Sunday, June 26, 2016

Week 17: And We're Having A...

I went to another appointment with the perinatologist this week. This doctor, unlike my last two, is asking me (although let's be honest, it's more like telling me) to come in for growth ultrasounds every single month throughout the entire pregnancy. This seems to me like more opportunities for the perinatologist to find something to worry about, and then discover was never really a problem all along. I am not a fan of this process.

To prove my point, I note that at my first visit, the perinatologist identified something called "arterial knotting." This was some apparent curliness in the arteries serving my uterus, and the concern is that it might cut off blood flow and restrict growth to the baby. I can't even give you a link for that one, because Google does not recognize this term. I'm not saying it's not a thing...I know Google doesn't know everything that doctors do...but I will say that whatever "thing" it is is highly experimental, theoretical, and hypothetical, and probably even the doctor couldn't tell me how or why it happened, or how or what will happen as a result, because no one really knows. I would bet $5 that there is no repeatable research study on the topic. But anyway, in the theoretical case that arterial blood flow to the uterus would restrict the baby's growth, I was put on baby aspirin to reduce the likelihood of clotting and thin the blood to help promote flow through those curly veins.

At this point in the pregnancy, however, the baby is growing fine and the arterial knotting is actually gone. The observation and diagnosis of the first visit turns out to be something no one really needed to know.

The placenta previa, however, is not gone. That's much more important to keep an eye on, because everyone knows that babies and mothers die if a mother tries to deliver vaginally with this condition. They usually hope for/expect resolution before 32 weeks. So once again - even though this information is important - we all probably could have gone without this information until much later in the pregnancy and been totally fine. This is becoming a familiar pattern...

Well, anyway. I suppose the sex of the baby is another thing that no one really needs to know at this point in the pregnancy, either. I don't think I would go for an ultrasound just to find out whether my baby was a boy or a girl. But dang, if you're going to subject me to hours-worth of ultrasound probing, I will insist upon knowing this aspect of my child's identity! To know something so important about my child, and something that will shape his experience in the world for his entire life, really connects me to him emotionally and mentally in a way that being pregnant with a he/she/it doesn't. (Which is hilarious, because in a physical way, I couldn't possibly be more connected to him than if we were conjoined twins.) Plus, once you have four boys, chances are you have one or a half dozen family members that just can't wait for you to get your girl.

Well, folks, our girl may yet have her day, but it's not today. In the words of the perinatologist on Wednesday: "Oh, that's not probably a boy. That's definitely a boy." God is making it abundantly clear that we were meant to be specialists in raising little men. May He likewise make us worthy of the important task to which He has called us! We certainly feel less capable of doing that work now than we did three years ago, but perhaps that is an example of "when I am weak, then I am strong." We don't get negative feedback on our parenting habits or our kids' behavior when they interact with other adults, so we may have to rely on that detail to steady us as we falter and fret and worry our way through caring for these little guys. Still working myself out of the rut, after all. We are basically thrilled to be welcoming another little man into our home. Over the years, we've collected a half a dozen boys names we haven't had the chance to use, so we'll simply revisit the list. Same clothes, same toys, same activities, no glitter or Disney princess movies. Uninterrupted masculinity.

And, as I work my way out of that rut, I feel like I can tentatively say...there's always next time (dire poverty and life-threatening illness or pregnancy-complication notwithstanding)? 

Sunday, June 19, 2016

Week 16: The End of A Hope or The End of Frantic Planning? The Start of Gnawing Anxiety or The Start of Patient Trust?

I couldn't decide on a title for this post, because this week felt like so many different things for me.

I realized this week that the interesting proposal of a few weeks ago will, in all likelihood, not come to fruition. One of the benefits of living with my parents during the last few weeks would be to have someone familiar to our children caring for them when I have to go to the hospital to deliver. My husband would still be working, and would meet me at the hospital. In theory, it would be convenient, since we'd be living with them. But my mother has activities (both work and recreational) she'd like to participate in and doesn't want to cancel them to watch my older boys when the time comes. My father will not be at home for most of November, so there will be no one else to assist with this responsibility. Though it's an area and a church community we lived in for 5 years, most of the women I know have a number of small children of their own, and would find it difficult to be available on a moment's notice to help me out. Furthermore, it's shocking how many of our friends moved away during the last year we lived with, so very few of the people who would be most willing to stretch themselves on our behalf are even there anymore.

So it is the end of my hope that my old OB, the one who delivered three of my children, will be able to assist me at this delivery. It's sad, not to have someone who is familiar with me, my way of caring for myself, the path my pregnancies follow in the last month, the path my babies take on their way out into the world. The end of the hope I had that this might be possible.

On the other hand, it is also the end of the anxiety that I had in thinking about living alone with my children while full-term pregnant, the end of anxiety I had about how my parents would react to the request, the end of the anxiety I had about all the new things my boys would break while we lived with them, the end of the anxiety I had about whether our presence was welcome in their home or not, the end of the anxiety I had about whether care from one doctor during pregnancy and another during delivery would work well or not, the end of planning and planning and planning for contingencies that were very difficult to foresee. So, it's something of a relief.

On the other hand, the anxieties about what my new maternal-fetal specialist will do or insist upon, what the maternal-fetal specialist will find and demand to do additional testing upon, what recommendation from the maternal-fetal specialist that the OBs will or will not take, what kind of conflict I will encounter with a new doctor when I tell them that I don't intend to induce at 39 weeks, and ultimately, whether the OB will refuse to see me as a patient any longer if I refuse certain kinds of testing and refuse induction under certain circumstances. I have, after all, been fired by a doctor in the past. The memory of that is rather overwhelming. The anxiety about future possibilities is rather suffocating. On the other hand, these are all circumstances which may not come to pass...

...and so I'm trying to make this a time of patient trust, prayer, and waiting. Absolutely nothing has gone wrong yet. I have not had any conflict with my doctors yet. None of the testing has showed an abnormal result yet. I have not gotten to 39 weeks and had to decide about induction yet. Nothing bad has happened yet, my mind is only filled with the bad things that have happened in the past and the bad things that could happen in the future. Nothing bad has happened. Nothing bad has happened. Nothing. bad. has. happened. (yet)

When did living in the present become so difficult? What do you do to help you get back to the present when you are anxious about the past or the future?

And as a side note, my weekly notes are finally caught up to my real pregnancy dates. From here, updates will be live weekly! My due date is November 27.

Tuesday, June 14, 2016

Week 15: IT'S ALIVE!

No matter how many pregnancies I undergo, it's still thrilling to feel the baby move for the first time. I felt it so unbelievably early with my first that I still sometimes wonder whether I might have been making it up. It was so consistent, and so much in the right place. It was a tiny little tickle that happened over the course of weeks and weeks the same, growing stronger and stronger. Then one day at 17 weeks it became a bump and it shocked me so much I cried out in surprise. My boss happened to be walking in the hallway, heard my cry, and poked his head into my office to make sure I was OK! Pregnancies two through four I don't recall the exact time when I felt the baby move at the first, but it was some time around the end of the first trimester. I kept waiting to see if it would happen earlier with those later pregnancies, as many women say has been their experience, but I think 9 weeks is just going to be my personal best, a record, and unrepeatable.

This pregnancy, however, detecting movement has been notable for a different reason. It's taken so long for me to feel it! At my 12-week ultrasound, the baby was definitely moving, but I could feel nothing. In fact, in the last week or so, I'd begun to worry about something being wrong. But today, as I sat on the couch with a sick toddler's face buried in my shoulder and his weight pressing down on my belly, I felt it. Bump. It took me just a second or two to recognize the feeling, and then I remembered, and I rejoiced! What a wonderful thing to know that your child is, undoubtedly, alive, and capable of moving himself around on his own. Then, an hour or so after dinner, I felt it again. Bump. I wanted to tell my children, but then I wasn't sure they'd understand and thought they'd want to see if they could feel the baby, and I knew they wouldn't be able to, so I decided to wait until I could truly share it with them when he's more grown. For now, it will just be my own hidden joy.

I can only assume that the reason it took so long for me to feel it is just because I'm moving around so much during the day that I hardly have much time to think about how I'm feeling about anything in particular. I'm accustomed, actually, to ignoring how I feel. Morning sickness? Push through. Fatigue? It's almost bed time. Hungry? Dinner's in a couple hours, and your blood sugar is looking GREAT right now, so don't mess that up. They also say that the uterus expands more after multiple pregnancies, so perhaps the baby just doesn't bump up against the walls so often. Plenty of room to move around in there!

It was pleasant to be interrupted and forced to recognize my newest little one. It was also a treasure that I was in the process of caring for my child whose littleness will shortly be supplanted by a new sibling's birth; that the baby who is no longer my baby was a force propelling me to recognize the hidden one; that caring for my youngest was not in any way hampered by the little one's assertion of his own existence. How about that for working myself out of the rut?

Friday, June 10, 2016

Week 14: An Interesting Proposal

I was recently fretting to a friend of mine about having to prove myself all over again with a new set of doctors. You'd think after delivering four healthy babies, they would simply trust that I know what I'm doing. Perhaps they do. But the schedule of testing that the maternal-fetal specialist suggested - growth ultrasounds every month from now until 28 weeks, then BPPs every week until 34 weeks, then BPPs two times per week until induced delivery at 39 weeks - truly is out of control. I haven't undergone so much testing in any of my pregnancies. I thought I'd get a pass with increasing pregnancies, but apparently not!

So I was fretting and complaining, as I'm often found to do. Then, my friend suggested:

"Why don't you just go back and live with your parents at the end of pregnancy and deliver with the OB who took care of you during the other pregnancies?"

It was a stroke of genius. As I talked it over with him, the idea began to sound better and better. My parents only live 90 minutes away, so it would not be difficult for my husband to get there when delivery time comes. And then I would give birth in a hospital I know with a doctor I know who trusts me and knows that I can do this. (Working myself out of the rut again! This blogging thing is truly therapeutic. Say, I wonder if the doctors know they might actually be making the depression and anxiety among mothers worse...?) No crazy excessive testing, no haggling with nurses and on-call doctors at the hospital about how I'm going to manage my insulin pump during delivery; just like old times. Which were mostly OK. At least they're familiar.

The good news is that my old OB is on board. Wahoo! Now I need to work out childcare. My mom didn't seem thrilled by the idea of me taking care of all four of my children in her home all by myself at the end of pregnancy. I can't tell if that was for her sake - the noise, the chaos, the broken chairs - or if that was for my sake - the crying spells, the loneliness, the fatigue. So I'm asking around to see if I can get a little help down here, but I'm extremely hopeful that this could work out.

Wednesday, June 8, 2016

Week 13: Why Does It Continue?

After last week's post, you may be wondering whether I am asking the question of why the human race continues in spite of the psychological and physical pain associated with childbearing, I can only give a few nudges in the theological direction. Theological thinking is what my husband does for a living, after all, and I've thought about it quite a lot on my own, too. Love, mostly. Because that's what God is. Because men and women love each other and when they do, babies happen. Good things are worth doing even when they are hard. And people are good. (Trying to work myself out of the rut here, thanks for bearing with me).

But in fact, the 'it' I question here is the fact that I still have morning sickness. My morning sickness dissipated very early on with my other pregnancies, and I assumed this one would likewise take its unwelcome presence out of my home with similar timing. But it has not. I am concerned that it might be some terrible gastrointestinal infection to which I succumbed because of our family's double whammy stomach bug, and for which there is inevitably no approved treatment during pregnancy. (In truth, it bears telltale signs of ongoing morning sickness, arising when my blood sugar is falling or when I haven't eaten for a long time). The quiet voice which assures me that this is normal actually causes a new form of panic to rise to the surface, as I know several women who were vomiting well into their third trimester of pregnancy. HOW MUCH WORSE IS THIS GOING TO GET? (In truth, I have not yet vomited a single time, and have managed my daily affairs without much additional difficulty. For example, I modeled the solar system and calculated how many miles it would be to Neptune if you considered each 10,000 miles as 2-centimeter for your scale. The answer is 3.47). Perhaps I'm having a girl, which seems to be a dear hope of my sweet mother-in-law. The panicky thought-rut-voice has no response to that possibility, as I feel entirely (and I mean, entirely) neutral about that question. (Now the quiet voice is wondering whether it's perhaps not normal to be so neutral on the question of my next child's sex given that I have four boys. Perhaps there is something wrong with me after all...!).

Sunday, June 5, 2016

Week 12: Depression

So postpartum depression is a big thing. I first heard about it when the crew coach at my high school was murdered by his wife, and the reason offered was that she was depressed after giving birth to their chid. Every doctor I've ever been to talks about it, friends always suggest it when you are struggling after baby is born, so many of the mom blogs I read talk about it. It's a big thing, everyone knows it's a bad thing, people care.

I think Simcha Fisher writes pretty intelligently on the reasons why mothers feel like they are going crazy after their children are born. Something about having other people judge you when you're going through something they are not, something about people wanting to hurry up and get the childbearing phase of their life over with, something about people treating pregnancy like a disease to be preventing until one day they want it but then taking care of the child sort of feels like a disease and who wouldn't be ashamed of feeling that way about their own child?

I experienced some paranoia for about two weeks after my first son was born, which I had often been inclined to attribute to some kind of hormonally-induced postpartum psychosis. He was hospitalized for a week, during which time my 25th birthday occurred. The kind PICU nurses encouraged my husband to take me out on a date for my birthday, and I was in absolute terror about what might happen to him while we were gone. Remembering the feeling not only surprises me now when I think about it, but even at the time, part of what frightened me so much was exactly how unreasonably frightened I felt. I could tell, even at that time, that it was a very unreasonable fear. Eventually, the potency of the feeling gave way to a rather dull level of daily anxiety as I tried to adjust to caring for a new little person.

I was pretty happy after my second and third sons were born. No strange psychosis, just the normal aches and pains and anxieties. The fourth, however, was different. For about three or four months, he would cry every time I put him down. I felt completely incapable of caring for him. It wasn't that I didn't know what to do, as I had learned all that I could do with the first three. It was that I knew exactly what I would do if he were my first and I simply couldn't do it for him. I just couldn't physically manage to hold him, bounce up and down, and walk around the house for hours because of the care required for all the rest of us. At one point while trying to prepare dinner, hold the baby, and walk and bounce around the house, I looked at my husband and asked him, only half joking, "Are we going to make it?" He looked at me very seriously and said, only half joking, "No. We are all going to die." True enough, life on this earth doesn't last forever! But his response also spoke of the absolute blindness into which we were walking. How will we take care of what has been given to us to care for? Are we adequately prepared for this? The only thing certain, it seemed, was that death would come in the end.

For some reason, after my fourth was born, I never got over the question of whether I was capable of caring for all the children I have. It's like the joke that Jim Gaffigan makes, "If you want to know what it's like to have a fourth, just imagine you're drowning, and then someone hands you a baby!" He jokes about it, which I hope means there's peace to be attained with the terrible feeling. But my anxiety levels are still terribly high.

In truth, though, I think the seeds of this feeling were planted from the moment my first was born; possibly even from his conception. The positive pregnancy test terrified rather than delighted me. Lying on my hospital bed an hour after his birth, with nurses just a button-click away and my husband snoring peacefully on the couch beside me, I realized that I couldn't physically lift myself off the bed to pick my son up out of his bassinet. This made it a physical impossibility for me to feed him or change his diaper, as mothers are supposed to do. Then, when I left him in the care of very competent nurses for just a few hours to go out for dinner, the thought of what might happen in my absence made me frightened almost to the point of paranoia, as I mentioned above. My mother-in-law confirmed my absolute terror in the presence of my child when she told me, after we got home, that I needed to relax around him. I remember one time putting him down to let him cry when he was about three weeks old because I didn't know what else to do, and feeling so angry and helpless and sad. The power of the feelings frightened me, because I didn't know what to do. I called a friend to talk me through it at that moment, and I'm sure that I left out some of the resentment and anger I felt because it was just so embarrassing to feel that way towards a tiny little crying baby. So I think it has far less to do with the number of children I have - this feeling of inadequacy has truly been with me from the very beginning - but I am reminded of it more or less at different times in my life as a mother.

So I've been overwhelmed by caring for my children from my very first moment as a mother, and that feeling came out in my post about our illness a few short weeks ago. It's not really about the number of children we have, though others may attribute the feelings to that fact. My paranoia about caring for my first son was definitely not about the number of children we have, nor was it about the hormones. I think it's truly about the fact that I'm not an all-powerful and all-knowing being capable of hitherto unknown heights of safety-consciousness around water, fire, and sharp objects, nor the soothing of all pains and cries which my child may feel. Do people expect this of me? Most days I expect it of me.

The feeling has lingered potently over the last year or so. When my husband was finishing his dissertation, I was left alone more often. One time I became so sick and tried to put off a fever by consuming excessive amounts of ibuprofen around the clock. The ibuprofen made my stomach bleed and I ended up vomiting blood and begged my husband to take the day off to help me with the kids. When my husband took his new job, I was left alone during the week while he lived near the university to begin his teaching work. It was then that I finally started to talk to people about it, ask people about it, consider counseling. I expected the situation would improve after we moved, and after getting some counseling, but apparently the ruts of anxiety and worry have been dug so deeply now that it will take a bit more time to find my way out again.

In the meantime, we conceived. And while all pregnancies have left me with a bit of fear and trembling, this one has left me utterly despairing of my child's life. I hate to write those words, about despairing of my child's life, and I hope that if my child reads them some day, he recognizes that it comes from a place of shame and weakness about my own abilities, rather than resentment and hatred of his being. It is precisely because his life is so good that I fear I cannot adequately care for it. I wish for him to exist, but I wish he had a better mother to care for him. I fear that I am giving to him a life of pain and suffering, and that I cannot make that life anything else. Postpartum depression is a real thing that everyone recognizes as a problem and a few people have attempted a solution for, but I have never heard of prenatal depression. I'm quite sure that's what I have. 

So perhaps because of my postpartum epiphany and depression after my first child was born - that I am incapable of protecting him from every danger, and incapable of meeting every need - I am abundantly aware of what I am incapable of doing for this new child. This I can't seem to come to grips with. Prenatal depression is my intimate companion this pregnancy, and I can only pray that my fears of unique inadequacy for this task are untrue: that I will be able to care for him, that God will make me a better mother fit for the task, and that his life will be full of happiness in spite of my poverty. Lord, have mercy.

Oh, and because this is a blog about diabetes and pregnancy I will note that yes, I actually do tend towards despairing thoughts about my abilities and the consequences it will have on my child's life when my blood sugar is low. Hooray for the CGM sensor which helps me avoid the worst of it!

Friday, June 3, 2016

Week 11: Maternal-Fetal Specialist

I think in some places it's called a maternal-fetal specialist, and in some places it's called a perinatologist. Anyway, this week, I went to see one.

I am somewhat wary of highly-specialized doctors. They jump into your care mid-stream, they know very little about your history except what's on paper (and there's no guarantee that they've read it), and they really, really, really love tests. So much. It doesn't always matter how invasive or painful it may be for you. They just want to know. It doesn't matter how expensive it is, because they always just figure insurance will pay for it. It also doesn't always matter whether the information it will give you will affect the way you care for yourself. They just want to know. Because...knowledge and information. No matter what. I'm beginning to see why the tree of the "knowledge of good and evil" was even a thing. Some people just want to know, whether anyone needs to and no matter the consequences. I feel like I'm outing myself as an ostrich burying my head in the sand on this one, but perhaps ignorance actually is bliss sometimes?

All that to say, I have found maternal-fetal specialists to be of this sort. I am working on making peace with them, out of necessity, because I think if I asked my OB to let me go without the extra testing, I would probably be rejected as a patient. (This has happened to me when I refused to come in for visits which seemed not to have much purpose, though that time it was an endocrinologist.) It's not that I always reject testing, but sometimes it feels like a non-stress test every other week, rather than once a week, is adequate. Or sometimes an ultrasound isn't necessary, and maybe we'll just see how things play out. I was burned by a maternal-fetal specialist in my first pregnancy when they told me that my son's growth was in the third percentile and I would have to go on bed rest for three weeks. As it turned out, their measurements were simply incorrect and a different clinic gave a different reading. I was also burned by a maternal-fetal specialist in my third pregnancy when they told me that my son might die before he was born, and the only prenatal "treatment" offered for his condition would be abortion.

Therefore, it was with another sigh and some more trepidation that I went to visit the maternal-fetal specialist this week. I explained that I would decline first-trimester genetic testing because it has something of a false positive and false negative rate, and there is no prenatal treatment for the baby if something bad does show up. "But, knowledge..." they said, and I said in reply, "But, knowledge will be more certain and actionable at a later date." I asked him if there was anything I could do for the baby if I found out at this point in the pregnancy rather than later, and he confessed that "stopping" the pregnancy is the only reason one would want to know sooner rather than later.

I was very pleased to see that they seem to trust me completely with my blood sugars. I was surprised that the nurse who assists diabetics during their pregnancies in the new office didn't seem to have a plan for following up with me about my blood sugars other than "as needed." Perfect. The only thing I need for my diabetes is a fortune-teller, and I haven't found a reliable one of those. So it's back to observation of recent patterns plus some intuition and guesswork, and that's going OK for me.

They did tell me two things that left me wondering how much I needed to know them. One was that I have complete placenta previa, but this situation almost always resolves by the third trimester. (I do know one woman for whom it did not, and that's a situation which requires a c-section. Peggy Vincent writes an especially riveting birth story about a case of placenta previa in her book, Chronicle of a Modern Midwife.) I guess I'm glad that I know about it, given the impact that it does have on delivery, but it does sort of feel like I could have gone in for an ultrasound at 28 weeks probably found out that it had resolved entirely if the doctor is so sure that it will resolve...

The other is that I have arterial knotting to the uterus. This is NOT a knot in the umbilical cord, which can cause miscarriage (before 20 weeks) or stillbirth (after 20 weeks). Blood flow to the baby is fine. It's just blood flow to my uterus which is lacking. I wonder how this developed? Was it there in my last pregnancies and they just never mentioned it or didn't notice? Will it go away? What kind of effect will it have on labor and delivery? Will it make my uterus work less efficiently during labor? I have a feeling I'm never going to get answers to these questions. You can try to Google it for me, but Google has turned up with nothing on the topic whatsoever. I have no idea what the relevance of this issue is. The maternal-fetal specialist told me to take some baby aspirin.

Do you like going to the maternal-fetal specialist? Am I missing something here that will make me more grateful for and less wary of their care? Does anyone know about uterine arterial knotting?

Wednesday, June 1, 2016

Week 10: We Got It AGAIN

We got that stupid stomach bug AGAIN. Or maybe it was a different one. It was awful.

I've also finally stumbled on alert settings on the CGM sensor that I think will work. I want a tight enough range that my blood sugars will be in a range that gets me a healthy A1C, but I also don't want it so tight that I'm getting alerts when I don't need to do anything about it, especially since the alerts tend to make me anxious and irritated. So 100-130 is way too tight, for example.

I've found that 80-150 seems to work. If I learn that I'm headed down at 80 mg/dL, I have enough time to grab myself some juice before I get down below 60 mg/dL. Same thing with 150: if I learn that I'm headed up at 150 mg/dL, I can give myself some insulin before I'm up above 180 mg/dL. I do spend a little bit of time ignoring the alerts at those levels. For example, occasionally I'm at 80 mg/dL and that's OK because I'm hanging steady and going to be eating lunch soon. Or I'll be at 150 mg/dL because I just ate a meal and it's going to take some time for my blood sugar to come back down. But I don't find myself tuning out the sensor or finding that I'm being alerted more often than I'd want to know. I'm getting better at staying between the lines, too, by eating small amounts to bring my blood sugar back up and watching my blood sugar on the way down to keep it from going too low.

Originally I didn't want to be bothered by the low blood sugar alerts when I was at 60 mg/dL because I've always tolerated 60 mg/dL as a necessary evil on the way to a healthy A1C. But when I set the alert for 60, I always seemed to end up in the 40s by the time the thing was said and done because it would take me a few minutes to look at the sensor after I heard the alert, and then it would take me a few more minutes to get the juice, and my blood sugar was going down all the time. And I realized that now I have the sensor, I don't HAVE to tolerate 60 as a necessary evil on the way to a healthy A1C! So I bumped it up to 80 mg/dL to accommodate the fact that it just takes me a little while to react when my blood sugar is going down. I still get down below 60 occasionally, but below 50 mg/dL has only happened once in the last month. That's a great feeling after having a handful of 20s, a few dozen 30s, and too many 40s to count in the last few years and pregnancies.

Similarly, I had originally set my high alert to 200, thinking that I didn't want to be bothered with how high my blood sugar was rising every time I ate a meal, but then I realized that most meals didn't bring my blood sugar up that much. My former co-blogger Jenn advised me that meals should only raise my blood sugar by about 30 mg/dL, and that has not been hard to do when eating less total quantity of food and fewer carbs. So if i'm at a good level pre-meal, then I don't have to tolerate 200 even at my peak after the meal. I usually do give some insulin if I get all the way up to 150, even if it's just a tiny bit. It's only the occasional meal that brings me up that high.