When Lauren sent us her birth story, Jenn and I were both amazed at how low her A1Cs were, and how small her baby was when he was born! Since both my boys were on the large-ish side, and knowing that doctors get squeamish about big babies from Type I diabetics, and also knowing that good A1Cs have all sorts of good outcomes for pregnant mothers and their babies, we asked Lauren to share with us a little bit about how she did it. This post came out of that brainstorming session as we thought about what worked and what didn't when it came to managing blood sugars during pregnancy.
I had a few ideas about how to manage blood sugars to keep my babies at a reasonable size after my second pregnancy, based on a post I read from the Navelgazing Midwife, but I have to be honest: very few of those ideas have panned out for me this time around. On the other hand, a lot of Lauren's wisdom had real credibility and a really practical application, based on my own experiences. We hope our experiences help you get through it, too!
LOWS ARE UNAVOIDABLE
Beth: As I've mentioned a few weeks ago, it's amazing how often your blood sugar ends up below 60 when you're aiming for 100. The best thing is just to learn how to deal with it. After all, lows might be more frequent when you're pregnant, but they can happen any time you're not pregnant, also. With two kids at my feet, asking for my attention, I often just have to stop at the first sign of a low blood sugar and check it, no matter who's crying (we're all worse off if I end passed out on the floor, after all), and no matter what, don't try to take a shower and in case you're tempted to try it, just know that fasting really will probably mess things up. I'm fortunate that I can always detect low blood sugars coming, and sometimes I can even tell when my blood sugar is dropping quickly but still at an acceptable level (90-100). Also, when I leave the house these days, I try to make the outings short, and I always bring more food (or Gatorade) than I think I'll need.
Lauren: With respect to avoiding lows, I would say that unfortunately they were unavoidable, especially during my first trimester. I had many, and my endocrinologist was constantly on my case to keep them higher. I use a Dexcom CGM, and I cannot fathom getting through a healthy type 1 pregnancy without it. I set my alerts very conservatively (in my opinion) for 80 on the low end and 140 on the high end. This was super annoying since it beeped constantly. However, it enabled me to fend off potential lows (and highs, although these were less frequent) before they occurred. I consumed MASSIVE amounts of lemonade and Starburst candies, which are my preferred hypo correctors. I just always had these handy and was willing to stop whatever I was doing to treat a low or high. I never went anywhere without one of these immediately available to me.
MEALS and FOOD
Beth: I feel like I've finally hit my stride with food now, at the end of my second trimester of my third pregnancy. The key for me this time? I'm trying to keep meal times to 60 carbs or less. I can always grab a snack (and may, in fact, have to) an hour and a half or two hours after a meal. It's a pain when I want to indulge in a nice dinner out, but it helps keep the dramatic lows and highs to a minimum. As far as I can tell, it has also helped me keep my weight gain down this pregnancy, and I'm keeping my fingers crossed that this baby might turn out just a wee bit smaller. I liked Lauren's idea about eating a very predictable diet, too, and have found that this helps particularly when I have lows. If I know exactly what Gatorade will do to my blood sugar (and how much and how fast), it makes it easier not to over-correct a low.
Lauren: I gave a bolus for all meals at least 30 minutes before eating, usually 45 minutes. Also, I ate an absurdly predictable, repetitive diet. As in, the same exact breakfast every day for the entire pregnancy. Lunches varied slightly. Dinners I had more flexibility, but I cook virtually all of our meals, so I could control everything that I ate. This way it was simpler to eliminate "problem" foods for my blood sugars (white rice and bread, "mystery" sauces, high sugar fruits, added sweeteners, etc...). I'm a human being, so I indulged in some "bad" foods, but extremely rarely. I don't think that this kind of limitation is necessary for everyone, but for me, it was truly the only way to be able to reasonably predict the response of my blood sugars.
CHECKING BLOOD SUGARS
Beth: I couldn't ever figure out how to calibrate the darned continuous glucose monitor (I had a Minimed one for a few months). I mean, my blood sugars are pretty good, but half the time, early in the morning, right after I wake up, is not a good time because my blood sugars would rise immediately and dramatically upon waking. The other half the time, my blood sugar is too low in the morning to calibrate. As for reliably having a post-dinner fasting blood sugar that was not too high, too low, and had been stable for 20 minutes? Forget it. I was usually in bed by the time that happened (sometimes I go to bed kind of early). So what I do during pregnancy is just check my blood sugar all. the. time. Including almost every time I wake up in the middle of the night to use the bathroom. Jenn tipped me off to the fact that truly, insurance companies want you to have a healthy pregnancy and a healthy baby, so it's OK to ask for strips to check your blood sugar 10 times per day (and that's about average for me during pregnancy). Sometimes I don't wait the full 2 hours after a meal, especially if I suspect I might be high or low. And I will sometimes check an hour or an hour and a half after that (even if I've eaten something small) just to make sure I'm still on track.
Lauren: As I mentioned, I use a Dexcom CGM, and I cannot fathom getting through a healthy type 1 pregnancy without it. I started using my CGM right before I conceived, so at that point I had no idea what my blood sugars were doing throughout the day, with the exception of the 5-7 times (or sometimes 3-4 times) per day that I tested. So basically I was seeing the roller coaster sugars on the CGM for the first time and concurrently learning that I was pregnant and my baby's well-being depended on leveling out that roller coaster. It scared the heck out of me! So I became hyper-vigilant about food; far more than my pre-pregnancy self.
Like many Type 1 diabetics, my pregnancy was closely monitored by a team of wonderful doctors. In terms of blood glucose management, I did find the very frequent visits to my endocrinologist and perinatologist helpful. My endocrinologist and I were constantly tinkering with basal rates and bolus ratios, as these changed at different times in the pregnancy. My perinatologist visits were helpful as well in managing blood glucose, though in a less direct way. With the frequent ultrasounds and measurements, he helped me to stay motivated in my BG management and not get hung up on a particularly bad day with ugly numbers. He often said things like, "Look at that healthy baby! He doesn't know your postprandials were high today!" This perspective I think helped to preserve my sanity!
Like Beth, I would definitely recommend requesting more supplies from your doctor, such as test strips and insulin. My bolus ratios got quite a bit higher when insulin resistance kicked in around 24 weeks, so I needed a higher daily dose to stay level. Also, my insurance approved raising my number of daily test strips from 5 to 8 (still insufficient, since my endocrinologist wrote a prescription for 10/day, but I took what I could get). You will need A LOT of test strips. There's just no getting around it.
Beth: I noted in my last post about uninterrupted sitting that even light levels of activity (the difference between a Saturday morning taking care of the kids and a Saturday morning bumming around on the couch, which sometimes looks the same to people without children but are, in fact, very different!) can help keep 2-hour postprandial readings down. I haven't had regular exercise this pregnancy, and I did during my last two, but I still feel that my blood sugars have generally been better this time than before (with a few notable exceptions. It's kind of painful to be reminded of it! But I really don't think the last two pregnancies were significantly better). Now that the weather is getting warmer, though, I do hope to get outside for walks.
Lauren: Although I am not a particularly athletic person, I did make efforts to stay active throughout my pregnancy. I believe that maintaining moderate levels of consistent exercise helped fend off some BG peaks. I love to do yoga, so that was my exercise of choice, but I would imagine just walking more and sitting less would encourage BG stability as well.