Diabetes and Pregnancy Part 1
We are thrilled to welcome Isabel Reeves aboard as a guest blogger. Isabel is a Credentialled Diabetes Educator and Registered Nurse and is currently pregnant so will write about her journey here. If you'd like to contact Isabel please go to her website here: http://www.diabetesedu.com.au/
When I was diagnosed with Diabetes at the age of 10 I was told a number of things but only a few really stuck with me. The rest of the information that I use now, I developed on my own, with my mum and through some Endocrinologists whose opinions and treatment I valued. However, most of the information I use on a day to day basis is information that I have worked out on my own, either through trial and error or through books.
I don’t really remember much from the time I was diagnosed with Diabetes. I know that I was a little bit sick prior to seeing the doctor and being diagnosed. I know I had to spend 1 week in hospital learning how to self-inject. I know that my mum did a lot of investigating on her own and finally found the thing that would get us out of hospital, the inject eze. I know that my mum was talking to anyone she could about diabetes to try and get more information, she met an elderly lady who was in the hospital having two toes removed and I know they were black and smelly. Gross but valuable in my forthcoming diabetes management. I don’t know, but I have had it in my head from about the time of my diagnosis that people with type 1 diabetes will have a hard time getting pregnant, that it would be dangerous and that the child and/or the mother may have problems. I do think that something was said about this when I was diagnosed but I do not know if it was quite as dire as what my head has remembered. I do however know that other people have heard similar negative stories about childbirth as a type 1 diabetic person. I can’t 100% invalidate these statements yet, but I know of many people who can and this gives me great hope.
A friend was talking to me the other day about a television show she was watching that featured a lady with diabetes who became pregnant in the 1950’s. My friend was confused because on the show, the lady was advised that it would be in her best interest to abort the pregnancy as she had diabetes. I explained that this may have been the case. Through trying to find information on the matter it does seem that there was an increased incidence of foetal death in women with diabetes. It was back in this day that people with diabetes were testing their blood glucose levels by urinating and mixing this with a solution, or later urinating on a stick to determine treatment options. Diabetes has come a long way and so to has pregnancy in diabetes to a point where with well managed diabetes there is minimal risk to a baby’s health or the mother’s health through pregnancy.
I can now be my own judge as I am pregnant, which is super exciting. At 18 weeks now I can say that it is possible. I planned this pregnancy and did all the recommended pre pregnancy tests, I was exercising, eating well, taking a pregnancy supplement, extra folic acid up to 5mg and Iron because I was a little bit low in iron pre pregnancy and my Hba1c had consistently been about 6.2% for over a year. I was ready. My husband and I found out we were pregnant quite early at about 2 weeks and I have been monitoring myself closely since then with a Continuous Glucose Monitor (CGM) and the use of my Insulin Pump and my husband’s occasional prompts when I decide to ignore the buzzing.
There are a lot of books and websites on pregnancy and type 1 diabetes. All of which say similar things regarding the different stages of pregnancy and the different changes that are needed for the basal rates and insulin requirements through this time. I have found these to be somewhat true however, I have often needed to change things slightly earlier or slightly later than what is recommended, highlighting the fact once again that every type 1 diabetic experiences their condition differently. Similarly, I’m sure that EVERY pregnancy is different as well. This all coincides to create your unique experience of both diabetes and pregnancy and these two things in combination as well.
I have been very lucky so far in my pregnancy in not needing to deal with a lot of things that are common in pregnancy with or without diabetes. But I have had ups and downs dealing with my diabetes and my insulin basal rates. One day these are right, the next they are completely wrong. Diabetes, as you all would know, is such a varied condition and things change day to day even if you
don’t have a small person growing in your belly, so managing this while there is something else feeding off of you is a completely different matter. But this is not the only thing I have to think of. Some of the things I have to think about at all times is what I am eating, how this will affect my blood glucose levels, how my basal rates that I currently have set will respond to a green smoothie instead of a curry with rice, not always great btw. I may not look stressed or like I am thinking a mile a minute and considering all aspects of what I am about to do, but I have been doing this for 21 years now and it feels almost like breathing. Maybe not breathing, maybe more like running – difficult to start and sometimes painful afterwards but generally it feels so good when you get it right. And it definitely feels so good every time I find out I have an Hba1c in the 5’s and 6s. Diabetes is something that comes as second nature to me now but it still takes determination, thought, motivation and perseverance to do it well.
To all of you pregnant mums with diabetes out there who are suffering from different aspects of pregnancy related illness, stick in there and just do the best you can each day. That is all you can do.
In pregnancy with diabetes there are numerous changes that have to be made at different times but these time can vary between individual. At 6 weeks I experienced a significant reduction in my insulin requirements and dropped my basal rates down by about 4 units a day. My overall insulin use during this time was about 10 units less than my normal for a whole day. According to books and my diabetes in pregnancy specialists this was not meant to happen until 8 weeks.
At 14 weeks I began to increase my basal rates and therefor my overall insulin use and now at 18 weeks I am using about 8 units more a day than before my pregnancy. They say that usually 18 weeks is where the increased insulin requirements are seen but I am an anomaly and every person is, so like everything in diabetes, it is a matter of doing what is best for you. From here on I expect a gradual increase in my insulin requirements to the point where these will be at least double my total daily insulin dose at the start of pregnancy.
Making these changes and monitoring my Blood glucose levels is something that takes up 100% of my time. Whilst I am not overtly focused on it, BG levels are always in the back of my mind and are always something I think about before eating, exercising, sleeping or even going for a meeting. Although, this is honestly not much different to what I was like pre pregnancy, there is just another being at risk if I don’t monitor it well.
I am using CGM currently and have been for the last 4 months from just before I fell pregnant and this has been a great journey as well. I have previously only used CGM on occasion and out of interest. But now, having it most of the time highlights the fact to me that things can change so fast. I know there will be a lot of you who have found that even if you eat the exact same thing one day and do the same insulin, this could completely backfire the next day despite the exact same circumstances. Can anyone explain this? I don’t think so. But it brings up the huge list of other things that impacts on diabetes in general; stress, quality of sleep, sickness, busyness, heat, cold and numerous others. All of these things which can impact your diabetes management whether or not you actually realise that you are experiencing them in the first place.
Some funny things I have noticed during pregnancy:
1. Changes to the speed at which insulin hits the body or the speed at which food is digested and absorbed or both
I have noticed more and more that if I give insulin just before I eat, the normal time I would give insulin, I begin to go low before my BG levels will track up due to the food I have eaten. This is
something that I have not noticed before at all. Normally my BG level would stay fairly stable or it would literally increase as soon as I start eating. I have tried different ways around this depending on what I am eating but nothing seems to really work appropriately. I have bloused 10 minutes through the meal, by that time I am already tracking high and the insulin doesn’t kick in soon enough to bring it down very quickly. I have tried doing a square wave bolus which has the same result. Insulin is not delivered fast enough and therefor I go high. The best one so far is the dual wave but I have noticed that I need it over a shorter time period that what is offered. So, if I do 75% of the bolus straight away and then had the other 25% in 15 minutes I reckon it would work perfectly. Extending the time period to the 30 minutes is just too long. Now that I am getting a little bit of insulin resistance my pre meal insulin bolus seems to be working fine again but I’m sure I will get back to you with some other eccentricities in this area.
2. My belly is GROWING!
For those of you that have never been pregnant, yet… it is weird! Granted I may be eating a little bit more than normal but my belly is growing in a fashion that is abnormal to the usual. Not that I have ever put on this much specific belly weight in the past. Every day I reckon it is slightly larger. I can still see my toes but not much more of my feet at this stage. I have yet to feel any movement in there at this stage but I imagine that will be fairly weird to. I think it is most miraculous to think that I am creating a human being at the moment with a working pancreas! How is this possible when mine doesn’t even have this function?
3. The vast amount of places you can really place an infusion set or a CGM
We all know there are set places where you are supposed to put your infusion sites and CGM sites but I am a protagonist and I have been experimenting as I tend to do, with different spots. As my belly is less comfortable with infusion sets at the moment, I have been using my outer thigh more, which I really love as well as my obliques and my upper abdomen. I am keen to try my arms but I might keep that one for the CGM sites as I am a dress wearer and I think it would be very difficult getting in and out of a dress with an infusion site on my arm. Who knows? Has anyone tried it? I have also been trying my CGM in different locations and am finding that these are all fairly similar for accuracy. It works on the thigh, upper and lower abdomen and inner thigh although the readings here are a little bit iffy if you ask me. For me, I cannot get a site to go in right on my oblique’s, I have tried it three times here and every time I get bleeding which I cannot stop or get rid of because of the awkward spot that it is in.
4. Greater acceptance of different foods
Pre pregnancy I was very averse to eating Pasta because it was very difficult to control my blood glucose levels immediately after and for a long period thereafter, lasting for a good 4 hours. I have attempted doing numerous methods of insulin delivery in the past including dual wave bolus, square wave and just giving a large whack of insulin. None of which worked effectively for me while eating pasta. For some obscure reason, now, in pregnancy, my body does not react as intensely to pasta and in some cases I don’t need nearly as much insulin to combat the immediate high glucose levels. Currently, I no longer require extra doses of insulin with pasta nor a dual wave bolus to combat that meal. I don’t know why this is but I am most definitely taking advantage and enjoying life’s pasta a tiny bit more frequently and without such trepidation.
5. CGM and pregnancy
I must say that Continuous glucose monitoring has been a saviour in my pregnancy. Honestly my management of my diabetes is not very different to pre pregnancy. I used to test 10-12 times a day, I still do that. I used to aim for quite tight control and an Hba1c of around 6 and I am still doing that. My control is significantly tighter than previously with my BG goals being between 4 and 8mmol/L at any given time, and I do manage to attain this. I am doing my best to stay away from high BG levels and rarely have one over 10 mmol/L now. Because of this, I am obviously at an increased risk of lows but I do keep a close check and monitor my CGM and make sure that I attempt to treat lows before they come.
I know that I have had this pregnancy thing quite easy and I am very lucky but I have had my difficulties as well. I empathise with those who have had a more difficult pregnancy ripe with every problem that a person can have; nausea, vomiting, exhaustion etc etc etc. I know it can get worse and I know future pregnancies could be completely different, so I am going to enjoy the right now and enjoy all that I am going through to create a healthy son for my husband and me. To all those beautiful pregnant people out there, congratulations on the impending birth of your amazing child. I wish you and your families a safe journey and a happy and healthy experience.