Type 1 Diabetes and Pregnancy

Judah, 1.5 years old (our first)

It's that time of night when I can't sleep. I'm pregnant enough that I get up to use the restroom almost every night at this time and just can't fall back asleep after due to being uncomfortable (I really dislike sleeping on my side). So Joe recommended instead of tossing and turning (I'm sorry if I wake you up love!) that I blog. So here I am... at 4 am... He encouraged me to write down my "book ideas" which, let's face it, will never become books. But this one, considering the phase of life I'm in, seemed the most relevant to put down for others. So here we go! Forewarning: I'm not an expert. I'm not a doctor in the medical field. And I'm not 100% sure that all of this is useful or even necessary. I just know from the experience of 2 pregnancies now (Judah and a little one we're calling Carrot until we find if it's a boy or girl in June) what works and what doesn't for our family. So you can disregard whatever you like.

Type 1 Diabetes and Pregnancy

I was diagnosed a little before my 3rd birthday with Type 1 diabetes, and have lived with it for 24 years now. I am not perfect, and during my teenage years I had horrible A1Cs (a blood draw that's done normally every 6 months to see your average blood sugar levels). So after marriage at 21, baby fever set in within two years and it came time to see if children (other than adopted) were even an option for our family. I'll say this now. There aren't a lot of resources other than other diabetic mom blogs detailing what it's like to be diabetic and pregnant. The majority of things found are frightening statistics of birth defects in diabetic pregnancies and a little info on what you need to do to prepare for pregnancy. But nothing on what diabetes and pregnancy even looks like from the medical perspective. So I turned to my endocrinologist (doctor specializing in diabetes) for more. Which leads me to my first point:

1. Find Your Core Team
This depends GREATLY (sadly enough) on your insurance. With our old insurance, I could pick and choose whomever was covered by BCBS-KC and go there. With our current insurance, I have to be referred. So our last insurance was ideal for this. With Judah, I already had an OB, but it was really difficult to even see their high-risk OB who they would refer me to once I was pregnant. Finally 9 weeks into the pregnancy, I had given up trying. Other things were frustrating in their practice and I needed an OB I could count on. So I actually turned to my endocrinologist for recommendations. First off, I loved my endocrinologist in Kansas City. If you are looking for a great endocrinologist in KC, I really recommend Dr. Lisa Hays and her staff. I get to why later. Dr. Hays recommended me to Dr. Jessie Holmes, who had handled many of her diabetic patients and also been her OB for her two children. It was a match made in God's providence. I cannot stress enough the important of a team that's working together wonderfully for you and your baby. Dr. Hays handled my diabetes (I saw her monthly) and Dr. Holmes handled the baby (monthly as well), both communicating with each other trends seen and tests I might need. There might be more doctors in your core team. Dr. Holmes had me see a perinatalogist for my sonograms. I think they would have handled my diabetes as well had I not opted for Dr. Hays to handle it. My family practice doctor who I saw for the normal things in life (like the flu) didn't really play a role because they would of had to refer me to a high-risk OB anyway. Dr. Hays had me see a dietitian, but I only saw her twice. I'll say this, if you haven't picked up on it yet- it can be almost a full time job being pregnant based solely on all the appointments you'll have.

Now, I'll clarify a bit the difference for us in not having this core OB/Endocrinology team. This time around, with being referred by my family practice doctor to both my endocrinologist and my OB, there's no communication. Granted, my new endocrinologist is a young guy (which isn't bad, he's just less experienced in the field) who when I told I wanted to get pregnant again and what could I expect from them, seemed both surprised and lax. He recommended an A1C of 7 (meaning average blood sugars being around 150) which was higher than my endocrinologist in KS recommended before trying. When I succeeded at this, and came back telling him I was pregnant, he was hands off. He said it was fine if my high-risk OB handled my diabetes and I could just see him our usual every 3 months. While my OB was a high-risk practice (I've rarely seen the same person twice), that doesn't mean they know diabetes backwards and forwards like an endocrinologist does. It was nothing short of frustrating. So with Carrot, I'm holding to the things I learned in my first pregnancy with Judah and being as strict with my diabetes as Dr. Hays was. My OB now doesn't always listen to my recommendations for changing insulin levels or what was done with my first pregnancy. Needless to say, I miss my KS core team.

2. What to Expect BEFORE Your Expecting 
With Judah, I learned that by God's grace and mercy you'll need to work your tail off and get your A1C down to a 6 (average blood sugar being around 120). With Judah, we started trying when I was down to a 6.7, which I had read on one of those frightening statistic sights had a low percentage of birth defects. It's important to get your blood sugars down and under control before you start trying. During the first 6 weeks in the womb, the baby's developing vital parts that can be severely injured by crazy blood sugars. I worry about Carrot because it has been much harder to get my blood sugars under control after I was pregnant, even though I had them in control before. We're looking forward to the 20 weeks ultrasound to make sure he or she is okay, and hearing that heartbeat at OB appointments is a blessing knowing it is strong and beating. So with prayer and hard work, it is possible to get your A1C down and blood sugars controlled before you start trying for a baby.

3. Not Pregnant... Not Pregnant... PREGNANT
It's pretty easy to tell when your pregnant just from your diabetes. You may not have all the usual signs of pregnancy just yet (nausea, tiredness, bloating), but a marked spike in your blood sugars that just won't go away will tell you something is up with your body. If you have your sugars under control beforehand, you'll see this change pretty easily. With Carrot, it was even more pronounced than with Judah. By week 2 or 3 into my pregnancy, my sugars would not go down without adjusting my insulin basal rates (I'm an insulin pump user if you were wondering). As I said, even before tiredness set in and then nausea, I knew I was pregnant.

4. What to Expect Now that Your Expecting
Appointments. The initial appointments to confirm pregnancy, to set a game plan with either your endocrinologist or, in my case now, your OB how to handle your blood sugars. A dietitian appointment initially giving you a helpful review of what eating like a diabetic looks like and what you'll need to up to get the proper nutrition during pregnancy. Sonograms and Bio-Physical Profiles (also called non-stress tests) during the third trimester (you sit in the comfiest of recliners and listen to the baby's heartbeat once or twice weekly). As I said, with appointments alone, it's almost a full time job, especially as you get later into your pregnancy. With Judah, I was a nanny for the first half of my pregnancy, and gave my two-weeks notice when I knew we were getting into the appointment heavy part of the pregnancy. But that's something our family could do. We had budgeted for us to live off of what Joe made so I could stay at home with our children. That was our choice, and it's been a blessing ever since.

Along with weekly faxing in of your blood sugars (both Dr. Hays and my OB here wanted this) to monitor any trends of highs or lows, you'll have your usual monthly OB appointments. Getting to hear the baby's heartbeat for the first time is an incredible comfort. Granted, the baby's heart starts beating around 4 or 5 weeks, but due to the dangers of sound waves before 10 weeks, you won't get to hear it until after 10 weeks. The key thing that is going to make your pregnancy different than a friend's without diabetes is the close control of your blood sugars. High blood sugars effect your baby the most, causing defects earlier on in pregnancy and high weight gain later in pregnancy. As you become more pregnant, you also become more insulin resistant (with Judah I was on 3 times the amount of insulin at the end of my pregnancy than when we found out we were pregnant). So close and careful monitoring of your blood sugars is vital for baby. With this under control, and again by God's grace and mercy that He is forming your child in the womb (Psalm 139), you'll be like any other pregnant woman. Emotional, growing, and jubilant that new life is growing inside of you.

I'll spare you the other things of pregnancy that you can pick up in normal books- where to find cute maternity clothes, what fruit size is your baby like this week (it's my favorite when they say obscure fruit like "Your baby is the size of a kumquat this week!"), how to handle pregnancy and exercise. If your watching your blood sugars closely, you know your body backwards and forwards and know what you can and cannot do. For example, this pregnancy I know I can't have a meal later than when I usually eat. My blood sugars drop if I wait, so this pregnancy scheduled eating is key. As I said, there just aren't books about being Type 1 diabetic and pregnant. There's lots of information on having Gestational Diabetes and while I don't know much about Type 2, other than controlling it with exercise, diet, and sometimes medication, I'd imagine it would be somewhere between Gestational and Type 1 in needing to control things.

So let's hop to the end of pregnancy...

5. The Third Trimester and Meeting Your Little One
By the end of pregnancy, as all those lovely stretchmarks really set in, is when you'll really need to be on the ball (as if you haven't been up until now!). It's highly common with Type 1 diabetics to have pre-eclampsia at  during the third trimester. Let me say, I gained 60 pounds with Judah, and 40 of them I lost in the first month after he was born because it was all the water-weight I gained with swelling. Exercise (within moderation), keep your feet up as much as possible, and if you have a loving husband like mine ask him to rub down your pained and swollen legs and feet. I knew pre-eclampsia was a risk that came along with being diabetic. So my blood pressure was monitored at every appointment with every doctor so watch for signs as it slowly kept creeping up. I didn't even go into labor with Judah. At 37 weeks, my blood pressure was high enough (it had spiked at like 165/90), and Judah's lungs were developed enough that they went ahead and delivered. So make sure that is being watched especially in your third trimester.

Another thing to expect, depending on your doctor, is that a Cesarean section (or c-section) might be your only option for delivery. The only downside of Dr. Holmes in KS was in her experience, babies of diabetics were so large and such had wide shoulders that it was dangerous for mom and baby to try a vaginal birth. My OB here has hope for a VBAC (vaginal birth after c-section), and plans to monitor the baby's weight gain as we get closer to time. If the baby gets over a certain weight granted, she too is more comfortable with a c-section. But Judah was born safely at 8lb 14oz via c-section. Recovery wasn't as bad as I had expected- they make you get up the day after, which it excruciating, but the more you move (within moderation) the faster you heal. The week after Judah was born, Joe had to return to work, and I was fine taking care of Judah on my own. So recovery isn't as bad as some say. You'll have more IVs than the usual patient- I think other than nursing safe pain killers via IV, I also had one of potassium (I think it was potassium- again I'm not a medical expert) that needed to be in for 24 hours after Judah was born to bring my blood pressure down. It made nursing tricky, but it was doable. I think the only downside of a c-section was that I couldn't hold Judah until after they had stitched me up and I was back in the recovery room. The nursing staff was fabulous, and very compassionate. So I really can't complain.

So finally, the big moment comes (whether labor or a scheduled c-section), and your little one is here. I wish I could express in words that joy. Seeing Judah for the first time was incredible. I wanted him with me 24/7 because after 9 months of having them inside you and then to send them off to the hospital nursery- I couldn't do it. Call it what you will, attachment disorder or whatever, but I didn't want this handsome little man out of my sight. But just because baby's here doesn't mean everything is gravy again with your diabetes. This is what made my endocrinologist and her staff in KS stand out in my mind. Dr. Hays was there every day, if not every other day, looking at my blood sugars. A few of her nursing staff who I enjoyed talking to even came to see me and Judah. That kind of care makes all the difference in diabetic care whether your pregnant or not. But, to the point I was getting to, your blood sugars will drop IMMEDIATELY after the baby is born. I don't think I needed hardly any insulin that first week. I was low by the time they wheeled me from the surgery room into recovery. So again, for your baby's sake, you'll need to keep a close eye on your blood sugars. I had fallen asleep with Judah lying on my chest in our hospital room, and "woke up" eating and unsure of my surroundings. I even had to be retold that I had given birth and was eyeing sleeping Judah with uncertainty. My blood sugar had dropped after my last nursing session and I had had an episode. Praise God Judah was alright and I didn't drop him or something more horrible. But your blood sugars are just as unstable after birth as they are during pregnancy- just lows instead of highs. They won't make perfect sense, but Dr. Hays and I did see a trend that my blood sugars would drop after nursing, which just meant I needed to snack on something (preferably protein-filled like cheese) while I nursed to keep that from happening.

Well, for all who actually read through this, that's all I can think of. If you have questions or comments, feel free to comment below and I'll do my best to respond. Pregnancy with Type 1 Diabetes is completely possible with careful monitoring of your blood sugars and diet. Children are a blessing from the Lord (Psalm 127) and having your quiver filled with them is a wonderful thing. Don't let the sin of disease get in the way of that joy.

Post Script: Levi Renwick was born Nov. 2, 2012 via c-section. The OB practice I was using went back on their "VBAC is okay" decision and told me that if he wasn't born by 39 weeks, they'd like to do a c-section. We walked, we ate spicy food, exercised, did everything we thought were sane (but avoided castor oil) and he didn't come. My body felt like it was almost ready. I had contractions daily, but they never went anywhere. He was sitting nice and low and head down. But, alas... docs don't like the idea of women giving birth to 10 pound babies naturally. So... Levi was born via c-section 9lbs. 14oz. 21.5in. Beautiful healthy baby boy. And let's face it... that's what we're going for right?

 Levi, 2 months (our second)