Sunday, May 29, 2016

Week 9: Finally Back in the Rhythm(ish)

I thought I'd done pretty well following my last pregnancy - postpartum, that is - in keeping tight control of my blood sugar. For me, this includes eating fewer carbs; eating less, period; skipping snacks or eating low-carb ones; eating much smaller amounts and waiting for my blood sugar to rise rather than eating a lot and subsequently spiking high. In the past, it's also involved scheduled nighttime alarms to check my blood sugar and more frequent finger sticks during the day. Now that I have a CGM it just requires continual attention to the receiver. As I mentioned, I thought I'd done pretty well sticking to the pregnant routine even in a non-pregnant state following my last baby's birth.

But the beginning of this pregnancy had me feeling like I hadn't retained ANY of my good pregnancy habits after my son's birth! I'm not sure whether it was little, minor deviations that pulled me far afield of the tight control I had during pregnancy, or whether it was just that I'd forgotten the feelings of pregnancy that make me hungry, tired, and feeling weak. During the first few weeks of this pregnancy, I really struggled to get back into those good blood sugar habits. My A1C was a bit higher at the beginning of this pregnancy (6.9). I think it's only this week I've had some success.

I suppose there's a temptation to resent the limitations and all the things I can't eat or can't do or can't enjoy, but somehow it doesn't feel that way. I feel a twinge of sadness every now and then that I can't enjoy a good meal with my husband or my friends in the same way, but the feeling doesn't threaten to overwhelm. It feels like, I think, what it is: a short period in my life that will eventually come to an end. Maybe it's also a function of my age: I've tasted enough of pretty much all the good foods there are to eat that I know I'm not missing out on the best of life by going without. And in view of what I'm trying to do here - that is, to create a healthy environment inside me for a little one - it just seems right to do it.

So it's not going without that leaves me bereft. The hardest part of this is learning the best way to tolerate the lows. Doctors want to avoid them altogether; I like that idea. Doctors also want to avoid highs altogether; I also like that idea. Enter diabetes reality, and there just needs to be a strategy for managing the lows that will inevitably come. So before pregnancy, I would eat a generous portion of whatever I wanted and then just give insulin if a high followed my quickly-treated low. But now, I have to take it slow to bring my blood sugar up, because my blood sugar has played ping-pong enough times for me to know that it's not a game I want to play anymore. So every time I see my blood sugar floating underneath that red line on my CGM receiver screen for more than 30 minutes, I begin seeing a stern doctor's face suggesting to me that my lows are too frequent and too long and she wants to make all kinds of dramatic changes to bolus ratios and basal rates that I have carefully adjusted based on close observations of my day-to-day life. But I've observed that bringing my blood sugar up during some pregnancy lows can take an hour or more. This slow rise keeps me from ping-ponging, but it freaks my doctors the heck out. In reality, though, I spend about equal amounts of time below the red line (that is, below 75 mg/dL) and above the yellow line (that is, above 150 mg/dL). (Thank you, Dexcom Clarity reports!) So how low is too low and how long do you have to be there before you worry? And which is worse, too high or too low? I don't know. Every day I fret myself into another forehead wrinkle with the wondering.

Thursday, May 26, 2016

Do I Have Too Many Children?

Monday - when my husband and I were both sick in bed - was a very unhappy, sad day, not only because of my pain, but because of the feeling that neither my husband nor I could adequately care for our children while we suffered our illnesses. Both my husband and I had to lie down most of the day, and this meant quarrels between the boys went unsettled, meals were poor in nutritional quality, and my 5-year-old left the property without asking permission. And yet, what could we do? Who could we ask to come to our home and risk exposure to the contagion to take care of our children? Most of our friends have their own young children, and young children in a home contaminated with that kind of sickness almost always leads to more sick children. Or who would come prepare for us a meal? There wasn't much chance that my picky children would eat it, and neither was it a good bet that my troubled gut would take it in either. Who could rush over to fix a lock on the gate that would somehow do the magical work of keeping our child from climbing the fence when he set his mind to it?

I feel quite certain that there are more than a few people (though perhaps fewer than I imagine) who would simply say: "You have too many children, and your life and their lives would be better if you didn't have them." Yes, it's true that we wouldn't have children to care for if we'd never had children. (Obv.) It's certainly true that we wouldn't have too many children to care for if we hadn't had them. But how, exactly, their life is supposed to be better if they don't have life is a riddle beyond me. And now that we know them, choosing between them which should have existed and which should not have existed is impossible. What of the love and happiness we would be lose if even one child were taken from us?

It's true, the love we bear for our children was a pretty weak and abstract idea at conception. Each time I've gotten the two positive lines on the pregnancy test, I haven't felt especially loving. I mostly feel nervous, and then tired, and then a few weeks later a little queasy. And this love, it had to grow all throughout pregnancy and childhood to accommodate difficulties of all kinds - nausea, backaches, heartaches, frustration. But before long, the thought of living without this love somehow becames so horrifying as to inspire physical symptoms of revulsion and panic. Sick children evoke more pity than almost anything. Cruel treatment of children sometimes makes people feel even worse than a pregnant woman with morning sickness. The death of a child has everyone looking around for someone to blame. What can be said of what we and the world they eventually live in would miss if my children weren't in it? Husbands, fathers, coworkers, friends, teachers, leaders, servants would be missing from the world. And yet people who think or say "you have too many children" do not consider these things.

Suffering parents don't need to hear, "your life would be better without your children." They need to hear that their suffering is not only evidence of some problem in their lives, but also evidence of the growing pains of love. They need to hear that the problems they have are not the people closest to them. The problem is a stomach bug, not the person afflicted by it. The problem is too few other people to care for the children, not the child himself. The problem is what the parents don't know or can't do by themselves, not the fact that their children need their love and care. This is what parents need to hear. Above all, they also need to hear that someone else loves their children, too; not that someone else believes there are too many of them.

Hopefully this doesn't sound bitter. I suppose it might be impossible for it not to sound bitter, because the truth is that I struggle mightily with bitter feelings towards people whose words or conduct even come close to suggesting that I would be happier without so many children. But the idea that I have "too many children" is one that is suggested in dozens of small ways, both by people who know us and people who don't. There's a fine line between, "you don't have to have so many children," and "a woman shouldn't have so many children," and "you shouldn't have had so many children." It's a line that's easily crossed in my own mind.

For example, it is a line crossed in my mind every time someone criticizes the Duggars, because how many is too many? It is suggested every time someone says I need to get away from my children to be happy. It is occasionally suggested when someone says "You must be busy!" but doesn't follow it up with an offer to babysit. It is suggested every time a relative asserts that my friends with five children have too many children, or asks why anyone would want 6 children at all. It is suggested every time a woman protests that she would never be able to have more than two, because the strong emphasis of her statement can also imply that no woman is strong enough to do it. Doctors, relatives, friends, and complete strangers have articulated it in so many ways, and it haunts my life daily. I pray you forgive me wherever I have wrongly assumed you are one of them, and beg you to be careful about perpetuating this belief upon mothers of many little ones. I lack the confidence that so many of my wonderful friends seem to have about their large families, and somehow the number five has really brought the issue to the fore.

All of this is, of course, made worse by the fact that I have diabetes. Pregnancy is hard, and harder with diabetes. Low blood sugars are more common, though they happen outside of pregnancy, too. My doctor once told me that I didn't "need to have 20 children" - a fact I wholeheartedly agree with - but he also strongly implied that having three was an example of ingratitude for the two already born. So where is the line between 2 and 20? How will I know that I've crossed it? This is what haunts me.

So I guess I've got some anxiety and frustration and questions, to go along with some pretty firm convictions about this season of my life. I'll close here quoting one of the greatest servants of the last century, who gave her life in love for the poor. She offers a thought that consoles me often: "How can there be too many children? That is like saying there are too many flowers."

Wednesday, May 25, 2016

Week 8: When Illness Strikes

So the other thing that happened last week was that my children developed an illness. Not a runny nose, feeling-a-little-sleepy kind of illness, but a projectile-vomiting kind of illness. I have gotten to point in my parenting where it doesn't even bother me if my kids have this one...unless I catch the same one, which always happens. So the stomach bug really does bother me a great deal.

Between my husband and myself, we changed six sets of sheets, washed 11 loads of laundry, and wiped up vomit off the floor on five occasions over the course of four days. In the same time, we went through 5 half-gallon bottles of juice, one 2-liter of coke, and a few small bottles of Gatorade just trying to keep everyone hydrated. And most of those were poured down the drain due to contamination with germs, rather than having been consumed.

Since the remaining three children who had not yet been sick became so on Monday night of last week, my husband and I got to Saturday and hoped we were pretty much in the clear. But as you probably guessed, we were wrong.

When my husband was lying in bed all day on Sunday, I secretly suspected he was exaggerating his symptoms, as I uncharitably always do when my children are sick. There was a very real part of me that knew my husband does not do this (his appendix came pretty close to bursting one time before he said anything about the pain), but he'd had a cold the previous Friday and I think what really happened is that I just couldn't bear the thought of going one more day without his help. So I pretended that it wasn't really all that bad and that he was probably complaining excessively (as I often do...oh, the irony!), and secretly resented him a bit.

Then, on Monday, I woke up thinking I had a bit of morning sickness, and tried to choke down my breakfast to get rid of it. But it only became worse. My symptoms increased in pitch, and I began to feel more and more sick. I became desperately anxious, worried that everyone else would think I was exaggerating my symptoms and that I wasn't really very sick and would resent me for it, and so I began to complain loudly about my pain (oh, the irony!). I laid down in bed to wait it out. I vomited, drank very little and ate nothing, as everyone else in the family had done. By the end of the day, my husband had cooked some pirogues and they sounded pretty good so I had a few to eat before regretting it and lying down to wait out the pain. Fortunately, the next day I felt better.

What was really happening was not that everyone secretly resented me and suspected that I was exaggerating my symptoms, but that my husband was just still not feeling well himself and the boys didn't really know how to help. My husband, of all people, didn't suspect me of exaggerating my symptoms, because he'd had the same ones just the day before. In fact, mine were probably not as severe as his, and yet his sympathy extended to me as though they were.

Side note about diabetes and illness: Some people complain about their blood sugars getting wildly high when they are sick, but I usually find that they trend low. Not dramatic lows, but just hanging out just a little lower than is comfortable. I'm usually able to manage it with some temporary basal rates, but the amount of time to assign to the temporary basal and the percent of basal to give is often wild guesswork. I usually do it in 2-hour increments somewhere between 10% and 50%, depending on how low it seems like it will get.

Saturday, May 21, 2016

Week 7: A Visit to the Doctor and A Visit to the Bedside of the Dying

This week saw me making two unusual visits.

The first was a visit to a new OB. After three deliveries with my OB in our old town, it was with some sighing and trepidation that I came to see a new one in our new town. It often feels like I have to convince new doctors about what I know and what I'm capable of, with both pregnancy and diabetes. There is a challenge to being "teachable" and humble before a knowledgeable professional, but also defending the lessons that one has learned over months and years of caring for oneself. Has anyone else found doctors a little "uppity" when patients give even gentle questions or feedback about the doctor's recommendations?  Or is this just a problem with me? Is it a male/female thing? Does it have something to do with endocrinology and obstetrics, or do other kinds of doctors do it too? Is this just because I've had a few children and maybe know more (or at least think I know more) than other diabetic moms do? I am weary of the need to prove that I care for myself and that I have some good ideas about how to do that.

Baby is a healthy 8 weeks and I was pleased to see that my ovulation date matched pretty closely the ultrasound measurements indicating baby's age. We saw a heartbeat and the doctor referred us to a maternal-fetal specialist for general diabetes care, which will be my diabetes reference point during pregnancy since I don't have an endocrinologist. It's not that I don't feel pretty sure of my own ability to adjust rates, but it is good to have someone to offer a different perspective on the problems you're facing. Convincing someone else that I have the ability may be an issue. I'm hoping that my CDE friend will assist in this capacity, too.

The second visit was to my grandmother, as she had been admitted to the hospital one last time at the age of 98. Following that visit her daughter, my mother, decided not to make her endure any more hospital admissions and simply place her in hospice care for whenever death may come to take her. It was an eminently sensible decision, as I had seen many hospital admissions - with their testing - become very disruptive for my elderly ancestor. Her short-term memory had been fading over the last few years, so she was unable to accurately report symptoms of pain and discomfort. She had recently lost clarity about even the most vivid of long-term memories. She forgot who many of us were. And finally, she had lost a great deal of her ability to speak and even understand verbal communications.

She was really so very childlike. It was striking to see her go through phases where she didn't want to be cleaned or have her clothes changed...just like my one year old. It invited pity to watch her try to express herself verbally, without success...just like a baby learning to speak. And just like caring for my children, it was so good for me to be with her in her final hours, to note well her weakness, her heavy breathing, her thin limbs, her lack of awareness of my presence, and to love her anyway. I visited her late on the evening of Thursday, April 21, and she died the next day.

Death consumes all of us, but life does go on. Some would say eternally. The child I have now will always remind me of the triumphant reality of life, life going on within me in spite of death around, the life of my child after the death of my grandmother. May she rest in peace!

Wednesday, May 18, 2016

Early Weeks

In my last pregnancy, I recorded each week rather diligently. This time, I sort of forgot to write about it, or even to think much about it. I also sort of wondered whether going week by week and publishing my thoughts publicly would encourage over-reflection and a rushing-to-judgment about diabetic pregnancy. My experience is almost certainly not universal to other diabetic women, and it's probably not even consistent from one pregnancy to the next. So to avoid overgeneralization about my own or anyone else's experiences in pregnancy, I'll simply make some observations here about the early weeks. If they jive with what you experienced in early pregnancy, too, let me know by commenting below! Perhaps we can make a pattern out of it and some day our doctors will listen to what the rest of us have noticed.

I knew very early, again, that I was expecting. This comes of natural family planning charting. I still have some difficulty identifying the day of ovulation - some months are easier than others - but I got it within a day this time. And for those who don't know, the day of ovulation is the one day of the month when a woman releases a prepared egg for fertilization. Some women have difficulty conceiving because they fail to ovulate, and some women have difficulty conceiving because the egg isn't released into the fallopian tube properly. (There are also any number of other difficulties with conceiving that a couple may experience, but these are two of them related to ovulation). Conception always takes place within a day or two of ovulation (if you release two eggs, this time is extended a bit), as the sperm cannot reach the egg until after its release, and the egg disintegrates rather quickly if it is not fertilized.

I had a few high BGs right around the time of implantation, but the phenomenon was not as noticeable this time as it has been in other pregnancies. I did notice that my blood sugars seemed a bit more even than at other times. Once I returned to baseline after a meal, my BG remained remarkably stable for hours, with the exception of about 45 minutes before my next meal. This was true whether my BG returned to a lower level (think 80) or a higher level (think 130). I'm not sure whether to attribute this difference to fact that I was measuring levels with the CGM rather then my blood. I do sometimes wonder if interstitial fluid glucose levels don't show the same changes that the blood does, and perhaps particularly so under the protective influence of the hormones progesterone or hCG. This is purely theory, though.

Immediately prior to the start of pregnancy, I had spoken to two certified diabetes educators (CDEs). Both of them suggested that I need to eat more frequently, both to relieve nausea in early pregnancy and to keep my blood sugars stable. I do go for a long time in the afternoon, between lunch and dinner, without eating. This period of fasting lasts about 6 hours. But in light of the above - that is, the general stability of my BGs following meals - I have not found eating continually to promote stability in my BGs. On the contrary, I have found that it promotes more frequent spikes, even when eating small amounts. Since about week 6, I have experienced nausea, and have also not found that eating frequently helps with nausea. The times when I notice nausea most are when my blood sugar is falling after a meal bolus, about 45 minutes after a meal. If I give insulin to account for the food that I eat, then I would likely experience this blood-sugar-falling nausea even more times per day. I am not anxious to do that.

So the early weeks dragged on rather uneventfully. Jenn, who has recently become a CDE (congratulations!), did suggest that I try to give insulin about 10-15 minutes prior to a meal. This has been a wonderful tip for my regimen, and I will use it whether I'm pregnant or not. My spikes after meals are not as high, which helps avoid the post-meal blood-sugar-falling nausea mentioned above.

Sunday, May 15, 2016

Back in the Race

Childbearing is not a race in many ways. There is no prize for getting to the end of pregnancy first. To the contrary, rushing to the end of pregnancy would be disastrous for your baby. There is no prize for shortest labor. In fact, short labors can be really scary. All conventional wisdom tells us that there is no prize for getting your child to the age of walking, talking, reasoning, or full maturity first. I hear the empty nest can be a very lonely thing. So "rushing it" can be problematic.

On the other hand, when you're in it, it sure feels a lot like an endurance event of some kind. The nausea and fatigue of early pregnancy, the growth pains of the second trimester, the heavy weight-bearing exercise of every moment of the third trimester, the final mile of childbirth, the recovery of the postpartum months. I think a race is a rather apt description for the experience of pregnancy, childbirth, and recovery, even if we don't measure the success of our childbearing adventures in "shortest time to finish line."

So while I am certainly not competing with anyone (and would not advise anyone to view it this way), and I'm not aiming to complete this process in the shortest amount of time, I do feel like I'm beginning another long-distance race. Let's think of it as a continual search for a "PR," or personal record. How to measure the outcome - a loving child who does what is right, rather than a child who does everything at the speed of a rabbit - is something I'll have to leave to the passage of time and the judgment of God.

That's right, I'm expecting again! This is my fifth pregnancy, and it seems like some unusual and undeserved gift that all my previous pregnancies ended with a live, healthy baby. The longer you hang out around parents, the more stories you hear of infertility, miscarriage and stillbirth. It keeps me humble. But it has, at times, felt like an undeserved burden, too. Couldn't I take just one risk or make one mistake with natural family planning and not have nine months to show for it? In the end, my fickle affections about the pain and difficulty of the endeavor do occasionally get in the way of recognizing the value of a new little human being.

I'm hopeful that the CGM will help me avoid a few more lows this time around. It's true that I get lows when I'm not pregnant, too, and I've mentioned this as an inadequate reason for a doctor to pressure a diabetic woman to avoid having a baby. But it's also true that when I'm trying a lot harder to keep it down because of another person whose health depends on my ability to do so, I make more mistakes. There's some balance between a good A1C and a healthy infrequency of low blood sugars, and I'm never quite sure that I'm doing that properly. So please pray for me and my family as I embark on this adventure!