Wednesday, August 31, 2016

The Rules Are Not Working

Now that I've had a CGM long enough to observe my blood sugar patterns following certain kinds of meals and certain kinds of exercise or activity levels, I've learned that many of the rules that have been given to me over the years about where my blood sugar should be at what times simply do not work. Or at least, they don't work in an absolute way. Or there are so many exceptions to them that it's not really a rule any more. Or I can't achieve them with the tools currently placed at my disposal. Or something. This is especially true during pregnancy.

The "rules" I'm referring to are threefold:

The first is the rule about waking up with my blood sugar at 60-90. My "fasting" glucose. I put "fasting" in quotes because do you have any idea how often I have to eat during the night to bring my blood sugar up from a low? I have tried to explain to doctors that sometimes my "fasting" glucose is more of a reflection of the blood sugar drama of the night before, and may have as much to do with a correction bolus given at 3:00 in the morning following a midnight snack as it does with the accuracy of my basal rates. And do they know how weird my basal rates get during the night, in an attempt to prevent the midnight low, and how hard it is to get that right in the first place? Furthermore, I spend a good percentage of daytime hours at or below fasting level when I'm pregnant, because I limit my carbohydrate intake to avoid blood sugar swings and because I tend to err on the side of low rather than high. That means that if I'm at 130 mg/dL all night because I can't otherwise figure out how to keep my blood sugar from dipping too low while I'm asleep, baby still gets his fasting blood sugar time and I get a good night's sleep. I assume that the 60-90 mg/dL number comes from non-diabetic women, which I am not, and which I have not been for 23 years. So I am henceforth excusing myself from following this rule.

The second is the rule about postprandial targets (one hour after a meal aim for 130 mg/dL, two hours after a meal aim for 120 mg/dL). During my first pregnancy, I tested my blood sugar 12 times a day in order to monitor all these values, and by the middle of the second trimester, I had determined that a one-hour postprandial of 130 mg/dL was impossible unless I wanted to be at 75 mg/dL and falling two hours later. Which I didn't want to be. So the way I left it is that I would shoot for below 130 two hours later, and I would just eat less frequently and fewer carbohydrates to avoid the BG spikes altogether. However, this has still left me with so many low blood sugars that my endocrinologist didn't like to let me manage my own BGs during pregnancy, I could have drowned in a bathtub when I decided to clean the remains of my thrown up dinner off my skin while my blood sugar was somewhere below 30 mg/dL, and I one time drew blood scratching my husband's hand when he tried to force-feed me Gatorade during a nighttime low BG episode. So I haven't worked out what my new 2-hour postprandial target will be, but I have a feeling it's going to have a lot more to do with where my BG started when I began the meal and how the curve on my sensor screen looks or should look. Otherwise these numbers - which are also probably based on blood sugars for non-diabetic women, a fact which has not been true about me for 23 years - haunt my imagination every time I go to adjust my basal rates or bolus ratios. I've also sometimes wondered whether synthetic insulin works differently enough in a diabetic's body that taking postprandial targets for women who produce insulin naturally simply places an unfair burden on a diabetic using the synthetic stuff.

The third rule is about bolus insulin/basal insulin percentages: that you're supposed to be giving 50% of your insulin by basal rate and 50% by bolus. I mess with my basal rates too often: during and following hard exercise, following a big meal, during sedentary periods on Sundays and travel days and sick days and all the rest. I use a combination of temporary basals and square correction boluses for this, and the numbers are just bound to work out incorrectly when I look at the percentages on my pump. I suppose I could use more temporary basals instead of square correction boluses to fix this problem and increase the percentage of basal rate insulin that it appears I am delivering, but somehow it feels easier to say I need to add 2-3 units over the next 2 hours than to calculate percentages to increase my basal rate (what is it again?). So I am going to do my best to not worry about this one anymore, either.

The only real rule I follow is that I'd like my A1C to be below 7.0 apart from pregnancy, and below 6.5 during it. I think that's manageable, and it leaves me a lot more room to experiment and try things out for a few months, rather than a few days. I'm not sure I should be held to non-pregnancy blood sugar rules on a day-to-day basis, as long as my A1C shows that I'm averaging out somewhere close to normal. Somehow I've been able to have 4 healthy babies and I haven't ever been able to follow the rules precisely. So I'm at least doing enough right to make it work out, right?

But I am looking for a new set of rules. Have you found any blood sugar management rules that just don't work for you? Managing my blood sugars without rules is a bit of a trial. Suggestions you've heard from your care providers, or that you've discovered on your own by tweaking your pump settings and observing CGM trends, are welcome!

Sunday, August 28, 2016

Week 26: It Does and Does Not Get Easier

This week I became overwhelmed by the thought that I would have to do this for another three months. Three months! I have the whole third trimester ahead of me. Traditionally, the third trimester has been the most difficult for me. Random ligament and joint and muscle pains, an inability to get good sleep, the frustrating grind of daily life which does not cease simply because my baby is taking up more and more room in a space that simply cannot go on expanding to accommodate him.

There are a few things that have gotten easier throughout five pregnancies. I know that so many pains the come because of pregnancy and labor likewise pass away. I've got a few tricks up my sleeve for keeping my blood sugars normal and my A1Cs down. I know some things that one should really freak out about (postpartum hemorrhage) and some other things that one really needn't worry about (babies with only one kidney). One is that I do not feel the need to apologize when other people have to accommodate my weakness. When I need someone to open the door a little wider so I can fit through, or when someone needs to slide their chair a little closer to the table so I can squeeze behind, or when someone has to walk a little slower so I can keep up, or when someone has to bend down and pick up something that I dropped because I simply can't get down there anymore. These things do not make me blush with shame. Some may resent me for it, some may appreciate the everyday opportunity to care for another human being, some may mock me, and I may wish that I were at the height of my strength so I could avoid the inconvenience it causes others. But I know that this will pass, that it's not a bad thing for other people to notice and meet the needs of a pregnant woman, and a great number of people become weak at the end of their lives and never recover, requiring compassionate care for months or years until their natural deaths. So I do not feel ashamed of my weakness.

But on the whole, I would not say that having babies really gets any easier. Why is this?

I was one time at a doula training. In a room full of two dozen women dedicated to natural childbirth, only a handful of these women had delivered their babies without an epidural. One woman, in particular, stood out, because she had given birth to nine children at home with a midwife. Nine babies! Nine epidural-free deliveries! She was the subject of much awe. This mother's experience took center stage one afternoon when another would-be doula asked her whether she was still afraid of giving birth, or whether she was just so accustomed to it that it was like no big deal. Chuckling and blushing, she said no. No, she still approaches birth with fear and trembling. It's too different, too important, and too intense to ever treat like it's no big deal. At the time, I couldn't possibly understand this. Hadn't she seen just about everything she could see during a pregnancy and labor so that she would feel absolutely confident in doing it again? Hadn't she experienced such a quantity of pain that no pain could ever again frighten her?

But now that I am enduring my fifth pregnancy and approaching my fifth labor, I realize how what this mother said can be true. I have known pain, and fear of the pain of childbirth doesn't own me. I did, after all, agree to a second, third, fourth, and fifth pregnancy. But it does not mean that I am not still afraid of the pain. Furthermore, I've heard countless women's birth stories and pregnancy tales. I've got my own to add to the bunch. But rather than giving me a sense of security about it, all it means is that I know just how high the stakes are. Sometimes seeing it so many times just tells you how many things have to go right for a woman to end up with a healthy baby at the end, and how important it is to the mother, the father, the doctor, the baby, their friends and family that baby and mother come through it unharmed. That truth gives me some pause and a sense of trepidation in the face of this monumental task.

To put it more simply, a friend one time asked me if it doesn't get easier? I answered, honestly, no. No, it doesn't get easier. You just grow accustomed to, and you stop raging against the fact of, being tired and in pain. I like to think it's humility, not cowardice, that keeps me from facing it without some fear and trembling...

Sunday, August 14, 2016

Week 24: Vacation

We were on vacation last week in the north woods of Wisconsin, which is why I did not post anything. But, since pregnancy has been happily boring lately, there wasn't a lot to say.

During the first few days of the trip I did have another few days of really high highs, similar to the problem I had when my husband and I went away for our anniversary at the end of June. I remembered the lessons of the last episode and increased basal rates rather than bolus ratios. This worked beautifully, though I tweaked the bolus ratios a tiny bit, too, and had to work out a few kinks for a few days in the basal rates.  In fact, I've been adjusting basal rates pretty much since then. I should probably admit that I'm adjusting my basal rates slightly all the time, really. But some adjustments are more dramatic, and that's what happened a couple of weeks ago.

My current basal rate regimen has a moderate rate (0.75 per hour) for the early morning hours, beginning at the early time of 3:00a. This basal rate remains until dinner time, at which point it increases to 1.10 per hour. It drops to 0.45 in the late evening, about bed time, and stays there for the earliest part of the night, until the regular day time rate begins in what seems the middle of the night (3:00a).

I went to visit my doctors this week, too. My OB is - somewhat surprisingly - a little concerned about my weight gain. I gained 6 pounds this month, bringing me to 21 pounds of weight gain and exceeding the normal pace of weight gain throughout pregnancy. I blamed it on vacation. Since the recommended level of weight gain is 25-35 pounds, she's worried I'll exceed 35 in the next 15 weeks of pregnancy. I get it. I've written about weight gain before, especially the benefits of not gaining too much, and I can certainly imagine that excess weight gain for mom could lead to an LGA baby. I've written about this before. But I honestly don't know what more I can do. I'm eating as little as it feels is humanly possible during pregnancy, and will continue to do so, but I've also got blood sugars to maintain.

So she wants to make sure I am walking every day. I, um, kind of am, but I don't actually leave the house very often. So I was trying to explain to her how infrequently I actually sit down during the day, what with taking care of four boys and all, making sure that the crayons are staying on the paper rather than the wall and hanging diapers and helping a pre-schooler figure out which bin is the right one for the Matchbox cars and turning on videos and turning on videos and turning off videos and coming downstairs to see if anyone is bleeding and so forth. I'm not sure she entirely understood, and she just repeated her question about walking for at least 30 minutes every day. I'm also not sure she entirely understood that leaving the house when your blood sugar is hanging out between 70 and 80, with three children who don't understand traffic signs, to go out on a walk in 90 degree heat, is actually probably not very healthy. She did tell me that I was the first person she'd ever known with more than three male children, so perhaps that accounts for the lack of comprehension about my daily life. I'm just going to keep answering in the affirmative, because I am certain that I spend at least 30 minutes walking around my house during the day, and probably more like 2 hours. I might be fudging it a little, but I think it's close enough to the truth to say it honestly!

I also visited the maternal-fetal specialist this week, and he said he was perfectly happy with baby's growth. Baby is right in the 50th percentile, moving like a champ, no problems to speak of. And the placenta previa is gone. Didn't I always say that was probably a problem no one ever needed to know about? Knowledge is not always power. Just ask Eve.