A1c: And…. Exhale

It’s hard sometimes to really keep track of diabetes control when you’re right there in the thick of it. When you’re testing more than 10 times each day, and wearing a CGM that gives you a new number every 5 minutes it’s easy to get lost in a sea of data. It can be hard to view the bigger picture and not get bogged down with minor imperfections, or the things that just aren’t going so well.

The more effort I put in to controlling my blood sugars, the worse I am likely to assess my control as being. Even when the figures clearly suggest that things are pretty stable, I always seem to view them as less stable than they were in the two weeks, or two months, before now. Maybe I’m just a pessimist. Or maybe I do it to protect myself from disappointment. Or to motivate myself to keep trying harder.

This week I visited the local Diabetes Centre for the first time since we moved out of London, and I transferred my care. Most of my pregnancy and diabetes care is being handled at the local hospital, but they also have a brand shiny new clinic in the centre of town. I didn’t really know what to expect on my first visit, including whether I’d be able to get an instant A1c result.

I must admit, I was impressed with the centre. It really is brand new, very light and spacious. And also incredibly quiet. Which is a change for someone used to busy teaching hospitals.

I met with my nurse specialist and we reviewed my DexCom data and blood sugars, went over basal rates and made a few adjustments to deal with late evening lows and early afternoon peaks. She tried to reassure me that I was doing just fine.

“So, when did we last have an A1c?” she asked, scanning through my records.

“It’s been a few weeks. It was at twelve weeks I think, and I’m sixteen now.”

“Shall we get one today, then?” she asked.

I genuinely think I’d have been able to say no. It was much more of a question than a statement. For a moment I deliberated. On the one hand I was pleased they had a machine on site, and I really wanted to know where I was at, to make sure I was on the right track towards keeping our baby as safe as possible. But on the other hand I was pretty scared. Scared of a result that was higher than I’d like, conscious of the fact that things hadn’t felt so stable lately. But even I had to admit to myself that it’s the only way to really get an objective idea of how things are going. So I agreed and we headed to lab room.

Two minutes later, my sample was in the machine and we were chatting about this and that as it counted down. We chatted about how big babies can be caused by all sorts of things other than diabetes, and I shouldn’t feel guilty or judged if my baby should end up being larger than average. We chatted about how big babies are usually perfectly healthy, and that actually a bit big is preferable to too small.

5.4%

The result flashed up on the screen.

I let go of the breath that I hadn’t realised I’d been holding.

Your Baby is What You Eat

People keep telling us all about the awesome responsibility of being a parent. About how this tiny little person will be thrust in to our arms after birth and from that moment be completely and utterly dependent on us to stay safe, grow and thrive. But I see pregnancy as an extension of that. I don’t think it begins at the moment of birth, it begins at the moment of conception. And in many ways the dependence that an unborn baby has on its mother is even greater than the dependence it will have once it’s on the outside, because absolutely everything that baby is exposed to comes through mum.

This is a difficult and emotive subject for many women with diabetes. In my experience we’re all acutely aware of how our own blood sugars have the potential to impact on our babies. Every time my blood sugar spikes a little higher than I’d like, I wonder if my baby is hurting in there. I wonder what damage is being done to fragile forming organs or, as I progress, what may be happening to the size of our child. I worry about lows that may strike out of the blue, sending me in to unconsciousness and depriving my baby of what it needs to survive.

This awareness might yet be a good thing though. I’ve been known to tell people that living with a chronic illness has some positives. (It doesn’t mean I wouldn’t trade it if I could, but I like to try and look for the silver lining.) Many people who live with diabetes are healthier, on a day-to-day basis, than our “healthy” counterparts because we have a better understanding of our own bodies and a greater awareness of what is happening within them. We’re better at listening to what we need. We see real day to day differences from the food that we eat and the exercise that we do that can often have a positive impact on the way we choose to live. In short, the idea of what we put in to our bodies affecting what we can get out of them is very real and apparent on a daily basis.

As a person with diabetes then, it’s fairly easy to grasp the idea that what we put in to our bodies whilst our babies are growing in there will affect the baby that comes out.

It’s like the old adage “You are what you eat”. Except in this case your baby is also what you eat. And a couple of pieces of research published in recent months have underlined this fact.

One study, reported here , showed how a decreased calorie intake in the first half of pregnancy could have the potential to affect the brain development and intelligence of the offspring. Granted, the study looked at baboons, but plenty of people would argue that I’m a bit of a monkey! I’m not sure that many people would presume excessive restriction of diet in pregnancy would be healthy, but it’s a worrying bit of research in the context of calorie deficit caused by morning sickness, and makes me glad that I continued to shovel food down my throat even if the choices that I made aren’t necessarily regarded as healthy ones. (Mini Mars bar, anyone?) Any food, it seems, is much healthier than none at all.

More interesting though is this study  which shows how the diet we are exposed to in the womb could alter the function of certain genes, which in turn can have later health consequences. This particular piece of research focused on the effect of low carbohydrate diets on childhood obesity. Logically you might have thought that stuffing yourself with carbohydrates would have the potential to lead to a bigger baby and fatter child, but in fact the reverse is true. A lower carbohydrate diet is actually linked to increased rates of childhood obesity. In fact, the size of the mother and the birth weight of the baby are much lower determinants for obesity than the level of carbohydrate in the diet.

This one is worrying to me because lower carbohydrate eating a powerful weapon against post-prandial blood glucose spikes. Current thinking on blood glucose management is beginning to look towards the size of glucose spikes (assessed by the standard deviation of blood glucose numbers) having as much effect on complication risk as the overall control (as assessed by the HbA1c).  This is particularly thought to be true during pregnancy and is the thinking behind the current guidance to keep the one hour post-prandial levels so low during pregnancy. And of course spikes themselves negatively impact the HbA1c anyway. Since carbohydrates raise blood sugar, minimising carbohydrate intake minimises post-prandial spikes and helps maximise stability and glycaemic control. Win-win? Except that this study has thrown a spanner in the works!

Before I ever got pregnant, I speculated with Ian – and only half in jest – that I would have to spend nine months eating a very consistent diet so that I knew exactly how to dose insulin for every meal and that most importantly I’d need to stick to a low carb diet. In the pre-conception period low carb worked very well for me and certainly contributed to me lowering my HbA1c below 6 for the first time in years. In the light of this study it seems fortunate that morning sickness hit me hard and threw any pre-conceived (pun intended!) ideas out of the window. I’m also thankful for so many low blood sugars which meant I got my quota of carbohydrates in Lucozade if nothing else.

This pregnancy thing certainly is a minefield. I feel like I can’t do right for doing wrong. Obviously I need good blood sugars, but the diet that helps me achieve those may be harmful in itself. All I can hang on to is that making the decisions about what I should and shouldn’t do whilst this baby is inside me is good practice for the millions of decisions I’ll be making for its welfare throughout its life.

Right. I’m off to find a chocolate biscuit!

Oopsie… Look What We Bought

I’ve not done tremendously well at sticking to the “not buying too much too soon” idea. 

It was supposed to be a few small items until the twenty week anomaly scan. A few cute sleep suits and a cuddly toy, kind of small items. Which does not at all explain how we today came to buy a car seat for the unborn baby. And worse…. A car seat for the car that we don’t yet own.

I could blame it on pregnancy induced madness, but I do actually have my reasons.

Although I’d decided that I wasn’t going to be buying until after twenty weeks, I absolutely was planning to do lots of browsing and lots and lots of research. Car or no car, I knew that we’d need a car seat. Virtually all hospitals I the UK will not allow you to leave the premises with a new born unless they are in a suitable car seat or you can safely get home by other means. Putting our new born in a pram and taking them home on the bus, whilst technically possible, is not particularly appealing. And hospital requirements aside, if our brand new precious bundle is going in a car, I want them to be as safe as possible.

So knowing we’d need a car seat, it was a good item on which to focus my research. Lots and lots of reviews and safety testing to read through. It was easy to narrow down the models that came out best in the safety tests, and from there pick out models that got good reviews from other parents. And pretty soon, I knew exactly which car seat I wanted us to get. I even decided which colour way I wanted it in, because it was a good gender non-specific design which would be good not only if we don’t find out the sex of this baby, but also for using with a potential sibling in future who may be of a different gender. (But let’s get this pregnancy safely concluded, before we go too much further with that train of thought!)

The problem came from choosing the colour way. Because I then discovered from the manufacturer’s website that the colour was being phased out. Cue a mad scramble to see how available it still was online. And then of course I found a really good deal price from a reputable high street retailer.

It was one of those “too good to miss” opportunities. I figured it might be foolish to buy a big piece of equipment so early on, but it could be equally foolish to let both the good price, and the seat I wanted, go.

So that’s how car-less parents-to-be came to own an infant car seat.

And as for the car – it’s in the pipeline. We didn’t need a car when we lived in central London, and even now with the mainline station less than ten minutes away, two supermarkets within walking distance and good links to shops and other amenities locally, we don’t totally need a car. But we do want one, if only for convenience, and we are looking.

The Most Comfortable Jeans in the World

I’m one of those girls that struggles to find jeans that fit me really well. I have pretty big hips and thighs, relative to a fairly small waist. Jeans that fit well on the hips are often left gaping around the back of my waist. Jeans that would probably nip in at my waist beautifully, I struggle to get over my thighs. And when I find some that fit well, there is a reasonable chance of them being too long, too short or in a style that I just don’t like!

Comfy jeans that fit well and look good are precious things to me. It’s a good job that denim is hard wearing and my weight doesn’t tend to fluctuate much, since when I find a good pair, I want to hang on to them.

So the thought of needing a whole new wardrobe to accommodate my expanding girth is not exactly one that fills me with joy. Nice elegant wrap tops, and lovely long, drapey tunics I can do. But Jeans have been worrying me.

So I was totally shocked this weekend, on my first foray in to the maternity sections of several stores, to find the most comfortable, well fitting pair of jeans I think I have ever owned. Of course, the wide jersey band at the waist gets rid of any waist fitting issues, so I was free to find a pair that fitted beautifully on the hips and bum. And I’m left wondering why women don’t wear maternity jeans all the time They adapt to every curve. There are no awkward button or inflexible waist bands to cut in when you’re slouching at the end of a long day.

When this pregnancy is over, do I have to pack my maternity jeans away in the loft?

Peek-a-Boo. We See You!

Our official “twelve week scan” was at our new hospital. It turned out to have been a very good thing that we’d already had our NT scan done privately since by the time the scan came around I was already at 14 weeks and past the cut off point for the NT measurement. Which meant that this scan, last Tuesday, just turned in to an opportunity to spy on our little beanie in there.

He or she was rolling around, stretching their little arms and legs out. And it was pure magic to watch.

I still. Cannot. Believe. This.

Diabetes Care Decisions

I’ve been going to the same diabetes centre for almost 12 years. I transferred there as a twenty year old student when I hit a brick wall with my previous doctors about transitioning to a pump.

They not only got me up and running on my first pump, but they saw me through my entire twenties. They took care of me through my battles with non-diabetes related health issues and helped me come out the other side. They saw me qualify as a dentist and turn from student to professional. They’ve seen literally hundreds of highs and lows, and everything in between, with me.

As a twenty-something woman, pregnancy was a bit of a recurrent theme at regular review appointments. In particular, the importance of not letting it happen without proper planning and of course the advice that if I should fall pregnant, I should tell them straight away, almost even before I told my partner!

In the event, I didn’t tell them quite that soon. Ian was with me when we did the pregnancy test, and both of our sets of parents heard the news straight away. But I did have an appointment the morning after my positive pregnancy test, and so my doctors were the next people, and the first non-family, to know. I was happy, sitting in that waiting room, waiting to share good news, wondering which familiar member of staff I’d encounter first. And when I went in to the consulting room I almost bubbled over. Everyone was happy for us too. They did another pregnancy test and concurred that yes, I was very definitely pregnant. And with a diabetic pregnancy, that’s when everything kicks in to high gear.

Or at least, it seems to. Suddenly there are more appointments than you know how to deal with. Your A1c has never been tested so often and your blood glucose records come under closer scrutiny that your average tax return. Everyone is working towards a healthy mum and a healthy baby at the end of the nine months, and is there to support you to help that happen.

Only, it didn’t quite feel that way. My frustration set in at the very next visit, the following week. I saw a new registrar who I’d never met before and didn’t know my history. A whole bunch of stuff relating to my complex endocrine story was dragged up again. Stuff that had been previously laid to rest long before we’d been given the go ahead to try to conceive. No one had mentioned this stuff again in a long time, but suddenly I was left with a horrible feeling that maybe I’d been foolish to get pregnant at all. None of my other worries or fears were addressed at that visit. There was quite a lot of “I don’t know” and even more “We’ll deal with that later”.

The issues got resolved, and I did get some fantastic support and reassurances from staff that know me better. But at the same time, I couldn’t help but feel that the stress with getting to these appointments was far greater than any positive outcome from them. It all started to feel a little bit pointless. I had the diabetes regime down pat. I knew everything there was to know about the risks of poor control and what I needed to do to stay healthy, and I was achieving excellent results. Now I just needed some normal pregnancy support. You know, the kind of care that non-diabetic and “regular risk” patients get in early pregnancy.

It wasn’t forthcoming. By the time I was approaching ten weeks of pregnancy and still all we’d done was talk about my numbers, it was getting a bit thin. I didn’t feel pregnant anymore… I felt like a numbers machine… a science exeperiement. Spending £25 and a two and half hour round trip to look at DexCom graphs that Ian and I can look at together at home, or even email to the hospital if we need extra input, was starting to really grate. And the final straw was when I was told that  got a “gold star” for my A1c of 5.8. “It’s brilliant I was told “We don’t normally see numbers like that until much later in pregnancy, when the blood volume really increases and the red blood cells turn over faster. This is the first time I’ve seen a number so low so early in pregnancy.”

That made me think “Whaaaaat…” Because it made me think that maybe they can’t be so hot at this diabetes and pregnancy thing if an A1c in the 5s gets remarked upon. But more than that it really cemented the fact that travelling all this way wasn’t worth it. As far as they were concerned, I was already doing great. I could agree on the diabetes front, but I wasn’t so sure about the rest of my pregnancy.

I’ve always been a bit of a diabetes care rebel. Not in terms of not doing what needs to be done, but more I terms of doing things my way. My parents started the trend by giving me extra insulin for treats as a child. They were frowned on at the time, but a quarter of a century later it’s the accepted norm. The thing is though, I didn’t want t be a rebel anymore. Becase suddenly this isn’t just about me anymore. It’s about our baby too. So I wanted to toe the line and do what was best for both of us. Which is why I felt so frustrated when the care we got didn’t feel like “best”. By default, they drove me to rebel.

First of all, I put my foot down and said I was only coming once a month, instead of once a fortnight.

But that still didn’t address the fact that I felt as though I was getting no routine pregnancy care. I didn’t like the fact that the hospital was so far from home, and couldn’t see how that might work if I went in to a spontaneous labour at the end of my 40 weeks. So I made a pretty big decision to move all my care to my new local hospital. It would mean that I could get my pregnancy and diabetes care closer to home, and deliver the baby just a few miles from home as well. Their reputation may not be as an internationally renowned teaching hospital, but they can provide excellent pregnancy knowledge and care, and as much diabetes support as I need.

It was strange, attending my first appointment at the new hospital this week. The people seem lovely, but of course I don’t know them like I know the people I’ve been working with for over a decade. I don’t know how the system works at the new hospital, or where anything is. But I do feel that I’ve made the right choice for my health, and my baby’s health, during this pregnancy.

I’m planning to return to my old diabetes centre just as soon as pregnancy is over. They haven’t really done anything wrong. It just wasn’t the right place for the pregnant me.

First Trimester: The Diabetes Edition

In addition to all the symptoms you read about in the ‘Yay, I’m Pregnant, Now What?” books (like the tiredness, and the morning sickness), diabetes brings a whole host of its own challenges to the first trimester party.

It starts just about the moment you see that second line on the pregnancy test , where three seconds of sheer elation is followed by lingering sense of panic. I’m guessing that all women experience some degree of worry during early pregnancy – about the risks of miscarriage and about keeping themselves and their baby healthy. But with diabetes in the mix, the stakes seem higher. Because one of the major factors that may influence the outcome of the pregnancy is directly in your control, but sort of uncontrollable at the same time. The sudden realisation that you need to keep your blood sugars on the absolute straight and very, very narrow day-in, day-out for the next nine months is overwhelming. More-so because you’ve almost certainly been trying to do that for a long time anyway, and know just how difficult, if not impossible, it is to do.

The worry about whether my best is good enough is something that gradually settled down in the background. It’s never gone away, stalking me wherever I go, but it has become a bit less front and central. To a point I need it there, to keep me motivated to put in the huge amount of effort that so far seems to be paying off.

Worry aside, if I had to pick just one word to define my diabetes during the first trimester it would be: hypoglycaemia. Oh yes. The lows moved in to the building and took up very firm residence.

I sort of expected it. Other women with diabetes, and my health care team, had already primed me that lows were a possibility due in part to all the efforts for very tight control, but also just because. I didn’t expect the lows to be so… persistent, though. My basal insulin requirements dropped like a rock, and I was often drinking my body weight in carbs, without bolusing, just to stay ahead of the curve. Which was pretty challenging when I also felt like throwing up the whole time. And there is little worse feeling than knowing you are low as you are vomiting up the juice you just drank to try and reverse the low. In the end, when I did eat I had to sacrifice good post-prandial numbers to avoid crashing lows if I was sick. I learned it was safer to wait at least a little while before bolusing in case the carbs never made it in to my system.

Despite all the sickness and lack of appetite, I still gained a couple of pounds in the first trimester. I can’t help but think this had more to do with all the empty calories from treating lows than it did with the baby growing inside me. My basal needs eventually levelled out at around 13 units per day, down from around 18 units per day before I was pregnant. That drop still makes my eyes pop.

But my A1c, 5.9% at conception, remained in the mid to upper 5s throughout those first twelve weeks. Each time I got a result back, the worry knot inside me loosened just a tiny bit. All the testing, all the insulin dose adjusting and even… even all the lows, seemed worth it if it was keeping our baby safe in there.