Sunday, July 31, 2016

Week 22: When Pregnancy Is Boring

I am just going to note that some weeks, especially in the second trimester, can be pretty boring. And I don't mind that one bit! I am accustomed now to the idea of having another little person in the house in a few months, which always takes about the first trimester plus a few more weeks. None of the testing has revealed any significant problems with baby's health. I remember the pain of childbirth and the fatigue of recovery, but because they are not imminent, I'm not feeling it very viscerally. I worry a little bit about preterm labor, because it's hard not to think about it at all, but I'm also pretty fortunate that it's never happened to me. My blood sugars are pretty good and pretty stable, after a rough, early second-trimester ride that I've experienced before. And the counseling. It's really helped with the depression that I've truly been feeling for a while now.

So that's it. There's just not a lot to say right now, and I'm pretty happy about that.

Thursday, July 28, 2016

NFP Awareness Week!

I don't have a lot to say about NFP, mostly because, in spite of giving it a good go, we haven't found a method that can reliably help us prevent conception in the 12-18 months after a baby is born. It worked before we had a baby, but then we got the continuous mucus thing. It might work again after a few years' worth of continuous mucus observations, but we've had babies instead. That is, perhaps, its own post.

So for us to be faithful to the Church's teaching on integral sexuality, it's either have another baby (I am now 22 weeks pregnant), or avoid relations entirely for months (which is why this baby and the Scholar will be the furthest apart we've ever had at a whopping 2.5 years). That is probably also its own post that I haven't been able to bring myself to write, for reasons which have also had me seeing a counselor. Perhaps soon...

But let me tell you that there is someone who is writing very intelligently about this topic, and if you are interested to learn more about NFP or if you are struggling with it and you didn't expect to, you should check out Simcha Fisher. She was the first person I saw writing about grave reasons to prevent pregnancy that included mental health and poverty and didn't necessarily include an imminent threat to a woman's health. She was also the first person I saw who wrote honestly about what it was like to be poor and practicing NFP and relying on government programs for help. She writes about NFP with a lovely sense of humor. She was the very first one to open up the conversation about how hard it can be after the Catholic community had spent many years discovering its benefitsLots of other people have added their two cents to that conversation, because there's lots that can be said.

But I have found that Simcha Fisher is the one who has most reliably moved the conversation about NFP in the Catholic Church in America forward, and she is honestly striving to practice obedience and fidelity to the Church's teaching on this point. And she has particularly moved that conversation forward during this NFP Awareness Week with several excellent posts. Consider today's:

"Hello, elephant in the room! I see you, and I'm ready to talk about you.
 "The NFP community is full of large families like mine. What the heck? How can we say that NFP is effective, and then show up with ten kids in tow? If a told you I had a really great system for losing weight, but I weighed 400 pounds, wouldn’t you snicker and look elsewhere for advice?"

This post is so good I'm going to quote it twice.
"NFP is easier to mess up than artificial birth control. There, I said it. If couples with normal fertility want to use NFP to avoid getting pregnant, they have to stay on their toes and be committed, and there’s no such thing as 'set it and forget it.' If you make a mistake in charting, or if you know you’re probably fertile and decide to have sex anyway, you can get pregnant when you really didn’t want to. And there are occasional head-scratchers, where you follow all the rules to avoid, and you get pregnant anyway. It does happen.
"Of course, these things happen to couples using contraception, too. Raise your hand if you know someone who conceived despite using condoms, or the Pill, or an IUD, or even some combination, or someone who trusts the Pill but skipped a day because life is hectic. Heck, I know couples who conceived even after a tubal or a vasectomy. Life is so life-y."
She also has an interview with America magazine, published this week, because lots of people recognize that she's an expert on NFP. She does speaking tours, for example, and she's written a book about it. Here's my favorite question and answer from that interview:
"How is N.F.P. similar to and different from artificial birth control?
"It’s similar in that it can be used to avoid pregnancy; but it’s different in the same way that eating a sensible diet is different from sticking your finger down your throat! Not a pretty picture, but you see the point.
"The thing about N.F.P. is that it’s just information. It doesn’t do anything to your body or to sex. It simply gives us the choice to work with our bodies as they already are. Every form of contraception adds something artificial to our bodies, or removes or alters something; and every form of contraception changes the character of sexual union—and sex is so strange and so beautiful and so powerful, it’s something that you really don’t want to mess around with.
"What you want is important, but how you achieve it is equally important. Another way to look at it: Say I desperately want to inherit my grandmother’s jewels. I could either smother the old bat with a pillow and forge her name on her will, or I could care for her until she dies, and then enjoy my inheritance. Same goal, same desire, radically different approach!"
She's also giving away a fertility monitor that she has found helps her space pregnancies this week, with the help of several donors. It's an expensive contraption and might help some couples find their available, infertile days during times when they need to prevent pregnancy. I still think that a discussion of a more total abstinence is necessary for some couples - not just 7-10 days during a menstrual cycle, but for many months when the need to prevent is real and the risks of conception while using NFP simply can't be tolerated - but her work has created the space for women and men and families and the Church to have that conversation, and for that I'm very grateful. Check it out!

Sunday, July 24, 2016

Week 21: Managing Fatigue

The more babies I have, the more I understand my mother, and this includes beginning to understand why she always seemed so tired. Practically the only crime in my family was waking up someone else who was sleeping, and that someone often happened to be my mother. She was an ER doctor, and her shifts would keep her awake at times when most people would sleep, so she needed quiet time to rest at home. When we went on family hikes, it seemed like we were always waiting for her to catch up with the rest of us. I have a distinct memory, as a teenager, of being kind of annoyed with her for walking so slowly when we got stuck on an unexpectedly long trail in the mountains of Argentina. When we visited my grandparents for Christmas vacation, it baffled me that no one else wanted to spend 20 minutes putting their snow clothes on to work up a sweat moving snow around in the yard before coming back inside, spending another 20 minutes removing said clothing to hang and dry. How could the adults just sit around playing bridge and reading all day long?

But of course, as is so often the case, I totally get it now that I have my own kids. And I totally understand why my own children have no idea what I am going through and why I seem so crazy tired all the time. I actually had the experience of hiking with my husband a few weeks ago, and I was almost appalled at how slow I was. I immediately recognized what my mother went through more than 15 years ago when we dragged her through the mountains of Argentina for nearly 10 miles. (I also felt an appropriate amount of shame for assuming my mother was...what? Lazy? How could I ever have thought an ER doctor with four children was lazy?).

I have found, this pregnancy, that I am more fatigued than during others. Taking care of the kids takes it out of me, so that's one part, but by no means unique to this pregnancy. Eating less takes it out of me too, but that is also not unique to this pregnancy. The summer heat takes it out of me, so maybe that's it. Or perhaps I'm just getting a little worn-out at the ripe age of 32.

Unfortunately, in addition to being tired a lot this time around, I am not very good at resting. When I do manage to sit down, the incessant call of chores, the nagging anxiety of things left undone, my husband's high expectations, and the never-ending needs and desires of my children don't truly let me rest. When I was pregnant with my very first son, my OB had to tell me to tell my boss that I was starting my maternity leave "early"...when I was 41 weeks pregnant. I tried to resume a regimen of walking for exercise, to train for a half marathon!, when I was 3 weeks postpartum. As a result, my postpartum bleeding went on far longer than it should have (9-10 weeks), because I refused to rest.

This has also been a persistent theme that has come up in counseling in at least half the sessions I've been to. It came up the night my first son was born, when I knew that I physically couldn't lift myself out of bed and needed to rest but felt so guilty for asking someone else to help. When I recalled this memory in a counseling session, my counselor asked me if I could perceive where Our Lord might have been with us on that night. At first I scoffed, and said, no, that was just the problem. He wasn't there. No one was there to to help. Wasn't that obvious? But then she asked me to sit with the memory for just a little while longer, and suddenly, he was there. And do you know where he showed up? He was speaking to the baby, whispering words of comfort to my son. (When I told my seven-year-old about this later, he said, excitedly, "Yeah, and maybe my crying was the only way I had of talking back to him!" That made me cry all over again for a very different reason.) Then my counselor asked me, "And what is he telling you there in your hospital room?" I don't know, he's not talking to me. I just told you, he's talking to the baby. Then, with almost a dismissive brush of his hand..."To rest. He's telling me to lie down and rest."

So I'm working to find appropriate ways and times to rest. Leaving the kids to fend for themselves a bit more is part of it. Simply telling the children that I'm too tired (and letting them live with that fact, even if they don't understand it yet!) is another part of it. Giving the kids verbal instructions more than physical help is another part of it. Often it's not running toward the crying and screaming right away, but waiting to see how the boys handle it on their own (usually pretty well!). When the kids ask to do something special or out of the ordinary, I try to get them involved in thinking through the problems of the new activity. As Christians, we reserve Sunday for rest, and my husband has always been particularly good about finding ways to keep the Sabbath in the modern world. And sometimes it's just a matter of saying a prayer, going to my bedroom and shutting the door for 15-20 minutes...

Sunday, July 17, 2016

Week 20: Humming Right Along

I had another ultrasound this week. The 20-week is such a big moment for most women in their pregnancies, but given how many I've already had, it was almost a non-event! The placenta previa still present but could still move. Baby looks great. At least we didn't find any missing kidneys this time around.

I am still tweaking my insulin rates. In fact, I've done so much tweaking from three weeks ago that I think I may almost be back to my original "units used per day," but they are delivered at different times than before. My bolus ratio for breakfast is significantly increased. My overnight basal rates have been adjusted to accommodate both lows I was having early in the night and highs I was having in the middle of the night. My daytime basal rate is a little higher, but my late morning and late evening rates are so low as to be almost non-existent. I sure do appreciate the Dexcom CGM for helping me to pinpoint the need for rate changes more precisely.

I also found an endocrinologist this week! He was very pleasant, unlike my last endocrinologist. He let his suggestions be just that - suggestions - rather than "commands" or "instructions." They were helpful. But he was also very respectful of all the observations I've made throughout five pregnancies and 23 years of diabetes, and it was such a relief. I will not be seeing him again until the last month of pregnancy, but of course, he told me I could call if I had any questions. A real gem! A1C 6.2. A little higher than my previous pregnancy records (5.4, I think, some time during the second trimester of my third pregnancy when I had a number of very serious lows), but much fewer lows. Quality of life is improved; hopefully baby will continue to grow at a normal pace even with a slightly higher A1C.

My regular OB (not the perinatologist) told me she thought that twice a week biophysical profile testing during the last few weeks of pregnancy was not necessary. "We know," she said, "that additional BPP testing at the end of pregnancy does not reduce stillbirth." Babies can still die in utero with twice a week testing for a mom and baby at term. I will wait to broach the subject of postponing induction from 39 to 40 weeks until we both see how the baby's growth and health progress throughout the third trimester. His size is just right for the time being, and hopefully we can keep it that way.

So it was a rather boring week full of doctor's appointments, but no news is good news!

Sunday, July 10, 2016

Week 19: Restoring Tranquility

When I say that I need to "restore tranquility" to my blood sugars, do you kind of understand what I mean? Avoiding having to give correction boluses, which always seem to bring me too low and never fast enough? And then having to guess at what to eat to bring it back up, and thinking that I've waited long enough and eating a little more, but discovering that I perhaps needed to wait just a bit longer and the desired rise in my blood sugar would have made itself manifest? And then my blood sugar is high again and I have to give another correction bolus? And then a meal time arrives and I know I need to eat but I'm not sure where I am in the food/correction bolus pattern I was dealing with for the last three hours? And I wonder why I don't have an eating disorder yet because I'm so anxious about what this new food/insulin bolus combination will do and I experience terror about something as simple as lunch? Then lather, rinse, repeat for not hours, but days?

So last week, early in the week, my husband and I went on a two-day vacation to celebrate our ten-year anniversary. We went hiking on both days, we slept in, and we had a very fancy, very indulgent dinner one night. It's a recipe for blood sugar weirdness. All the kinks probably could have been ironed out within a day or so, except that I think there were some pregnancy-related changes afoot. As a result, it's taken me almost a full 10 days to identify the source of the problem and correct it. Ah, now I remember why I had sworn off traveling in previous pregnancies!

I first did nothing, because I didn't know what to do and we'd been traveling and I didn't want to make any changes for my normal life that were based on not-normal-life-activities. So then after a couple days, and realizing that the wackiness was not going away, I tried adjusting bolus ratios. I increased them (meaning, 1 unit:8 carbs instead of 1:10). The first day I only adjusted one meal-time bolus ratio, but the next day I adjusted the other two, also. I tried to be diligent and wait for three full days before making any additional changes, but my panic was growing because the problem was not resolving. I didn't need three days of a new bolus ratio to tell me that. The basal rate was increasingly suspect. So I brought bolus ratios back to their normal level, and dramatically increased basal rates. My basal rates are so weird that I have never had an endocrinologist or certified diabetes educator fail to raise an eyebrow when I tell them what they are. But the sensor is really helping me keep track of where they should be, and they are only getting weirder.

The changes I had to make to restore blood sugar tranquility were basically widening the extremes of basal rates that I already seem to live with. Before this latest round of changes, my low rates were about 0.35 and the higher daytime rates were about 0.70. But the changes I finally ended up with are as follows. An extremely low basal for the late evening (starting at 11p) and early morning, return to daytime levels smack dab in the middle of the night (2a), increase slightly around dawn and breakfast (5:30a), extremely low again following breakfast (8a to 11a), and then a pretty high basal from lunch through to bed time.

The basal rate I call "extremely low" is only 0.15 per hour. I occupy such territory for about 6 hours of the day. My normal daytime basal is so much higher (1.0 per hour) that I am still tinkering with it a little bit, mostly bringing it down bit by bit. But for now, it is keeping me a little on the low side of stable. That works out OK during pregnancy, because I spend a lot of time in the kitchen and I always have food with me, and now I have the sensor to tell me when I really need to pay attention. It's a little harder to live on the low side of stable than the high side of stable, but I've always supposed this to be healthier for baby, so I'm just going to suffer through it for now. I'm hopeful that, over the next week, the sensor will help me get it even tighter than I ever could with finger sticks.

Sunday, July 3, 2016

Week 18: Up, Down, and All Around

This week was probably the first time in this pregnancy when I felt like there was something just hugely off about my insulin regimen. But honestly, I couldn't say whether a new, moderately stable regimen would be required, or whether it will prove to be a passing problem. This is because my husband and I went on a 10-year anniversary trip and my days were very different than usual. We went hiking and slept in, for example. I'm making a few tweaks here and there, but trying to avoid huge changes until I have a few more days to observe.

As an example of some of the blood sugar weirdness, after returning from our trip, I had three overnight lows where my blood sugar simply tanked. I had previously been struggling with overnight lows between 1a and 4a. I had gotten them basically under control by the middle of the first trimester, with the help of the CGM. These new lows  occurred at the same time, but were very extreme, and evaded all my standard prevention techniques. I am only moderately ashamed to say that I woke up in the middle of the night and ate an entire pint of ice cream on one of those nights. On another night, I ate two small 12g-carbohydrate cookies and an entire cup (er, approximately, because I never actually measure these things out) of boiled potatoes before I went to sleep, and that seemed to prevent the worst of it.

Another difficulty I've mentioned reared its odd-shaped head again: a rise in my blood sugar that seems somehow related to the meal, but begins much longer after the meal than you'd expect (1.5-2 hours), and is not associated with a high-fat meal. I have been told by multiple diabetes educators that this is probably due to a high fat meal like pizza or Chinese food, but this is never the case for me. Sometimes the meal was a big one, usually moderate in carbohydrate content (40g), and very infrequently something out of the ordinary. This postprandial rise happens in such a way that I have zero ideas about why, because it's very irregular. A few nights after dinner here, once after lunch there, and then it goes away for a few weeks. I'm sure that it was occurring before I had the sensor too, but I have only been able to observe it clearly in the last few months. Before I probably would have attributed it to a 2-hour postprandial high associated with poor carb counting.

The last example is this that my meals - especially breakfast - almost universally seemed to require a higher bolus ratio. It's possible but doubtful that it's a problem of carb counting because I control carbs tightly during pregnancy to avoid really big swings (and because I know I will end up consuming the carbs I missed at meal time to treat a low blood sugar some time later). It's possible that it's related to the hormone progesterone that helps to maintain pregnancy except that I don't think progesterone varies so much day-to-day. I think it's most likely that it's related to metabolic processes like the burning of fat and glycogen which are either so messed up because I've been diabetic so long or that are just difficult to predict because they are sensitive to so many changeable factors (caloric intake, hormones including those related to stress, and baby happenings). And also, I'm not sure I have any idea how to fix any of these problems, should one or the other prove to be the source of the symptom.

I have also experienced a few episodes of low blood pressure. Not exactly the problem that you expect during pregnancy, right? I am struggling with how to treat for it, because it requires an increased intake of salt. An increased intake of salt means an increased intake of food; an increased intake of food usually means an increased weight; an increased weight means an increased amounts of insulin to deliver; increased amounts of insulin to deliver give me hives because if I get it wrong my blood sugar is so, so wrong. Do I sound like I'm developing an eating disorder? I feel like I sound like I'm developing an eating disorder. Anyone know of salty (high sodium or high potassium) foods that don't mess with blood sugars too much? Maybe peanuts?

By the by, in case you're worried about that eating disorder joke, which I maybe shouldn't joke about at all because I think its sadly common among diabetics, I will note that my weight gain has been perfectly normal this pregnancy. Twelve pounds at 17 weeks, and that's about half the recommended weight gain for pregnant women by the end of their pregnancies. I've tried really hard to keep weight gain moderate because of my personal experience that modest weight gain prevents serious insulin resistance. But I know its a temptation, and if I had any indication that my eating habits were harming myself or baby in any way, I would bite the diabetes bullet and just give the extra insulin.