Tuesday, November 8, 2011

Tell Me Sweet Little Lies

Today's Prompt: 3 Truths and 1 Lie. Tell us three truths about your condition. Now tell us 1 lie. Do you think we'll be able to tell the difference?

I'm going to take a slightly different take on the prompt today and discuss my health condition in relation to pregnancy. I meet women online everyday who have been told something scary or inaccurate about becoming pregnant with pre-existing diabetes. Their doctors throw around frightening terms like "congenital malformations" and "stillborn." Their mothers tell them they shouldn't "risk it." That's just not the reality for most women and it hasn't been the reality for me. I'd like to set the record straight. Here are my 3 truths and 1 lie.

Women with type 1 diabetes can have perfectly healthy pregnancies with minimal interventions.

A woman with diabetes can need as much as 300-400% of their normal insulin intake per day during pregnancy or as much as a whole unit for every gram of carbohydrate.

Type 1 and gestational diabetes are essentially the same thing during a pregnancy.

The baby's blood sugar is generally about 80% of the value of the mother's during pregnancy and newborns have lower target ranges than adults.

Do you know which one isn't true? Let's take a closer look at each statement.

Women with type 1 diabetes can have perfectly healthy pregnancies with minimal interventions. True! Women with Type 1 all over the world - of every size, shape, race, and age - have perfectly healthy pregnancies everyday. I've been really grateful to have the resources of the Oh! Baby!!! group on TuDiabetes, the Positive Diabetic Pregnancies Yahoo group, and the book Balancing Pregnancy and Pre-Existing Diabetes to see the truth in this. Some women deliver naturally, some have VBACs and VBA2Cs, while others (like me) schedule caesarians. Some women have higher A1cs (7s and 8s), while others keep the recommended range of below 6.5% during pregnancy. Some women have fertility issues, while others don't. Some have children with perfect health, and others don't. Really very similar to the basic concerns and risks of the general population.

This isn't a melodramatic Julia Roberts movie from the 1980s. It's the 21st century. What stands in the way of type 1s having kids (should they want them) is a lot of out-of-date misinformation and fear-mongering - often from their parents, grandparents, physicians, and friends. If you manage your numbers as closely as you can (which most women are incredibly motivated to do during pregnancy), your risks of problems are essentially EQUAL to anyone else's. The scary truth we have to accept is that, yes, sustained poor control (sustained highs, not testing BG, A1c's over 9) in the first trimester can disrupt the development of the baby's spine, brain, and heart during a period when many women might not yet know they are pregnant - which is why women with T1D are encouraged to be in tight control before trying to conceive.

If you manage the first trimester to the best of your ability, your biggest concern as a type 1 is that the baby may put on weight in your final trimester if high BGs continue to fuel too much glucose to the baby. A large baby could have trouble passing through the birth canal and may need to come out early via induction or c-section to avoid birth injuries. And sometimes the condition of a diabetic woman's placenta results in the need for an early delivery. Another reason for tight control is that your glucose passes through the placenta, but your insulin does not (molecules are too large), so the baby's pancreas is sometimes having to take up the slack, which can also cause lows for the baby in the first 12 hrs after birth as the baby's pancreas adjusts to a less "sweet" environment.

Most type 1 pregnancies do include aggressive monitoring from your medical team as a safety precaution against these concerns, with lots of extra ultrasounds (I had 12 with Sweetie) and non-stress tests and visits to measure the baby's weight and organ development, but the end result is peace of mind and the healthiest outcome possible.

I am SICK of people - mainly older family members and older acquaintances - perpetuating myth and fear about my health condition and my family planning choices. I feel constantly on the defense of my choice to have biological children. It's my right and it's my diabetes management. I guarantee I know more about this than you do, so calm down. I am offended that people think my efforts at good health indicate that there were "problems."

A woman with diabetes can need as much as 300-400% of their normal insulin intake per day during pregnancy or as much as a whole unit for every gram of carbohydrate. True! As my perinatalogist told me once, "Your placenta doesn't know you have diabetes. It's just doing its job." And one of its jobs in the last half of the pregnancy (20ish weeks onward) is to produce HPL (human placental lactogen). In a woman without diabetes, this hormone causes insulin resistance in the mother so that plenty of nutrients are siphoned off to the baby in case the mother is malnourished. It's evolutionarily advantageous for our species!

In a woman with diabetes, however, it means that you're pouring insulin in by the buckets to try to counteract the effects of this hormone. Some women need as much as a unit of insulin for every 1, 2, or 3g of carb coming in. With Sweetie, I went from 50u per day pre-pregnancy to over 150u. I'd have meal doses that would exceed the max dosage allowed by the manufacturer of my insulin pump. My insulin to carb ratio was down to 1:3. That means I was taking 5u for a single slice of bread!

It's challenging to avoid highs when your body seems so resistant to staying in range, but it just takes lots of persistent checking and correcting. As my doctor reminded me, "Feed the baby and don't be afraid to take enough insulin to cover it."

I've had people assume that diabetes goes into remission during pregnancy. Ha. More like goes into hyperdrive.

Type 1 and gestational diabetes are essentially the same thing during a pregnancy. False! There are some distinct differences. Notably, Gestational diabetes usually shows up after week 20 (so no concerns about that first trimester development or first trimester lows) and these women generally do not suffer from low blood sugars. They do not suffer the volatility of type 1 blood sugar management. Most never need to take insulin. GD comes on in the last months of pregnancy as a response to those hormonal changes I mentioned above. It's still unknown why it affects some women and not others (and unfortunately many women who develop GD during a pregnancy have an increased risk of developing Type 2 diabetes later in life). Women with GD can often control the insulin resistance with diet, exercise, and sometimes also with insulin. According to my endo, the big difference in how doctors have to treat this condition is that you can aggressively increase their insulin with almost no risk of lows. Their bodies can still self-regulate to a degree.

In a type 1 pregnancy, however, it's a balancing act to keep the standard deviation and range as tight as possible, with the A1c as low as possible, while avoiding the severe lows that we experience doing it all manually (artificially) without a pancreas. While lows do not particularly affect the baby, no fetus needs its host mama to be unconscious or seizing from a debilitating low. In many (but not all) women, excessive lows are extremely common during the first trimester. Others of us - the weirdos - experience insulin resistance from the get-go and enjoy both extremes. Guess which one I am. I don't experience first trimester lows that others talk about, though occasionally I rebound down into the 40s from aggressively treating the highs I see.

Anyway, this distinct difference between pre-existing D and GD has me going round and round with my perinatalogist. He insists that my BG never be over 120. Both my endocrinologist and Dr. Steve Edelman (the well-known endocrinologist affiliated with TCOYD) rolled their eyes at my perinatalogist's suggestion and called it unreasonable when I relayed it to them. My insulin is in my system for 4 hours after I take it. If it peaked so fast that my BG never crossed 120 at the 1 hour post-meal mark, I'd be "on the floor" (as my endo said) at the 3 hour mark.

So if your doctor is treating you the way he or she would treat someone with GD, educate yourself enough that you can be your own advocate (as I do) or find a new doc! My CDE's suggestion is that I just lie to the man and tell him my blood sugar is 100 mg/dL all of the time. I'm seriously debating doing this. Yup, 100. All the time.

The baby's blood sugar is generally about 80% of the value of the mother's during pregnancy and newborns have lower target ranges than an adult. True. Well, according to my perinatalogist. I haven't been able to confirm it in an online source yet. That certainly makes me feel better when I'm over 140 though.

And yes, the normal range for a newborn, though currently debated in some medical circles, is between 40 (or some say 45) and 60. When Sweetie was born, my first question was to ask about her blood glucose level. It was 54 and she was declared perfectly normal. If the blood sugar is lower than that at birth from Baby's pancreas overcompensating for Mommy's high glucose, Baby is generally given glucose water or encouraged to nurse until the BG stabilizes (within first 12hrs of life). From that point on, your diabetes is no longer their body's concern. Unless they swallow one of your test strips, of course.

If you want to have kids, there are many options available to you. Don't discount the old-fashioned way as one of them.

Additional Resources on Pregnancy and Type 1 Diabetes:
JDRF: Type 1 Diabetes and Pregnancy
Diabetic Mommy
Diabetes Forecast Magazine (ADA): A Guide to Pregnancy with Diabetes

This post was written as part of NHBPM - 30 health posts in 30 days: http://bit.ly/vU0g9J.


  1. Woo Hoo! I got them all right! I knew No. 3 was the lie. :) And as you already know, you are an inspiration. One day, you will be my go-to for things like this. And even though I already knew you were preggers, CONGRATS all over again! :)

  2. Wow, Melissa! Really inspiring! I am curious about breastfeeding though.....when you breastfed the baby, would the insulin you were taking transfer to the baby through the milk? Would like to read a similar list for after baby is born. Since a lot of family members have diabetes, I have researched quite a bit. But there is still so much I don't know!

    Kudos to you! You are doing a great job spreading awareness. I really enjoy reading your blogs (although, don't always comment).


  3. You mean I'm not the only one who lies to the Perinatologist? (good to know..you'd think they'd have more of a clue just how different T1 & GD are!) Great post, I enjoy reading accounts of folks who have been through it & had healthy,beautiful babies.(despite the doom & gloom predictions)

  4. Divya,

    Thanks for the idea. I'd love to write about breastfeeding, but I think I will save that for the spring when I'm at it again!

    Breastfeeding offers many benefits to the baby, of course, but the one that made me adamant about doing it with Sweetie was the decreased risk of her developing type 1 or type 2 diabetes! It's perfectly safe for the woman with diabetes, but causes lowered blood sugars so we often have to snack before or during a session.

    Insulin through the milk is not a concern (once it's in my bloodstream, it's working much like your own insulin, and besides, you or I or an infant could even ingest insulin with no change in our bodies). OBs, endos, and lactation consults all agree that a woman's blood sugar level does not affect the milk either, but there is one endo who has written on the topic who encourages women to "pump and dump" if their BG is over 150. Her belief is that the milk changes and becomes less filling (sweeter) and can lead to irritable babies. I never saw that and I breastfed Sweetie whether my BG was 40 or 400. Never saw a change in her intake or mood.

    In some women with type 2 diabetes and/or a history of PCOS, low milk supply can be an issue, but again, it didn't apply to me. It's hard to say which lactation issues are simply normal for that woman or related in some way to her health conditions.

  5. Glad to see that you're spreading that education! Ladies, if you want more info on just gestational diabetes, I highly recommend poking around: http://egestationaldiabetes.com (the recipes are written by a nutritionist). But I've seen some other good ones, another is: gestationaldiabetesrecipes.com. Any-whoz...yes, they are treated differently!