The Amniocentesis

We arrived early for the 9AM appointment. Sitting in the waiting room, I was excited and nervous, giddy even. My stomach was tying itself in knots. Our car was loaded up with our hospital bags and the car seat just in case.

Earlier in the week, when I explained the plan to colleagues and friends, they were alarmed. “You’re having an amnio? Isn’t that risky?”

I repeatedly explained what the doctor told me. Yes, an amniocentesis carries a small risk of miscarriage. That’s why they use them sparingly in the first trimester to detect genetic and chromosomal disorders. But at 37 weeks, technically full term, “miscarriage” is really nothing more than an early delivery, so the risk of fetal death is just about nill. Even if I were to go into labor and deliver the baby as a result of the amnio, the chances that he would not survive were next to nothing.

In the exam room, the ultrasound technician lubed up my belly and started running the wand over it. We looked at Baby NoName’s limbs and kidneys. She measured his leg bone, his belly, his head. She estimated his weight at six pounds, four ounces, right where he should be for 37 weeks. She looked for big “pockets” of amniotic fluid and estimated the amount of fluid surrounding the baby. She tried in vain to get us a picture of his face, but he had “dropped” so far into my pelvis, that she could not get his whole face, just a profile. “Oh well, we’ll see his face in person soon enough,” I said with an anxious laugh.

The doctor came in and asked if we had questions. Not really. The procedure is pretty straight-forward. They use a needle to extract amniotic fluid from the uterus so that they can determine whether or not the baby’s lungs are fully developed. I asked how long it would be until we had the results. “We’ll call you with the results by 4PM tonight. But I can usually tell just by looking at the fluid. It should be cloudy.” He warned me that the needle is really long. They’re kind of one-size-fits-all, so they need to be pretty long to accommodate moms with a bigger layer of fat. I looked away because I didn’t want to see the needle. I don’t have a problem sticking myself with a needle, but I’m not so comfortable when someone else is wielding the syringe.

He turned out the lights so that he could focus on the image on the ultrasound screen. He joked, “I have to turn out the lights so that I can see better.” I focused on the screen, too. That long needle was kind of freaking me out.

He inserted the needle and I prepared for the sting. But it didn’t hurt at all. Actually, the insertion felt a lot like an insulin shot. After that, I could feel the needle in my belly, but there was no pain. It just felt kind of weird. The whole thing was over in just a couple of minutes. The nurse turned on the lights. “Looks good and cloudy,” he said.

Next he did an internal exam to check my cervix. I was not dilated at all. So assuming that the test results confirmed his “cloudy” diagnosis, Cervidil would be our next step.

In the meantime, we headed over to the fetal evaluation department at the hospital for an hour-long non-stress test. They wanted to monitor the baby and my uterus for normal activity, heart rate, and contractions just to make sure that the procedure did not cause me to go into labor. Baby NoName performed his characteristic turns, kicks, and flips, and, an hour later, the nurse declared the test a success. We were free to go.

The next four or five hours were the hardest part. Waiting for that phone call was excruciating. Right on cue, though, at 4PM, the office manager called from the OB’s office. The results were in and Baby NoName was ready. “Come to Labor and Delivery tomorrow at 5PM. Eat before you come. In fact, eat something good, because they won’t let you eat once you’re admitted,” she advised.

Wow. This is it.

Finally, an Update

First, let me thank the couple of readers I have who have hung on with me through my most recent hiatus. Things are getting kind of crazy in my little world now and blogging has definitely taken a back seat. Without further adieu, here is an update on what’s going on and how things are going.

I am officially 36 weeks pregnant today. Baby NoName is still passing his non stress tests with flying colors. I was scheduled for one yesterday, Memorial Day, and the Fetal Eval Department was closed, so I had to go to Labor and Delivery for the appointment. It was kind of nice to get a sort of dry run for finding L&D and where to park again. The maternity ward was pretty quiet. I’m hoping for the same environment on the big day.

Luckily, when we arrived at the reception desk, I recognized the L&D nurse from the Fetal Eval Department. She fills in there from time to time. Along with Baby NoName’s regular kicks and heart beats, she also recorded two contractions. She says this is normal at 36 weeks. They are just “practice” contractions. They were so weak that I didn’t even realize that they were contractions. They felt kind of like Baby NoName was stretching inside my uterus and just pushing his little walls to their limits. If I have more than six in an hour, I should call my high risk OB.

We officially have a plan for the birth now. Seeing as both baby and I are healthy, we have planned a tentative induction for 37 weeks. That’s next week! I think that if I had resisted and tried to wait this out until closer to 40 weeks, my doctor would have agreed, but the truth is I am tired and grumpy. The testing and prodding and doctor appointments are really starting to get to me. I’m not sure how much longer I can take this routine. Couple that with an increased risk of fetal death in the last month for type 1 diabetic moms, and I am more than ready to get this show on the road.

So the plan is that we have an amniocentesis scheduled for next Monday. The amnio is used to check the maturity of Baby NoName’s lungs. Apparently, the only real risk with an amnio is contractions. When you get an elective amnio in the earlier stages of pregnancy this is more of a risk because it can lead to miscarriage, but at this late stage, the risk is much less because the baby is much more likely to survive if you go into early labor. Basically, contractions at this stage are OK because we are more or less ready to deliver the baby anyway.

If the amnio shows healthy, fully-mature lungs, then we are ready for the induction. If my cervix is not yet dilated, I will be admitted to Labor and Delivery the same evening for Cervidil. This is a prostaglandin gel that they apply to the cervix to soften and thin it. Then they will start the Pitocin through an IV in the morning. Pitocin is an artificial version of oxytocin, the hormone that my body would make naturally during labor to cause contractions.

If I am already starting to dilate on my own, then we will just wait until the next morning, skip the Cervidil, and start with the Pitocin.

I am a little freaked out about the whole induction process. I’m reading that Cervidil can cause painful but non-progressive contractions. And Pitocin can cause contractions to be more painful, but ultimately not work well enough to progress the labor. I have heard horror stories of inductions that last three agonizing and exhausting days and then result in c-sections anyway. It seems that sometimes induction works and sometimes it doesn’t. I expressed my concerns to my doctor who told me that these scenarios are all possible, but that there is no way to know if induction will work until we try it.

He is strongly in favor of induction over a straight c-section given that Baby NoName and I don’t have any of the standard diabetic complications. It is hard for me to believe, but my eyes, my kidneys, my blood pressure, baby’s heart, baby’s weight, and baby’s spine are all perfect. I guess all of those late-night BG checks and the never-ending appointments are finally paying off.

So I made a deal with him. We will try induction for one day (24 hours if we have to use the Cervidil the night before.) If I am not progressing and am not at least semi-comfortable, we will move forward with the c-section rather than waiting another day or two as is his standard procedure.

In the end, I think it just comes down to me freaking out about the whole labor and delivery thing. No matter what route he takes to get out here, it is not going to be a walk in the park,. So ultimately, it doesn’t really matter which avenue he chooses as long as he is healthy.

A Day in the Life of a Diabetic Mom-to-Be

In response to Karen’s great Diabetes Blog Week idea, and also in response to Saffy’s question about how I fit in all of the pregnancy-stuff around work, here is my contribution. The topic is “A Day in the life . . . with diabetes.”

5:45 AM: Can’t wait any longer. Have to pee. I’m dancing in front of the toilet while I fight with the vial of ketone strips. Finally.

6:00 AM: My husband stumbles into the bedroom headed for the shower. Seeing as I have been up at all hours of the night for months now, he usually sleeps on the couch. One of us might as well get a little sleep, right? “Are you done in bathroom?” he asks. I mumble “yes” from under my pile of pillows. I can’t believe it’s time to get up already.

6:30 AM: My husband leaves for work. I do a test: 97. I crank up the laptop and upload my BG readings out of my pump, then print them for my doctor.

7:00 AM: Into the shower. A frantic hour of readying myself for the day ensues: shower, hair, teeth, breakfast, packed lunch.

8:15 AM: Another test: 98. I’m late. I throw everything into my laptop bag and rush out the door. Along the way, I discuss this BG reading with my inner self: “It’s only been an hour since breakfast. Will I be low at the two-hour mark? Maybe not … I did have peanut butter with breakfast. I stuff my meter in my coat pocket and pull out of the garage.

9:05 AM: I’m late for my non-stress test. I roll into the parking garage and make a mad dash for the fetal evaluation center. They hook me up to the monitors, and Baby NoName sleeps. We give him a little jiggle, I drink a glass of ice water, and we use the “alarm clock” to try to wake him up. Finally he startles and starts dancing in there. The peaks and valleys are recorded on the red and white graph paper. A half hour later, the nurse is satisfied. She permits me to move on to the next appointment of the day.

9:45 AM: I arrive on the other side of the hospital at my High-risk OB’s office. I am making good time. Sometimes the non-stress test takes an hour. The office manager smiles and calls me by name from behind the sign-in desk.  I sign in, pee in a cup, and weigh myself. It turns out that the Ultrasound Tech is ready for me already. I do a quick test while I’m sitting on the exam table. The Ultrasound Tech has to wait for me and I feel guilty. 156. Damn peanut butter. I ignore the “insulin on board” recommendation of my pump and dial in a .7 unit correction. Let the ultrasound begin.

Baby NoName is doing great, although the tech discovers for the first time that the umbilical cord is a two-vessel cord, not a three-vessel cord as we originally thought. The doctor assures me that it is nothing to be concerned about, but I make a mental note to google the difference later.

I realize that I left my BG readings on the kitchen counter … or somewhere. Pregnancy brain again. I will have to fax them in tomorrow.

10:45 AM: I finally arrive at work. Another test: 93. Much better. On to e-mails and meeting preparations. I sneak in a quick glance at a couple of DOC blogs between projects. I’m starving, so I eat my mid-morning snack.

12:30 PM: Lunch break. BG is 115. I head out to my car for a thirty-minute cat-nap. I am absolutely exhausted.

1:00 PM: Back in the office, I get back to work, and nosh on my packed lunch. Sometimes it’s one of those “healthy” frozen dinners. Today it’s a ham and swiss sandwich and an apple. Due to digestive woes, low blood sugars, and cravings, my pregnancy diet contains a lot more carbs than my non-pregnancy diet. BG is 62, a little low, so I take a little less insulin than the pump suggests.

4:30 PM: The office is starting to clear out. BG is 55. I peel an orange and start to munch on it while I work on one of many never-ending projects. For whatever reason, my BGs have been plummeting in the evenings, so the 4:30 snack has become a normal part of my pregnancy routine.

6:30 PM: One final test before I hit the road: 83. Afraid that my sugar might be dropping, I grab a handful of M&Ms from the office candy dish. I pack up and leave because the “late shift” support rep is locking up, even though I don’t have all of my hours in for the day. This means tomorrow will be an extra long day.

7:30 PM: I am at home, collapsed on the couch. My husband and I are trying to think of something to eat for dinner. All I want to do is sleep, but my BG is low AGAIN. We settle on grilled cheese sandwiches. I am delighted because he is doing the cooking AND the cleaning up. We watch a little TV while we eat and catch up.

9:00 PM: I can hardly hold my eyes open. I get ready for bed, do a test, take my pills, and double-check my stash of juice boxes and gum drops on the nightstand. Satisfied that I have enough sugar to make it through the night, I fall into bed. Because I under-bolused for dinner in fear of another low, I am at 180 now. I take a small correction bolus and settle in under my pile of pillows.

11:00 PM: My husband is on his way to bed. He wakes me up to test. 105. The number barely registers before I roll over and fall back asleep.

2:00 AM: I have to pee. Again. And my hip is killing me. While I’m up, I test. 65. Eyes closed, I slurp down a juice box and then drop it on the floor in the general vicinity of the trash can. Close enough.

4:00 AM: Again with the peeing and the testing. Luckily, my BG is in the “safe range.”

6:00 AM: My husband stumbles into the bedroom … another day begins!

There are a bunch of other D-bloggers participating in Diabetes Blog Week, too. Check out the list on Karen’s blog here.

24 weeks

On Monday I made the bi-weekly trip to “the big city” for my appointment with the high-risk OB.

I am starting to get the hang of the whole thing. I’ve not gotten lost for a couple of weeks now, and I’m finally starting to remember which level of the parking garage to park on for the quickest access to the office.

Except for the excruciating hip pain I told you about yesterday, the appointment went according to plan. According to the nurse, my blood pressure was “beautiful” and the heart rate was “perfect.”

The doctor observed that my weight is good, and when I commented that I am always starving, he said, “Don’t starve, eat!” I don’t think he knows what he’s saying … he may have unleashed a monster. Some days I feel like I could eat everything in the refrigerator! He reminded me for a second time that my insulin needs will probably triple over the course of this whole journey, and that the increase is totally normal and it’s not because I am doing anything wrong. It’s just a consequence of those pesky pregnancy hormones and the placenta that makes them.

He asked if I was having any other problems aside from the hip pain. I mentioned the swollen feeling in my pelvis and he explained that this is also normal. He says the ligaments are stretching to make room for my huge uterus. As an aside, I mentioned that my heartburn seems to be making an occasional appearance again, but that this was the least of my concerns given the fact that the hip pain is keeping me up at night. We tabled the heartburn discussion for now.

The appointment ended with the now standard hug and a smile. In two weeks, we are scheduled for another ultrasound.

This past weekend we also did a little baby shopping with my husband’s family. Our baby gear collection now includes a pack and play and an umbrella stroller, and finally the little guy has a couple of t-shirts and a sleeper. We also looked at cribs and bedding, but we didn’t purchase any. We are so indecisive! A special thanks goes out to the in-laws for their generosity this weekend! We had a nice time, and are really happy with the gear.

16 Weeks

Today I met with the High-Risk Ob for my 16 week check-up. His office is in a larger city nearby and while I am typically pretty good when it comes to directions, this city really seems to give me a hard time. People who live there admit that the street signs are pretty much worthless and that you really need to “just know” where you are going. So it is no surprise that I got lost on my way back to work. I’m not 100% sure where I lost my way, but goodness knows I’ll have plenty more opportunities to figure it out over the course of the next 5 months.

The good news is that everything checked out well. The heart rate was strong (oh, that sound!) and my blood pressure was good. We talked about my blood sugars and he suggested a few tweaks to my basal rates to help with these crazy lows.

I asked him about the ketones, and he was also concerned about them. He advised me to eat at least 15-30 grams of carb every three to four hours. He said protein was not really necessary at this point and that if it does not sounds good to me, I do not have to force it. In fact, he said that when I needed the protein, my body would self-regulate and protein-rich foods would start to sound and taste good again.

He also said that eating a small portion of carb more often would help keep my sugar from dropping into that crazy low range so often. Finally, he suggested that I try more complex carbs and I mentioned that I have had to avoid my typical fiber-rich carbs, but that I have had good luck with pasta.

He recommended Dreamfields pasta. He says it will not cause as drastic of a spike in my sugar, but does not have the fiber that my digestive system cannot tolerate right now. However, I see on their Website that Dreamfields has 5 grams of fiber per serving. That sounds like too much for my delicate digestive system these days. Have you tried Dreamfields? Did you have digestive side effects?

He also started the ball rolling for me to talk with a nutritionist. I am really happy about this. I have to admit that I am overwhelmed by all of these new eating challenges lately and I am concerned that my baby might not be getting all of the nutrients he or she needs.

My next appointment is in two weeks and we will review blood sugars again then. In four weeks I will see him again for an ultrasound and we will hopefully find out if this little one is a “he” or a “she.” Wow!

14 weeks

I had my 14 week checkup with the OB on Friday. No ultrasounds today, but they did check the heart rate with a nifty little machine that looks like a mini ultrasound. It transmits sound but not pictures.

Oh, that heartbeat sound … I don’t even know how to describe the relief and joy it brings me. A sort of wubb, wubb, wubb, with a fluid-like noise in the background … it has to be the most reassuring sound in the world. Every time I hear it, I breathe a huge sigh of relief and get this huge, goofy grin on my face. That’s our baby in there!

I was concerned because the heart rate is down from the last visit, but the nurse assured me that it was totally normal for the rate to fluctuate from day-to-day. So I am trying to let that worry go.

My weight is pretty much the same as it has been throughout the pregnancy, excepting the period of the worst morning sickness when I actually lost weight. At best, I am up 1 or 2 pounds from my pre-pregnancy weight. I keep forgetting to ask the doctor if this is acceptable. According to the BMI chart, I was in the overweight category pre-pregnancy (thank you, insulin resistance … and cookies), so all of the pregnancy charts I’ve found say that this is a normal weight gain for the first trimester. Still, being the irrational worrier that I am, I could use a little reassurance from the expert. I need to remember to ask this question next time!

I met with the doctor, too. We talked about switching to the high-risk OB, an idea I am starting to warm to, but I still want to double-check with my Endo first.

Then we talked a little about Type one Diabetes. Her husband works in sales for Accu-chek, so I showed her my much-loved Accu-chek Softclix lancing device and raved about it. I don’t even use an Accu-chek meter anymore, but I am still hanging on to this “poker.”

We also talked a little about CGMs. She was familiar with them, but did not know a whole lot. From what she had heard, all of the calibrating and the inconsistent readings sure sounded like a pain. I tend to agree with her, but I’m still thinking about the Dexcom. I would normally just make do with my finger-sticks, but this pregnancy has left me with some remarkably wild shifts in my BGs (sometimes in as little as one hour) and it sure would be nice to spot those trends before the 24 mg/dL hits.

We also discussed the results of the first genetic test, the nuchal translucency test. The test showed good results for our baby. The chances of Down Syndrome are one in 8,000. This is really good because the normal chances for a baby being born to a mother my age are one in 410. So the test shows that the odds that our baby has Downs are even less than they are in most babies born to mothers who are my age. It’s nice to have that little bit of reassurance.

The rest of this genetic test checked for other chromosomal abnormalities, but the lab reported that they cannot determine the results of this test conclusively in an insulin-dependent diabetic. An interesting tidbit that the high-risk OB probably would have already known.

On my way out I talked a little to the phlebotomist (the one who draws your blood.) We talked about how hard it was to draw my blood the last time and she commented that it is important to keep your BGs as steady as possible before a blood draw. A low BG causes the body to sort of go into shock which causes your veins to collapse. I can’t find any research backing this up, but it does seem to make sense.

All-in-all, the visit was pleasant. I scheduled an appointment to have blood drawn for the next genetic test. My next task is to schedule my first real appointment with the high-risk OB, but I won’t do that until after I talk to my Endo.

Consult with the High-Risk OB

Last week I had an appointment with the high-risk OB. My regular OB practice sent me for a consult. Originally, my OB told me that he felt comfortable taking care of my pregnancy, unless anything unusual happened, at which point he would refer me to the local high-risk OB. But then, the message got mixed up. You see, my OB works as part of a larger practice, and despite my attempts to see only my doctor, I managed to see three different doctors and a nurse practitioner over the course of my first few months. And each of those practitioners had their own opinions about the best strategy for a healthy Type 1 pregnancy.  It was confusing at best.

As a result of all of this confusion, I ended up at the high-risk office for a consultation. The high risk OB works alone, without partners. There are obvious advantages to this set up, but also disadvantages. For example, when we went for my consultation, the doctor was delayed because a C-section he was scheduled to perform was bumped from the OR. When there is only one doctor in the practice, there is no partner to share the load. On the plus side, there are fewer conflicting opinions and more consistency. But there are fewer ideas and fewer minds working on my “problem.”  There just isn’t an easy answer, is there?

At the appointment, he was practically dumbfounded by my record A1C (5.3 — Yay!!!), but he did pour over my BGs and suggest a few tweaks to my basal rates. I liked that he seemed open to my opinions, and to  a  more collaborative approach to managing my sugars. He said that I probably know more than him about the disease given my 27 years of living with it. He might be right, but it sure is nice to have a professional opinion every now and then!

On the down side, it seems that he wants to manage my endocrine issues throughout the pregnancy. This is not necessarily a bad thing. Afterall, he did make good suggestions. But I am just now getting this relationship with my Endo worked out. And he does have my A1C down to record lows. I hate to abandon that relationship.

My OB from the regular practice called the next day to say he thinks that the high-risk OB should manage my entire pregnancy. He feels that I would get the best care that way. I can still have some of my run-of-the-mill appointments at my regular OB’s office so that I don’t have to spend so much time on the road (the high-risk OB is in a neighboring, larger city), but the high-risk guy will be in charge and he will deliver my baby.

But there is this nagging feeling in the back of my mind that maybe this is not the best solution. Sigh. I don’t know what to do. I just don’t want to screw this up. My baby is depending on me.

I have an appointment with my Endo in early January, so I expect to ask him  for his advice. I think he may be a bit miffed that he is sort of  being forced out of the equation by the high-risk guy. But maybe my Endo knows another high-risk guy who works more closely with the Endo. As a third alternative, I asked my mom to ask her Endo for advice. Her Endo recommends a hospital system in another surrounding city, but it is even further away from home. However, that hospital seems to be “the place” for pregnant diabetics in the area. And it has had that status for quite some time. In fact, it is the same place that my mom delivered me 31 years ago.

So what should have been a settling appointment has left me with new questions and few answers. Maybe I just need to relax a little and go with the flow? What would you do?