2021 Diabetes Update

There really isn't much new to report on the subject of my diabetes, but there are a couple things of note: 

I'm still taking Levemir and Novolog insulin, and still breastfeeding my now almost-1.5-year-old daughter (usually about 3 times a day) - though it's hard to tell how much milk she's actually getting these days... I think she mostly wants to continue breastfeeding for the mama snuggles. :) Because I'm nursing a lot less frequently than I used to be, I end up having to increase my Levemir (long-acting) insulin by 1 or 2 units every couple months or so - my fasting blood sugars start slowly creeping up, and if they're consistently above 110 or so for a week or two, that's when I experiment with adding another unit of Levemir, usually at bedtime, though sometimes for my both my evening and morning doses. My doctors told me that would likely be the case - that as I breastfed less, or weaned completely, my insulin needs would increase. Currently, I'm taking 6 u. Levemir in the morning and 7 u. at bedtime. For meals, I usually take 2 u. Novolog with breakfast and 2 u. with dinner. Lunch tends to be a smaller meal, and often with less carbs, so I can often get away with not taking any insulin with lunch - but if it has more carbs than my typical lunch, I really should take 1-2 u. of Novolog at lunchtime too (though I don't always remember). 

I also continue to use the Dexcom G6 CGM (continuous glucose monitor), which is back to being pretty darn accurate (most of the time) now that I'm no longer pregnant or immediately postpartum. The biggest problem I've had with it lately is that Dexcom apparently changed the adhesive used to get the sensor stick to the skin - before, I would have problems with the adhesive coming off before the sensor's 10 days were up, and I had to use another overlay patch to make sure the adhesive stayed in place; now, the adhesive sticks a lot better but it also gives my skin a bit of a rash. I am not the only one experiencing this over the last year - there are a lot of forums dedicated to people discussing their skin's sudden allergic reaction to the adhesive, and various tips/hacks they've tried for how to fix it. I talked to both my PCP and my endocrinologist about it - the PCP was a little horrified at all the red patches all over my abdomen, and told me stop using the Dexcom at once, and talk to my endocrinologist about getting a different type of CGM instead; meanwhile my endocrinologist was like "how much does the rash bother you? because the G6 is the best CGM on the market right now, so if you like how it's working for you otherwise, you might just have to deal with the rash..." We've moved since then, and I've yet to see my new doctor (I have an appointment tomorrow, actually!), so we'll see if they say anything new. I've been dealing with it for the last year, and my skin seems to be having less of a problem with it over time, so unless a really easy solution comes along, I'll probably just continue with the G6. The rash is localized to where the adhesive patch is, and it might be itchy for the first day or two or wearing a new sensor. When I remove the sensor after 10 days, there's a red mark where the patch used to be. It was taking a month or so before that red mark would fade (so that I would have at least 2 or 3 red marks of previous patches on my abdomen all at once, in various stages of redness), but now they're fading faster, and by the time the next sensor's 10 days are up, the previous red mark is now more or less completely gone.

One of my biggest worries about my diabetes this past year was obviously the covid-19 pandemic. Type 1 diabetes was one of the chronic conditions in the "higher risk" category, meaning that if I contracted covid-19 I was at a higher risk of having a severe illness. Because of this designation, I spent the last year being more vigilant than many people. With a few exceptions early on in the pandemic, we had groceries delivered or picked up groceries curbside nearly every week. We didn't go out anywhere, or take our baby out anywhere, other than outdoor locations like parks where social distancing was fairly easy to maintain. It was such a relief to be able to finally get my covid-19 vaccine. I got the first dose of the Pfizer vaccine in March and the second dose in April, and didn't have any side effects with either, other than a sore arm at the injection site for about 24 hours after the shot. In early May I was considered "fully vaccinated" (two weeks after my 2nd dose), and we've spent the last month slowly starting to venture out more places - while still following CDC recommended guidelines for mask-wearing and social distancing.

The final diabetes update I want to mention is this amazing way to organize my diabetic supplies, which my husband came up with and executed soon after we moved into our new house. I wanted a way to be able to keep all my supplies that I use on a daily or near-daily basis organized and close to the kitchen table, while not taking up space on the kitchen table itself, or on the kitchen island. These supplies include my insulin pens (which are not kept in the fridge after they are opened and in use), my pen needles, my sharps container (a half-gallon size empty milk jug), my meter and test strips (for times when I need to double check what my CGM is telling me), and my little notebook where I keep track of food data and when I take my insulin. (Extra supplies, such as extra boxes of needles, lancets, and CGM sensors, I keep on a high shelf in the kitchen pantry, since I only need those every 10 days (for the CGM sensors) or every 15 days or so (for the needles). And extra insulin that haven't been started yet are stored in the refrigerator.) My husband attached this little basket to the side of the fridge for me, large enough to store my daily supplies, and also added a little shelf underneath it, on a hinge so I could fold it up when not in use, or fold it down when I needed to rest my insulin pens there while taking insulin, or my notebook there when I needed to jot down a note. I really love this system (it's been working great for me for the last 4 months we've been living here), and I really appreciate him building it for me! I just had to show it off/brag about him here. :)

Thanksgiving

It's Thanksgiving week! Since I have no new art to show you (see my previous post about moving), I thought I'd take some time to list all the things I have to be thankful for this year instead. I know for many 2020 has been a really rough year, in many ways - and I feel very fortunate to have so have so much to be thankful for in such a bleak time.

The year started with the birth of my daughter on January 1st. What a way to start the year! It has been amazing these last ten and a half months watching her grow. From nursing to pureed foods and sippy cups, and now to eating the food off our plates; from barely being able to lift up her head to learning how to roll and sit and crawl and stand; from sleeping constantly to never wanting to sleep at all (why sleep when there's so many things to learn, so many rooms to explore, so many ways to play!) - she has been a constant source of wonder and joy throughout 2020.

On a similar note, I am also so thankful for my husband, who is the best dad to our daughter. The pandemic meant all of his classes for his master's program went fully online in the spring; once he found a job and started working full-time again, that was also remote. I love having him home so much, especially while our daughter is so young; even if he's working, he's still close enough that he can join us for walks around the neighborhood or a bit of playtime during his lunch break. He has gotten to watch her grow just as intimately as I have, and they have a wonderful bond. It's also been amazing for me, to have someone around to help get her down for naps and bedtimes when she just refuses to sleep, and to share in some of the daily stresses of parenting a baby.

I am thankful to have spent the majority of this year in Rochester Hills, which has so many great outdoor spaces. Over the summer, when we were bored staying inside our house but didn't feel comfortable taking our daughter to all of the places I'd once imagined taking her during her first year (to the library, and to stores, and to the zoo, and to anywhere else fun I could think of), we still had plenty of opportunities of places to go. We visited several nearby parks and took her on walks (in her stroller or in a baby carrier) along the Clinton River Trail, which was a lot of fun for her and our dog, and great fresh air and exercise for all of us.

I'm grateful that my husband was able to find a job he's really excited about, working for a non-profit he's really excited about, and that his new employers value his health and are taking this pandemic seriously. I'm also grateful that we were able to find a house we love in a neighborhood we love in Ann Arbor, and that we have the time to move there more gradually than we otherwise probably would if my husband wasn't working remotely and was already in the Ann Arbor office.

I'm thankful for our families - those who have been able to visit (once the stay-home order was lifted), entertain the baby, and help us move; and those who live farther away but still made time for countless Skype and Zoom calls to visit with our daughter safely (and virtually). They say it takes a village to raise a child, and this pandemic has isolated many from their villages; I'm so appreciative of the efforts made to make sure that wasn't our fate.

Diabetes & Pregnancy: The 4th 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
Diabetes & Pregnancy: The 3rd Trimester
Diabetes & Pregnancy: Childbirth

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.

***

My last post about my diabetes talked only a little about how my blood sugars and insulin needs changed after giving birth on New Year's day, January 1st, 2020. The focus of that post was more about managing my diabetes during labor and delivery, with just a few passing comments about changes that happened in those first few days after, while I was still in the hospital. This post will pick up where that one left off, continuing through the first three months postpartum - a time period some refer to as the "4th trimester," when a person's body readjusts to a state of no longer being pregnant.

Before becoming pregnant, I had only been on Levemir (basal insulin); I had no prescription for Novolog (mealtime insulin) until I first saw MFM at 8 weeks gestation. (MFM = maternal fetal medicine, the doctors and nurses who helped me manage my diabetes while pregnant.) My pre-pregnancy Levemir doses were 5 u. in the morning and 7 u. at night, for a total of 12 u. Over the course of 9 months of pregnancy, my total Levemir increased to 16 u., though we shifted when the bulk of it was taken, to 10 u. in the morning and 6 u. at night. I also started taking insulin with meals; by the end of my pregnancy, I was taking 12 u. Novolog with breakfast, 5 u. with lunch, and 6 u. with dinner. This increase in insulin requirements happens because the placenta causes insulin resistance - meaning that my body needs more insulin to process the same amount of blood sugar. (Though to be fair, I also wasn't eating the same amount of carbs during pregnancy as I had been before... Once I had access to mealtime insulin, I didn't need to be on a lower-carb diet anymore - and was actually told NOT to be, since growing a baby requires quite a bit of energy from carbohydrates. So I also was giving my body more blood sugar to process, as well.)

It was expected that after giving birth, my insulin needs would go back down to approximately what they'd been before getting pregnant. But I wanted to continue taking mealtime insulin after giving birth so I had a bit more flexibility with the amount of carbs I was "permitted" to eat - especially since I was planning on breastfeeding for the first several months of my baby's life, and would need similar dietary needs for breastfeeding as I had while pregnant. And that meant I couldn't just revert back to exactly what I had been taking pre-pregnancy, when I was taking enough basal insulin to cover post-meal glucose spikes as well. Still, those pre-pregnancy doses gave us a baseline to start at, with the expectation that it might take a bit of time to figure out exactly what insulin doses I should be taking for my basal insulin and at meals.

Taking all that into consideration, MFM recommended that I try 4 u. Levemir in the morning and 8 u. Levemir at night, for a total of 12 u. of basal insulin (same as I'd been taking pre-pregnancy). They also suggested that I try NOT taking any mealtime insulin at first, doing only 1-2 u. corrective doses if my blood sugar was high two hours after eating, until I better understood how much insulin it might be prudent to take with each meal. I wasn't super into that idea (it seemed like the first step toward ending up back where I was pre-pregnancy - only taking basal insulin and not having access to mealtime insulin), but they were the recommendations I brought with me to the hospital nonetheless, and what I planned to implement in the first few days after delivery.

That plan lasted one meal.

Other than a 2 am snack a few hours after giving birth, my first real meal postpartum was breakfast on January 2nd. Following MFM's plan, I took 4 u. Levemir and no fast-acting mealtime insulin. Three hours later, my blood sugar was at 197, and I took a corrective dose of 1 u. - which did the trick and brought me back down to normal ranges. Still, I was over that nonsense. Managing my diabetes at the hospital required jumping through a ridiculous series of hoops multiple times a day: reminding the nursing staff when to check my blood sugar (per their own protocols - I had my own ways of checking my blood sugar on my own any time I wanted), asking the nursing staff for access to insulin, having a doctor sign off on the dose, and waiting for the insulin to be brought into the room - all while my hospital cafeteria food grew cold as I waited. Taking a "wait and see" approach with every meal just meant even more of a hassle - a hassle I didn't need on top of everything else. We were dealing with my baby daughter's low blood sugar, treating her with glucose gel and formula, and trying to establish breastfeeding; I didn't want to be subjected to extra blood sugar checks in the middle of all that, making decisions to correct highs after the fact. It seemed easier to just take preemptive insulin and avoid the highs in the first place.

Of course, I was also still very much in the mindset of keeping a very tight control over my blood sugars - a mindset that it was hard to get out of. For the past year and a half, I'd tried to keep my blood sugars below 120 at all times - during my first pregnancy (which lasted 8 weeks and ended in miscarriage), during my second pregnancy (which was full-term), and during the months in between, when I started using my CGM and we were trying to get pregnant again. When you start thinking of anything above 120 as bad, 197 seems downright criminal. (Compare that to the typical recommendation for (non-pregnant) diabetics: keeping blood sugars below 180. If that's the goal, 197 doesn't seem nearly as off-target.)

There was also this: I expected to experience lows postpartum. I'd read that some diabetics struggle with low blood sugars when breastfeeding, and so had taken precautions to strategically leave snacks around my house in the places I planned to do a lot of nursing, just in case that became an issue for me. I also brought a lot of snacks with me to the hospital, for this same reason. So I felt more prepared (both mentally and literally) to deal with the possibility of lows than highs.

All of this meant I started requesting 1-2 u. of mealtime insulin with breakfast, lunch, and dinner (depending on what my blood sugars were before eating, and what exactly I was planning to eat). I suspected this might require a change to my basal insulin, since now my total insulin levels were likely higher than they needed to be - but I figured it'd be easier to take too much insulin and then treat with more snacks if I needed to, than to not be taking enough insulin, and need to add more - especially since I often had to wait at least a half hour (and sometimes as much as an hour or more) between my request for insulin and when the hospital staff would bring it to me.

Still, even with that extra mealtime insulin I started taking, I didn't experience a postpartum low until 6 am on January 4th. I was getting so little sleep (up all hours of the night trying to breastfeed or pump, and visiting my baby girl, who had been taken to the NICU for a couple days to monitor her nasal congestion, breathing, and jaundice levels) that I was often hungry and ate frequent snacks - my body's way of compensating for lack of sleep, I guess. I decided to run an experiment; the night of January 3rd-4th, I didn't eat any snacks after 10 pm. Finally, I saw the low blood sugar I was expecting. When the nurses came to check my fasting blood sugar, I was at 61; my CGM said 62. During my pregnancy, I only very rarely felt hypoglycemia symptoms; for my first postpartum low I again didn't feel any symptoms. The nurses brought me graham crackers, and I ate those before breakfast.

I was discharged later that day, even though my baby was still in the NICU. We were allowed to board in another hospital room closer to the NICU for a couple days. My insulin pens were returned to me, and I was once again able to manage my own diabetes, but we were still on the hospital premises until our baby was also discharged on January 6th. I knew from the "experiment" I'd done that I had to eat a snack at least once overnight - one of the times I was up anyway, nursing or pumping - or risk going too low. Alternatively, now that I had access to my own insulin again, I also had the option of adjusting my insulin however I saw fit, without having to run it by the hospital staff. I could choose to not take insulin with a snack or meal, and then more easily correct it after the fact, if I saw myself going too high. Or I could decrease my basal insulin, to compensate for the fact that I was taking more mealtime insulin than MFM had originally suggested.

At first, I continued to follow the insulin plan I had been doing (4 u. Levemir in the morning, 8 u. Levemir at night, and 2 u. Novolog with breakfast, lunch, and dinner), making sure to eat snacks in between meals when needed, and at least once overnight. I made it through the night of January 4th-5th this way with no problems. But the next night, my CGM urgent low alert went off before I ate my middle-of-the-night snack, and I found myself needing juice and a snack during one of the few chunks of time I'd been able to set aside for sleeping. A few hours later, when I woke up to eat breakfast, I was back down to 74 again - not low, but getting close.

I was beginning to understand that I was trying to keep unnecessarily tight control over my blood sugars. I didn't need to subject myself to occasional hypoglycemia in an attempt to keep my highs from getting too high; I wasn't pregnant anymore, and didn't need to stay below 120. Now, it was more important for me to avoid lows, rather than to avoid highs - especially if my body was still unaware of my hypoglycemia, showing no symptoms. What might happen if I was unknowingly low while holding and carrying around my newborn? I had to ease up on my blood sugar control to take better care of myself - so I could also take better care of her.

My daughter was discharged later that day, and we finally got to take her home. At home, I ran an even greater risk of hypoglycemia for two reasons: 1) I had access to a wider variety of food, including options with fewer carbs, meaning I ate fewer total carbs throughout the day than I had at the hospital, and 2) now that she was no longer in the NICU, she was under my and my husband's care 24/7, without help from the NICU nurses. It was harder to find time to eat several snacks throughout the day just to keep my blood sugars up, when I was responsible for every feed (no more supplementing with formula!). That night, my blood sugar was at 77 at 10 pm. I decided it was time to start decreasing my insulin; I took 6 u. Levemir instead of 8.

This was the right choice - my blood sugars stayed pretty steady within a good range of 70-140 over the next couple of days. I hadn't had another overnight low. Still, when I called MFM to discuss the change I'd made to my nighttime insulin, they recommended that I decrease it even further, going down to 4 u. Levemir at night. They also suggested I cut my lunchtime dose to 1 u. instead of 2 u. (Though, I admit - going through the whole process of using an insulin pen needle to take only 1 u. seems a bit silly to me... I usually choose to either not take any insulin, or to take 2 u., depending on what my blood sugar is before eating and what I plan to eat.) 

A few weeks later, I switched my care back to my regular endocrinologist, and he agreed with my decision to continue taking those doses (or near those doses, per my discretion) - so that's precisely what I've been doing since January 8th:

- 4 u. Levemir in the morning

- 2 u. Novolog with breakfast

- 0-2 u. Novolog with lunch

- 2 u. Novolog with dinner

- 4 u. Levemir at bedtime

This seems to be a good amount of insulin for me. There are times when I see slightly higher numbers than I grew used to seeing over the last 1.5 years - but those "highs" aren't too high, just higher than what I was aiming for when I was pregnant. There are also times when I have occasional low blood sugars. But both scenarios seem less frequent than I was experiencing when pregnant - my blood sugar in general stays steadier, with fewer peaks or valleys. Everything acts a little more predictably, and easier to control.

In fact, everything has gotten so much "easier" that I've stopped counting calories and carbs of the things I eat. I still try to eyeball portion sizes and guess how many carbs I'm eating, but I don't add everything together when I make a recipe. Maybe I've just gotten better at guessing what 40-50 g. carbs looks like, after meticulously counting everything for several months; or maybe it really is that my blood sugars are steadier even if my estimate is "off" and I'm closer to 30 or 60 g. It probably also helps that I continue to use my CGM (continuous glucose monitor) - I can see at a glance what my blood sugar is doing and if it's trending up or down, which in turn influences what I decide to eat for a given meal or snack.

When I started making this change, I thought I'd only do it for a couple months. Recording every gram of carbohydrates I ate was just too much to keep track of on top of recording nursing sessions and diaper changes. (The first I'm still keeping track of, so I know how often (and how long) my baby eats; the second we kept track of for only the first 3 weeks or so, to make sure she was having enough wet/dirty diapers). But as time went on, and my blood sugars still stayed within a good range, I decided to continue being "more lax" about what I was eating. 

Constantly counting carbs can start to feel like an eating disorder after awhile - even if it's done for a healthy reason, like knowing how much insulin to take. I find that it can really start to negatively impact how I feel about certain foods, leading to me thinking of foods as "good" or "bad" - and myself as "good" or "bad" depending on what I choose to eat. I want to model for my daughter how to have a healthy relationship with my body and food. I don't want her growing up thinking that some foods are "bad", nor do I want her seeing me obsessing over numbers and constantly adding up nutrition facts in my head to determine whether or not I can allow myself to eat something in that moment. I don't want to pass on disordered eating to her.

If/when I am pregnant again in the future, I will probably have to revert back to my hyper-vigilance, making note of everything I eat. Not only is it important to have tight blood sugar control during pregnancy - it's also a lot harder. Part of that is because the targets are stricter - but it's also just hard to keep up with the changes a pregnant person's body is going through. Eating 30 g. of carbs vs. 60 g. of carbs makes a much bigger difference, and everything seems to follow a much less predictable pattern, which makes simply "eyeballing" foods a lot more difficult. 

In fact, I may even have to revert back to recording what I'm eating once I stop breastfeeding, and my body once again readjusts to a new normal. My endocrinologist told me that I will likely continue to need only about 12-14 total units of insulin a day as long as I'm exclusively breastfeeding. Not only does nursing burn calories - it also creates another avenue for excess glucose to exit my body, in addition to the traditional avenue of urine. (For those who don"t know, the full scientific name diabetes mellitus actually comes from the Greek words for "sweet urine".) Of course, I don't want to give my baby excess glucose through my breastmilk - but the fact remains, in those rare times when my blood sugars are a little too high, I probably do... to the benefit of my own blood sugar, at the expense of hers. (Thankfully, my baby's pancreas is better equipped to handle that excess.) Once we start introducing solid foods in a few months and she starts breastfeeding less and less frequently, my insulin needs are likely to increase a little again. But for now, I seem to be doing okay without recording everything I eat, and I intend to continue doing it this way until my blood sugars show that that approach is no longer working. I'm hoping that, moving forward, keeping such careful track of my carbs will be a the exception rather than the rule - something I only do temporarily, when pregnant or going through a similar hormonal shift (e.g. menopause), or when I'm making a lifestyle change (e.g. weaning off breastfeeding, or if I suddenly decided to start training for a marathon or something - HA!).

Another thing I've had to readjust since giving birth is how I wear my CGM sensor. During pregnancy, I had so many problems with my CGM giving me false low alerts, or going entirely offline and being unable to register my blood sugar, that I started wearing it on the back of my upper arms instead of on my abdomen. (My growing baby bump made it hard to have enough available belly fat for the CGM, which is inserted into subcutaneous fat tissue.) For the first few weeks after giving birth, I continued to wear it on my arm - until my arm started giving me the same sorts of problems. My postpartum body now had plenty of belly fat to work with - and my arms did not, as my baby continued to grow and I spent much of my days carrying her and holding her. So I switched back to putting my CGM sensor on my abdomen instead.

There is one final aspect I want to talk about - the guilt and worry that comes with being a diabetic mother. Every time my baby has a health problem, I wonder if my diabetes caused it. When my baby had some trouble with nasal congestion and breathing in those first few days after birth, was it because of all the IV fluids I was given during induction - something that wouldn't have had to happen if I hadn't been diabetic? When she had jaundice - both in those initial days and over the course of the next several weeks, in what was ultimately determined to be "breast milk" jaundice - was it because I, a diabetic, was breastfeeding her? When her blood work came back indicating high liver enzymes for several weeks in a row, even after her jaundice had finally disappeared, was it because nine months in a diabetic womb, or months of being breastfed by a diabetic, or just an unfortunate combination of my "autoimmune disorder" genes, had somehow damaged her liver or some other liver-adjacent organ (such as the insulin-producing pancreas)? 

We all have predispositions we might pass along to our children, and things that we've experienced that we want to see our children spared from - but from my perspective, being diabetic seems to amplify those worries. I'm not just worried about passing along some bad genes or less desirable habits - I also worry what the physical environment I'm exposing my daughter to. Hopefully as she gets older - once she has spent more time outside my body than inside of it, and as I wean her off my breastmilk someday - her body will feel less connected to my own, and those worries, at least, will start to fade. Then my diabetes and the choices I make for how best to manage it will only affect my body, my health - and not also hers.

Diabetes & Pregnancy: Childbirth

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
Diabetes & Pregnancy: The 3rd 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.

***

As I wrote in a previous post, my baby girl was born on New Year's day, January 1st, 2020, weighing 8 lbs 10 oz and measuring 20.5 inches long. That post delved into how I managed my diabetes during the last trimester of my pregnancy; this one will discuss a much shorter scope of time: the single week from Monday, December 30, 2019 - Monday January 6, 2020.

I was told to take half as much basal insulin (Levemir) as I usually did the morning of Monday, December 30 - the day I was scheduled to come in for induction - but to continue taking my full doses of mealtime insulin (Novolog), and to eat normally throughout the day until I came to the hospital birthing center at 3 pm to start the induction process. I had prepared a birthing plan ahead of time, and left space on the paper to write down my most recent insulin doses over the previous 24 hours, so the hospital staff would know how much insulin was in my system upon my arrival. I also made a note at the top of my plan of my usual end-of-pregnancy insulin doses (16 u. of Levemir - 10 u. in the morning + 6 u. at night; 12 u. of Novolog with breakfast, 5 u. with lunch, and 6 u. with dinner) and my pre-pregnancy daily insulin doses (12 u. Levemir - 5 u. in the morning + 7 u. at night; no mealtime insulin). And at the top of my birthing plan, I included a patient history, which listed my diabetes diagnosis, pregnancy A1C ranges (4.8-5.6%), the location of my Dexcom continuous glucose monitor (on my left arm), my daily medications (Levemir, Novolog, prenatal vitamins, calcium supplements, and baby aspirin, the last of which was discontinued at 36.5 weeks of pregnancy), allergies (amoxicilian and sulfatrim), and previous surgeries (the D&C I had after my miscarriage in September 2018, and an appendectomy in February 2001).

The plan itself included the following points:

- I would like to be consulted before any adjustments are made to my insulin or glucose IV, and any time treatments are suggested for high or low blood sugar. Please keep in mind that I tend to be very sensitive to insulin and can have frequent lows. If at any time during labor my blood sugar is consistently less than 70, my insulin drip should be decreased or temporarily turned off.

- I would like to be in charge of managing my own blood sugars after delivery, including the use of my own insulin pens and needles.

- I would prefer to walk around during labor. If fetal monitoring is necessary, I would prefer a wireless/mobile fetal monitor.

- I would like to labor without pain medication. I will ask if I would like something for pain; please do not ask me.

- I do not want an episiotomy, or for vacuum extractor or forceps to be used, unless there is a medical necessity.

- I would like to delay cord-clamping for 2 minutes or until the cord stops pulsing. After clamping, please use the provided kit to donate the cord and placenta to a public bank.

- I would like skin-to-skin contact as soon as possible and to breastfeed within an hour of delivery.

- I would prefer that any non-urgent procedures or assessments of my baby be done in the room with me, including any treatment of low blood sugar, if possible.

- If my baby has to be separated from me for any reason, my husband will go with the baby and my doula will stay with me.

- After the placenta is delivered, I would like my insulin drip to be switched to my lower pre-pregnancy basal insulin dose, or shut off completely.

The plan was to take misoprostol pills overnight from December 30 into December 31st, and then start pitocin in the morning, as part of a gradual induction process. Until the pitocin started, I was able to eat normally; an insulin drip was not required. (But while the pitocin was in use, I was to be on a "clear liquid" diet only - water, ice chips, popsicles, broth, and juice.) I had been told that I would be able to use my own insulin pens and needles during those times when I wasn't restricted to that clear liquids diet - including early labor and after delivery. So I brought my pens with me to the hospital, and once I was out of triage and was assigned to an antepartum room, I gave my pens to the nurses to have them taken to the hospital pharmacy for verification. Once in the antepartum room, I was also given my first dose of misoprostol with dinner, and the nurses inserted a saline lock into my right hand, so they would be ready to quickly start the insulin drip (or IV fluid) whenever necessary. 

I was hooked up to a non-mobile fetal and contraction monitor an hour before, during, and for one hour after each misoprostol dose. This was just like the NST (non-stress tests) I'd been doing once a week for the last several weeks of my pregnancy, with two small monitors that were strapped to my belly. Because this monitoring was happening overnight, I didn't request a mobile/wireless monitor - I would be lying in bed most of the time anyway. But it did mean I had to call the nurse anytime I needed to pee, so they could remove the monitors and hook me back up once I returned to bed. At arrival, I was 0 cm dilated, but having contractions (non-painful, barely-noticeable ones like most people have at the end of their pregnancy, as their body starts getting ready). The misoprostol regulated these contractions into a noticeable pattern, which I could watch on the monitor. Unfortunately, they were too close together (happening every 2 minutes when they wanted them closer to every 3 minutes) for where my body was in the process, and there was concern that my uterus would start tiring out too soon doing so many "unproductive" contractions. I was told to drink more water, and was also given some IV fluid, to try to space them out before they gave me the next dose of misoprostol. I was finally given the 2nd dose at 10:30 pm, and the 3rd dose at 3:15 am. 

At 7 am on Tuesday, December 31, I got another cervical check, and they determined I was 2-3 cm dilated. I was given the chance to eat breakfast and take my usual mealtime insulin, and then was moved from my antepartum room into a labor/delivery room after I was finished eating. There, they placed another IV, this time in my left hand. The first attempt didn't work (my wrist was swelling up around the vein, where fluid was leaking in), and the second attempt was a particularly bloody affair that was gruesome to watch - but after ten minutes, I was set up with my second IV. My right hand was for IV fluid and insulin, and my left hand was for the pitocin for my induction, a glucose drip, and antibiotics (since I had tested positive for group B strep). This meant that at any given time, I had up to five bags to carry around with me on two different IV poles. Walking around the room and up and down the hallway, trying to go to the bathroom, and getting in and out of bed all required intricate choreography to keep the lines from tangling. Still, I wanted to walk around to try to get my labor going, so I requested the mobile fetal/contraction monitoring. It was another thing to keep track of, on top of so many other things - a heavy box that I could either wear around my neck or shoulder, or hang on one of my IV poles, and every hour or so I would have to end up back near my bed to recharge something (my IV monitors, or the fetal monitor), but at least it meant I could move around a bit and wasn't fully restricted to the bed.

The nurses started my pitocin, antibiotics, and IV fluid at 9 am. They wanted to start the glucose and insulin drips at the same time, but I reminded them that I had just eaten breakfast and taken 10 units of Novolog an hour ago - and that it would make more sense to wait at least another hour, for my the fast acting insulin I'd taken with my meal to start working through my system. If they started me on an insulin drip on top of the insulin I'd just taken, I feared I'd go low. I also didn't see why I needed to be on glucose yet - I was contracting regularly, but they were not strong contractions; I was still in early labor. I had also JUST eaten breakfast. I was not in need of glucose for energy - nothing was happening yet! So they called in a doctor for consultation, and the doctor agreed that we could wait and see what my blood sugar was two hours eating first - if it was above 120 at that point, we'd start the insulin and glucose. Somehow this wasn't communicated fully to the nurses though - because though they didn't start me on the insulin yet, they did start me on glucose. I didn't realize this had happened until nearly an hour later, when I noticed my CGM saying I was at 145, and I took a closer look at what IVs were actually being pumped into my system. Two hours after eating, the hospital blood sugar check had me at 157 - because of course my sugar was high now that they'd given me glucose on top of my breakfast! I don't want to be cynical, but in that moment, I definitely was. They seemed very eager to switch me over to hospital insulin, so they could more closely manage how much insulin I was taking, and it made me wonder - had they started my glucose early just to ensure I would be above 120, prompting the insulin protocol into effect?

I'm sure they're used to diabetic patients that require a lot more insulin, making it more important to start the insulin drip sooner rather than later. In fact, it probably would've mattered more for me too - if I had actually transitioned into active labor and given birth that day. But that wasn't in the cards, and once they started me on the insulin drip it quickly became apparent that I really didn't need much of it at all. Following their own protocols based on what my blood sugar readings were every hour, I was on insulin for only three hours before they stopped it. They started me at a rate of 2 u./hour at 10:30 am. At 11:30, my blood sugar was measured at 109. At 12:30 it was down to 68, at which point they reduced my insulin drip to 0.5 u./hr. And an hour later, my blood sugar was at 65, prompting them to shut off the insulin drip altogether. They continued to check my blood sugars every hour, but as they stayed below 100 for the rest of the day, the insulin was not restarted. At 2:30 pm, I was at 89; at 3:30 pm, 90; at 4:30 pm, 96.

Meanwhile, they gradually increased my pitocin throughout the day, from 1 mu/min up to 8 mu/min by 3 pm, but nothing much was happening. (My husband and I watched a lot of Netflix and Disney+ on his laptop to pass the time.) A cervical check at 4:30 pm confirmed that there had been no progress since that morning - I was still only 2-3 cm dilated. It was decided that my baby wasn't ready to be born in 2019 after all. The pitocin, glucose, and antibiotic IVs were suspended. The plan was to repeat the cycle we'd already done - another night of taking misoprostol, and then restarting the pitocin in the morning. This meant my "clear liquid" diet restriction was lifted, and I was able to eat dinner and breakfast again. 

This seems like a good time to point out how my meals and insulin pens worked in the hospital... I expected that once my insulin pens were verified, I would get them back and be able to use them - but I guess that was a naive assumption. In actuality, they were kept at the nursing station for the duration of my hospital stay, and anytime I wanted to use them I had to ask a nurse to get them for me, and wait for the dose to be verified by a doctor, before I was able to administer the medication. On the one hand, I understand why they do this (liability reasons), but on the other hand, it was beyond annoying. The doctors and nurses in the maternity ward were (obviously) often busy with more pressing matters than deciding how much insulin I was allowed to take. I would tell the nurses when I ordered a meal, and tell them again when my meal arrived, but still my meal would end up sitting in the room for an hour or so, getting cold, before I would finally be brought my insulin to take with my food. (Couldn't they have just had me sign a form promising I wouldn't sue them for any insulin mismanagement that happened on their premise, and then let me manage my own insulin instead? Seems like that would be less aggravating for everyone involved...)

After doing this for dinner on December 30 and breakfast on December 31, I was rather fed up with the whole procedure. I assumed (again, perhaps naively) that the problem was that I had insisted on bringing and using my own insulin pens, instead of the hospital insulin. So for dinner on December 31, I acquiesced and told the nurses that I would take the hospital insulin instead of requiring them to find my Novolog pen at the nurses station and get it re-approved. Unfortunately, using their Humalog syringes didn't go any faster; I still had to wait until a nurse was available to check my blood sugar, put it into the system to see what insulin dose was recommended for me, get a doctor (and myself) to sign off on that assessment, go get the Humalog, and wait for another nurse to be available to administer it - all while I sat there staring at a plate of food I wasn't able to eat until all those steps had been completed. The first two times, it was annoying; this time - after a day of not being allowed to eat anything solid - it was even more so.

That second night, December 31st, I had my first misoprostol dose at 8 pm. My next dose was at midnight, to the sounds of nurses shouting "Happy New Year!" to each other in the hall. My husband and I did nothing to acknowledge the new year (the new decade!); our room was dark, and we were both trying to rest up for what would be a long, tiring day to follow (assuming my labor finally started progressing). That first night in the antepartum room we'd both been too excited at the thought of meeting our baby soon that we hadn't gotten much sleep, but after a rather boring day of waiting for things to happen, we were both able to get more sleep the second night. (No small feat, as I was woken up frequently for blood sugar and blood pressure checks, fetal and contraction monitoring to assess whether my body was ready for the next misoprostol pill, and being woken up to take said pills.)

My last dose of misoprostol was at 4:30 am on January 1st. I was given hospital Humalog with my breakfast at 8 am, given another cervical check (still 2-3 cm dilated, with no further progress overnight), and the pitocin and my antibiotics were resumed at 9:30 am. This time, they didn't begin the glucose or insulin right away - as a result, my glucose two hours after eating was only 87, and it wasn't until around noon, when my blood sugar was at 113, that my glucose and insulin drips were restarted - the insulin at a rate of 1 u./hr.

The pitocin was increased more quickly on January 1st than it had been on December 31st, and I was up to 6 mu/min by about 1:30 pm. By 3 or 4 pm, I started getting consistently painful contractions for the first time. A cervical check put me at 4 cm dilated - finally some progress! We called our childbirth doula to join us at the hospital, and she recommended positions and breathing exercises that helped me manage my pain without requiring medication. (I already had so many IVs pumping medication through me - I really didn't want any more!) As my contractions grew more painful, my blood sugars also started to climb. I wasn't eating anything - at one point some chicken broth was ordered from the cafeteria for me, but I wasn't able to concentrate on drinking much of it - and as far as I know my glucose IV was kept at a similar level throughout the day (though honestly I never really looked at it, so I have no idea); the increase in my blood sugars then, was mostly (if not completely) due just to stress and the exertion of the labor process. 

By 6:30 pm, my blood sugar was at 115 and the insulin drip was increased to 1.5 u./hr, by 7:30 my blood sugar was 131 and it was increased again to 2 u./hr, and at 8:30 my blood sugar was at 144, and the insulin drip was dialed up to 3 u./hr. At this point, I was given another cervical check; I was at 8 cm dilated. My blood sugars briefly evened out a bit (at 9:30 pm, they were back down to 131), but around 10 pm I started pushing, and this again raised my blood sugars. At 10:30, the glucometer tested me at 156, and my insulin drip was increased to 4 u./hr... And at 11:09 pm, our daughter was born!

You may wonder how I remember what my blood sugars were doing during all of this, or what my insulin was adjusted to. But the answer is - I don't remember. Before going to the hospital, when I thought about the labor/delivery process, it was SO important to me that I be aware of what was going on and how my diabetes was being managed by hospital staff - but when it was all happening, it was often the last thing on my mind. The nurses would tell me they were increasing my insulin, and I would just nod; I no longer cared what they did. I was too busy concentrating on getting through the next contraction. But my husband and our doula helped me keep track of what was happening, and they wrote down notes for me so that I'm able to refer back to them now and piece together what happened, which I'm so grateful for.

Within an hour of our daughter's birth, it was no longer January 1st. At midnight at the beginning of January 2nd, my blood sugar was 142, and my insulin and glucose drips were both cut in half. Again, I didn't really care what they did to my IVs at this point; I was barely paying attention. I was holding my new baby and trying to breastfeed for the first time, while my ob/gyn worked on some repairs. At 1:30 am, my insulin drip was cut in half again, and my husband and I were presented with a tray of food in case we wanted a snack before the cafeteria opened up again for breakfast at 6 am. I assume it was the same sort of tray they gave every family - there was nothing diabetic-specific about it, and all of the options (sandwiches, chips, juice) were full of carbs. I ended up eating half of a turkey sandwich, and a protein bar that I'd brought from home. I wasn't really hungry, but felt like I should probably eat something. At 2:30 am, they were finally ready to move us from our labor and delivery room into a postpartum room; my blood sugar was down to 115 at this point, and the insulin drip was shut off.

I got maybe two hours of sleep that night, in little chunks, once we were in the postpartum room. I was also, understandably, a bit distracted with my new baby still. So I wasn't really paying attention when, at 6:30 am, a nurse came to check my blood sugar for a "fasting" number. (I put "fasting" in quotation marks because usually to be considered fasting, it has to be at least 7-8 hours since last eating - but I'd eaten that half a turkey sandwich and protein bar sometime around 2 am, only 4.5 hours earlier.) My blood sugar was high - 193. The nurse put this into their system and got back the recommendation to give me a corrective dose of 2 u. of Humalog - a fast acting insulin I usually only take with meals. She administered the insulin; distracted and half asleep, I wrongly assumed she was giving me my morning Levemir dose, which I usually took when I checked my fasting blood sugar. This caused a lot of confusion at 8:30 am when my breakfast arrived and we started going through the process of checking my blood sugar and figuring out how much mealtime insulin I needed to take with my breakfast. The nurse was trying to tell me I needed to take my morning Levemir, which I thought I'd already been given; and I was trying to tell her that I didn't need to take any insulin with breakfast, since my blood sugar was at 101 and I'd been told weeks ago by MFM not to worry about taking mealtime insulin right away after delivery. (MFM had recommended that after delivery I go down to 4 u. Levemir in the morning + 6 u. Levemir at night, for a total of 10 u. - close to the 12 u. I'd been at pre-pregnancy. They also suggested that I not take mealtime Novolog (or the hospital's Humalog equivalent) with my meal, waiting instead to see how the meal affected my blood sugar, and then giving myself a corrective 1-2 u. dose if needed. It wasn't as important to keep my blood sugars down now that I was no longer pregnant - in fact, they told me it was better to be slightly high than to be too low.)... Eventually, we sorted it out and I took my 4 u. Levemir with breakfast, with no additional mealtime insulin. Three hours later, my blood sugar was at 197; at which point I took a corrective dose of 1 u. Humalog.

The nurses were also repeatedly checking our daughter's blood sugars throughout the day. One of the potential problems caused by diabetic pregnancies is low blood sugar (hypoglycemia) in the baby. Because the baby spent the last 9 months in a sugary womb, their pancreas got used to producing more insulin to manage that extra sugar - and now that they're on their own and no longer exposed to as much sugar anymore, their pancreas is producing too much insulin, which can cause hypoglycemia - until their pancreas readjusts to the new levels of insulin they now need. Our daughter's initial blood sugar soon after delivery had been within normal ranges, but by 12:30 pm - about 13 hours after her birth - they were too low, and we had to give her glucose gel, which the nurses rubbed into her gums. Perhaps her blood sugars would have been low anyway, just because of my diabetes and how high my blood sugars were at the moment of her delivery - but it definitely didn't help that she was congested and having trouble breastfeeding, and couldn't get her blood sugars raised from my breastmilk either. An hour later, her blood sugar was still a bit low, despite the glucose gel, so she was also given a bit of formula in an oral syringe. Her blood sugars did not dip so low again that she required more glucose gel - but she was given formula a few more times over the next several days, mainly because she was having trouble breastfeeding.

It is not uncommon for babies to have some congestion after birth, given all the fluid they're exposed to both in the uterus and during the birthing process - but our daughter's excess fluid was sticking around longer than usual. Given that it was interfering with her ability to successfully breastfeed, and given that I had tested positive for group B strep during pregnancy and had been on antibiotics during labor, there was some concern that it wasn't just "normal" fluid build-up after all, but a sign of infection. My antibiotics were supposed to be administered every 12 hours during labor, but my last dose hadn't been given, as I'd been in the middle of pushing when it was due. As a result, 12.5 hours had lapsed between my last dose and when our daughter was born, which was considered "inadequate." To top it off, my group B strep had been resistant to the most effective antibiotic, and I had an allergy to the second choice (amoxicilian), meaning that I'd been given their third choice antibiotic, which was considered not as effective. All of this led to our baby being taken to the NICU for three days to monitor her breathing and administer antibiotics (just in case), while we awaited the test results to see if she actually had an infection. During that time, her congestion got a lot better, and we slowly were able to see some success breastfeeding. She was also treated for jaundice while she was there. Eventually, her results came back infection-free, and she was finally discharged on Monday, January 6, 2020 - exactly one week after my husband and I had arrived at the hospital to start my induction.

Later, talking to (of all people) my lactation consultant, it was brought up that maybe our baby had so much excess fluid in her nasal passages and lungs because of all the IVs I had for the 14 hours immediately leading up to her birth, and for 7 hours the previous day. All that extra fluid could've also accounted for her size at birth - 8 lbs 10 oz, about 10 oz more than I was expecting her to be, given my growth ultrasounds at the end of my pregnancy. At the hospital, doctors and nurses at shift changes kept asking me what kind of labor/delivery experience I'd had, and whether there was anything abnormal about it. I never really knew how to answer that question, and ended up saying, "I mean, I was induced? So it took awhile to get started, but once it did, I think it progressed pretty normally?" I assumed they wanted to know if she'd gotten stuck at all on the way out, if my labor had momentarily stalled, if the doctor had needed to use tools to help her get out, if her heartrate or my blood pressure had ever been too low or too high, etc. - all things that hadn't happened. But maybe I should've brought up all the different fluids I had pumped through my veins during labor and delivery - the IV fluid, the glucose, the insulin drip, the pitocin, and the antibiotics. Of course, those things should have been listed in my chart; I shouldn't have HAD to tell them - but clearly not everyone looks carefully at the notes the previous doctors and nurses have written from a day or two earlier. Maybe they would've been less concerned about my daughter's congestion and difficulty breathing if they'd considered that aspect of her delivery; maybe it would've been more obvious that it was "normal" fluid that she just needed a bit more time than the average baby to work out of her system, and not an infection.

In any case, it was actually kind of nice having her in the NICU for a few days - the worries about her health notwithstanding. It meant we got to spend a few extra days in the hospital, which meant more opportunities to talk to lactation consultants and nurses. The nurses in the NICU were especially helpful with tips on how to help our daughter latch and suck and figure out how to breastfeed, working around her congestion and showing me how to pump to help my milk supply come in faster. I was discharged earlier than our baby was - on Saturday, January 4. Thankfully, the hospital let us continue boarding there, in another room (our 4th different hospital room since our arrival) closer to the NICU, while our daughter was there. Even better - once I was discharged, I no longer had to wait for nurses to bring me my insulin anytime I wanted to eat. My insulin pens were returned to me, and I was able to fully go back to managing my blood sugars on my own.

I have more to say about what my blood sugars looked like in those first few days, weeks, and months after giving birth, as I readjusted back to non-pregnancy target ranges and much lower doses of insulin - but as this one is already quite long, I'll save all that for another entry, which I'll write and post here soon!

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.

***

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!

Diabetes & Pregnancy: The 2nd Trimester

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.

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:

1. 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)
2. 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
3. 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
4. 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)
5. 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
6. 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.