulin resistance a bit (the book Pregnancy with Type 1 Diabetes by Ginger Vieira warned that insulin resistance might begin around 16 weeks, which I'd passed 7 weeks earlier) - but in the end, diabetes is still diabetes, and even if my pancreas isn't as malfunctioning as others', it's still not functioning as it should be. It's easy for me to forget that sometimes.
In the last 5 weeks of my 2nd trimester, MFM increased my morning Levemir from 5 u. to 6 u. to 8 u., and my bedtime Levemir from 3 u. to 4 u. to 6 u. (and then, when 6 u. proved a bit too high, back down to 5 u.). My mealtime doses were also tweaked - my breakfast Novolog went from 3 u. to 4 u. to 5 u., lunch went from 3 u. down to 2 u., and dinner went from 3 u. to 4 u. With small adjustments being made nearly every week (or even multiple times a week), it started getting very difficult to keep track of what I was supposed to be taking when.
To put another way, I was taking a total of 17 u. of insulin each day at the start of 23 weeks, and a total of 25 u. of insulin by the end of 27 weeks. This was increased gradually at first - I was steady at 19 u. for two and a half weeks, for instance - but then at 26 weeks, MFM started adding more insulin in greater jumps. I had a week with fasting blood sugars consistently between 90-110 (when they're supposed to be under 90), and after that MFM just started piling on the changes (or so it felt to me).
In the past, they usually adjusted me by 1 unit at a time, and then waited a week or so to see if that would be enough - but on October 8 they had me increase my morning Levemir from 6 u. to 8 u., and on October 10, only two days later, they also asked me to increase my bedtime Levemir from 4 u. to 6 u. It solved my high fasting blood sugars (at 27 weeks I was back down to between 70-82 every day), but it also, unsurprisingly, caused a resurgence of hypoglycemia issues. I had 5 days of low blood sugar in the last two weeks of my 2nd trimester, and on the very last day, my CGM urgent low alert went off overnight (twice!) for the first time in 8 weeks. I had to treat hypoglycemia at 1 am - and again at 5 am - and then for the rest of the morning, I continued to struggle getting my blood sugars to stay up. At 7:30 am, before breakfast, I was at 61; by 10:30 am I was back down to 72 and having to eat a snack; and less than two hours later, I was at 62, requiring me to eat an early lunch. After that day, I convinced MFM to back down a little, scaling my bedtime Levemir back to 5 u.
On the plus side, I was able to eat fewer calories most days (those hypoglycemic days notwithstanding), now that I had more insulin resistance. For a few weeks, I was gloriously not worried about low blood sugars at all. My daily calories averaged between 2100-2200 from 23-27 weeks - which was not only more in line with how hungry I was/how much I actually wanted to eat, but also slowed down my weight gain a bit (and which I hoped might also help prevent my bigger-than-average baby from getting any bigger). Still, by the end of the 2nd trimester, I'd already gained 23 lbs. compared to my pre-pregnancy weight - and I had the entire 3rd trimester still to go.
At 24w2d I had another check-in with my OB. This time, my fundal height measured 24 cm - right on track to where I "should" be for how far along I was. For a few days, I worried less... But then at my third 2nd trimester ultrasound at 25w1d, my baby's estimated size/weight came back as being in the 92nd percentile, and all my anxieties and guilt about having a "big baby" resurfaced.
To be clear, I'm not trying to fat shame here. I have nothing against "big babies" in general. I wasn't even that concerned about the idea of having to deliver a larger-than-average baby, which is probably what most pregnant people are worried about when their baby is measuring large. It was just that I was worried I was responsible for making my baby bigger than they otherwise would be, due to the unavoidable fact of my diabetes. If I hadn't been diabetic, I wouldn't have thought much of it - I would've chalked up my baby's size to genetics or something, and looked forward to seeing all those cute rolls on my baby's arms and legs. But because of my diabetes, I was filled with mommy guilt that my baby's size was my fault. I worried I was giving my baby a difficult start to life, and a childhood potentially riddled with health problems, all because of the glucose they'd been exposed to in utero.
That same day I had my A1C tested for the first time since the end of the 1st trimester. Given how big my baby was measuring, how much weight it felt like I'd gained, and my recent insulin resistance, I thought it might be higher than my previous 5.1% result - but hopefully not too much higher. (After all, I was trying so hard to control everything and keep my blood sugars as low as was safely possible for me to do!)... So imagine my surprise when the result came back as 4.8%! All those hypoglycemic episodes had outweighed the few 200+ blood sugars I'd had after all, and my average blood sugars remained solidly in the standard non-diabetic range of 4.0-5.6%. It confused me, frankly. With an A1C like that, what more could I do than what I was already doing? And how could my baby's size be because of my diabetes? Maybe I wasn't at fault after all!
I had another ultrasound at the very beginning of my 3rd trimester (28w1d), which showed my baby now in the 96th percentile.
 |
| A 3D sonogram of my baby's face, from my ultrasound at 28w1d pregnant - the very beginning of my 3rd trimester. |
My doctors seemed divided in opinion. On the one hand, they still congratulated me on my (mostly) excellent blood sugars (though they also seemed a bit more keen to point out the couple of times I'd gone high); on the other hand, they were non-committal about if my diabetes was influencing the size of my baby. One told me, "Whether it's because of your diabetes or not, making changes to your insulin probably won't make it better at this point. You're just going to have a big baby."
They also started talking about the possibility of an induction earlier than 39 weeks again, and how I wouldn't be able to manage my own diabetes during labor and delivery - I would have to be on an insulin drip so the doctors could control my blood sugars themselves. When I started to question whether I would really need to cede all control over my insulin to doctors who didn't even know me or my diabetes, I was told that if I wasn't on an insulin drip it would make the doctors "irritated" and "uncomfortable." As if my priority when I'm in the middle of childbirth should be being a model patient and doing whatever they tell me, instead of advocating for what I want and need based on what I know of my body and my diabetes. Uh, NO. I don't think so. If that's the person they're expecting me to be, they're about five years too late.
In fact, here's how much I'm NOT that person anymore: about halfway through my 2nd trimester, I decided to hire a doula - a childbirth coach/companion. I worried that doctors and nurses would see the word "diabetes" on my chart, make assumptions about my risk factors, and then make decision about how my labor and delivery would go based on those assumptions, without consulting me first. There were a lot of things I was concerned about - whether or not I'd be induced or require a c-section, whether I'd be allowed to move around or if I'd be connected to too many wires and machines (IVs, fetal monitors, etc.) to leave a hospital bed, and how much I would be allowed to manage my diabetes while in the hospital. I worried that if I was given insulin through an IV, I'd be given way more than I needed, and/or that if hospital staff were in charge of treating any hypoglycemia episodes that may occur, they would over-treat me and make my blood sugar skyrocket (like they did after my D&C last year, when the post-op nurse saw that my blood sugar was slightly below 70 and gave me a huge cup of apple juice to drink, which resulted in me having to deal with 300+ blood sugars for the rest of the day after I was discharged).
I knew I would feel more comfortable with someone in the room (besides my husband) who will help me advocate for myself, ask the questions I want to ask, make sure doctors explain their recommendations to me and keep lines of communication open, remind me what my options are, and emotionally support me through the whole process - whether I end up having a relatively normal labor and delivery, an emergency c-section, or somewhere in between. Based on several articles and books I read, it seemed like a doula was exactly what I wanted - and now that I'm already getting pushback from doctors when I bring up my preferences for and concerns about labor and delivery, I'm so happy that I made this decision to have a doula on my team.
In the end, I realize I probably won't have much of a choice on the insulin IV during labor and delivery - but if I agree to it, it won't be because it's what will make the doctors comfortable; it'll be because it's what makes me comfortable. My priorities are figuring out what's best for myself and for my baby - not what's best for my doctors. For them this is their day to day job; for me, it's an experience of a lifetime, one of the most important days of my life, which I'll remember forever. And when I look back on this experience, I want to remember feeling empowered - not coerced into medical procedures or protocols I wasn't comfortable with and didn't need to do.
There's one last thing I want to talk about regarding my diabetes during this trimester - and that's to talk about the effort it takes to manage a chronic illness. I did already explain this in my last post about diabetes, but I don't complain often (except in blog posts I create specifically to complain, like this one), so please bear with me if I repeat myself a bit. :)
Near the beginning of my 2nd trimester, I switched from using Fiasp brand mealtime insulin (the last of the free sample pens my endocrinologist gave me before I was pregnant) to Novolog (the brand my insurance covered with my new mealtime insulin prescription, which now cost me $40/month). I also got a prescription for meter test strips for the first time; before I was pregnant I was not going through my insurance for test strips at all, and was simply buying them on Amazon. Without a prescription, I was using the Contour Next glucose meter, and paying $34 for 100 strips. With a prescription, I switched to True Metrix (the brand covered by my insurance), and ended up paying only about $4 for 150 strips.
Obviously I was glad to save some money (especially now that I was paying for mealtime insulin)... but those savings didn't come without a price. Getting my test strips through the hospital has proven to be a much greater hassle than just placing an Amazon order. First, I had to pick them up in person because my signature wasn't yet in the system for them to auto-bill my insurance. I was assured it would be smoother in the future, and that next month I could just call, ask for a reorder, and they'd be shipped directly to my house. But by the next month the hospital's medical supply distribution center had changed hands (and names), requiring all prescriptions to be resubmitted. This resulted in three back-and-forth phone calls before I was able to relay this message to my doctor's office and get this problem solved, and then another few days before the request went through, by which time I was down to my last couple of test strips. (Good thing I have a CGM as a backup way of checking my blood sugars!)
And the third month I went to reorder supplies? I had to go through the whole process of resubmitting my prescription again, because somehow they had "no record" of my prescription ever being resubmitted the previous month - or the package of test strips they'd sent me. Then, when that third month's supply finally arrived, it was the completely wrong thing. Instead of getting True Metrix test strips, I was sent AccuCheck lancets (which aren't even lancets I can use, because they require an AccuCheck brand lancing device which I don't have). I had to call them back (again) and ask them to send the test strips I needed.
Refilling my insulin is also often a chore, this time requiring arguments with my insurance. For much of the 2nd trimester I was not taking enough Novolog every day to finish an entire insulin pen before it expired (which, due to the nature of insulin, is 4 weeks after the pen is removed from the refrigerator and used for the first time). This meant that my insurance wouldn't let me refill my prescription when I needed to, since according to them I "hadn't used up" my last refill yet. I had to argue that it didn't matter how much of the pen I used - if I was following the instructions from the medicine's manufacturer, I would need a new pen every 4 weeks regardless. (And I had to make this same argument every 4 weeks, because the solution was always just a one-time override, and not changing whatever needed to be changed so that it wouldn't happen again.)
During my 2nd trimester, I really started to notice how much time and energy I was putting into managing my diabetes every day - and how much harder it was to keep track of everything for so long. I spend a lot of time:
- Keeping track of what my blood sugar is doing (both on my CGM and verifying the CGM's accuracy with at least a few follow-up finger sticks a day)
- Being constantly vigilant about when I need to eat next and what I should eat next - which also entails deciding whether or not I need to pack a snack and/or insulin pen(s) in my bag every time I leave the house; planning meals and buying groceries up to a week in advance; calculating the calories, carbs, and fiber of every ingredient in every dish I prepare; looking up those same nutrition facts online for any restaurant I'm planning to go to, so I can decide ahead of time what to order; and making a note of those three stats for every bite I put into my mouth
- Reorganizing all those pen-and-paper notes I keep into an online spreadsheet so that the info is easier to assess and find patterns, downloading CGM data to my computer from my receiver unit, and printing out all my charts and graphs to take to every doctor's appointment
- Remembering what my current dose of insulin is and making sure I take the right amount from the right pen, for 5 different injections taken at 4 different times every day (and properly disposing of my medical sharps, taking them to an appropriate recycling facility when the containers get full)
- Dealing with hypoglycemia alerts, sometimes multiple times a day and/or in the middle of the night, having to figure out each time if it's a false alert or real, and (if real) making sure I treat the low blood sugar as required, even if I don't want to - including trying to prick my finger and line up a drop of blood onto a small test strip in a dark bedroom in the middle of the night, or eating a snack when I'm not hungry, and
- Reordering test strips and lancets from the aforementioned dysfunctional hospital medical supply center, refilling prescriptions for insulin pen needles and two different types of insulin at Walgreen's, and reordering CGM sensors, transmitters, and overlay patches from another medical supply company, or from Dexcom directly, as needed.
All of that management requires a lot of physical space (our kitchen table is covered in my diabetes notes, paperwork, and prescriptions) and mental space - and sometimes it takes a toll on me emotionally. When I make a mistake (and with that many things to constantly keep track of, mistakes are inevitable), I feel guilty. By 23 weeks (before my craziest insulin adjustments even started), I was already seeing proof that managing every aspect of my diabetes was taking its toll on me. Things that should've been easy to remember started falling through the cracks.
As mentioned briefly above, I forgot to take a lunchtime insulin dose at 23 weeks pregnant, resulting in a post-meal blood sugar of 160 (which I actually thought was pretty good, considering I'd taken 3 less units of mealtime insulin than I should have). Then, a few days later, I finished a box of insulin needles and went to grab a new box off my shelf - only to find that there wasn't one. I'd been so sure I had another box in reserve that I hadn't bothered to check once I noticed the box I was using was getting low - but somehow 40 days had passed since I'd last filled my needle prescription and I'd gone through all 200 needles. This discovery resulted in a frantic phone call to Walgreen's, checking ALL the Walgreen's in the area, and ultimately having to get a different brand of needles than usual (a brand I disliked, because I found that I was more likely to bleed and bruise when using them), which I picked up just minutes before the pharmacy closed (because of course this happened on a Sunday when the pharmacy closed early). I was very lucky that I ended up not having to miss a single insulin dose due to my error; if I'd had to wait until Monday morning to pick up the prescription, I would've missed at least 4 doses, for a total of 16 units of insulin. I had no idea how badly that might have messed up my blood sugars, and was glad I didn't have to find out.
(Though, can we take a moment to please note the ridiculousness of the situation? I HAD medication on hand, just not the conduit to get the medication into my body. I think when you pick up your month's supply of insulin they should include the needles with it, instead of requiring two different prescriptions. Or, you know - maybe not require a prescription for those tiny insulin pen needles in the first place, but just have them available over the counter, on the shelf next to the test strips and lancets... But I digress.)
That was just one small mistake (and one I could easily blame on "pregnancy brain"), but it could've had serious consequences. I had another such mistake after my insulin doses started frequently changing after 23 weeks - I was looking at my evening Levemir dose (6 u.) instead of my morning Novolog dose (5 u.) in my notes and ended up giving myself 6 u. of Novolog instead of only 5 u. Again, in the scheme of things, this wasn't a disaster - but only by sheer luck. I happened, completely by chance, to almost do the right thing, and the difference of 1 unit didn't affect my blood sugars much. But what if I'd grabbed the wrong pen too, and given myself 6 u. of Levemir instead of 5 u. of Novolog? I would've had significantly more basal insulin in my body than I needed, and would've fought dangerously low blood sugars all day long, likely requiring a trip to the hospital to bring them back up.
I know that these sorts of mistakes are inevitable. I try my best to be diligent, but it's just impossible to be completely aware of everything I'm doing all the time. Still, when they happen, it's hard not to blame myself and feel guilty. Even when I don't make a mistake at all, but simply follow the plan my doctors and I have developed, things still happen - things that I want to believe I have control over, but which I probably (for whatever reason) just don't. Despite trying to eat right and get my insulin doses right, that first 200+ blood sugar two hours after eating wasn't the only one I had this trimester (there were two others, too). And despite my 4.8% A1C, my baby is measuring in the 96th percentile. Whether I have an explanation for something ("I forgot to take an insulin dose, and that's why this blood sugar is higher than I'd like") or not, I worry about it. I worry that my diabetes is hurting my baby.
According to everything I've read, the last trimester (particularly at 7 and 8 months of pregnancy) is the hardest for managing diabetes, because that's when insulin resistance is at its peak (thanks, placenta!). It may get a bit easier during the last few weeks, with insulin needs plateauing or even decreasing a bit as my body prepares for labor. And then, after labor and delivery of the placenta, my insulin requirements will likely go right back down to pre-pregnancy levels. Unfortunately, I don't know what those "pre-pregnancy levels" might be for me, since before my pregnancy I was 1) not taking any mealtime insulin, and 2) eating a low-carb diet to address that fact. I don't particularly want to go back to that (especially since I plan to breastfeed, and will likely need to maintain a fairly similar diet to what I've been eating while pregnant in order to successfully do so), but that means I don't know what my non-pregnancy insulin requirements will be, given that I've never regularly taken mealtime insulin when not pregnant. Maybe we'll start with the lowest doses I took during this pregnancy, and adjust from there?
I plan to write two future blog posts on these topics - one about managing my diabetes during the 3rd trimester and during labor, and another about managing my diabetes postpartum - but these likely won't get posted for quite some time. When my 3rd trimester is done, I'll have a few other things on my mind (a baby, for instance, and transitioning to motherhood!), but I'm hoping to have that 3rd trimester post available by March 2020, whether my little one arrives in January 2020 as my estimated due date would suggest, or in late December 2019, as my MFM doctors are likely to push for.
No comments:
Post a Comment