5 Month Endo Appointment

I had my regularly scheduled monthly appointment with the endo this morning and the verdict was positive. Here are a couple of takeaways:

The ketones are gone! Now that my BGs are starting to even back out (thank you, insulin resistance), I am no longer bottoming out overnight. This has cured my ketone issue and, perhaps more importantly, means that I can forgo the 2AM snack. Yay!

My A1c is even more awesome this month — 5.2. How is that even possible? I am suspicious, but the doctor is happy with it, so I’ll take it.

I have occasional slight swelling in my ankles now, but nothing to be concerned about … yet. My blood pressure is still good.
After a week of annoyingly high post-meal BG spikes, I adjusted my bolus rate yesterday. My endo is kind of weird about me making my own changes (something we disagree on), but he accepted it and we are leaving the rate alone for a week or two to see what happens.

He thinks my basals might still be a smidge too high, because I tend to spike too high an hour after a meal (160 range), but then drop to 90 or 80 at the two hour mark. This problem might sort of itself out as my insulin resistance grows, though, so we’ll keep an eye on it. Just for comparison purposes, and to show you that everyone’s diabetes is different, I just read that Kerri is now on a 1:6 insulin-to-carb ratio as she struggles with the later stages of pregnancy. In comparison, I was on a 1:6 ratio before I got pregnant (thanks again, insulin resistance!), and am now at 1:5.

My endo had lunch with the local Dexcom rep last week, and they are apparently more willing to do a trial of their CGM product now. I tried to get a trial a couple of months ago, but the rep in the corporate office would not do it. I had given up hope. I called the local Dexcom educator today and she is sending me a trial package this afternoon. She says it’s so easy that she can walk me through the set-up on the phone. So I might be sporting a Dexcom soon!

I picked the doctor’s brain a little about Metformin for Type 1s. I have been reading that more and more Type 1s with insulin resistance are using it to help with the weight gain and increased appetite that insulin can cause (See this post from Amy over at Diabetes Mine. I even read recently that they are using it more and more in the second and third trimester with pregnant Type 1s. We agreed that it is not really necessary for me right now because my insulin needs are just starting to increase past my pre-pregnancy levels and because I am not gaining too much weight (actually, I am gaining less than is expected.) But he seemed like he would consider using it during the third trimester or after the pregnancy depending on how things are going. I am happy that he was receptive.

It is snowing like crazy here again today. We are expecting another 10 inches or so before the end of the day on Thursday. Isn’t it time for spring yet?

Tomorrow morning we are off to the High Risk OB for the 20 week ultrasound and, hopefully, we will find out if this little munchkin is a boy or a girl. I can hardly wait!

Food for Thought

I had my much-anticipated appointment with the dietitian today and it was definitely worthwhile.

As I have mentioned in previous posts, my diet has basically fallen apart over the course of this pregnancy. Between treating the ever-present lows, soothing my nauseated stomach, and catering to my temperamental digestive system, I have thrown all of my diabetes-friendly diet techniques out the window in favor of foods that are comforting, easy to digest, and quick to raise a 24 mg/dL blood glucose. Out the window went my fiber-rich whole grains, fruits, and vegetables. In their place, I am living on juice boxes, white pasta, white bread, and gummy candies (my newest craving.)

But I am into the fifth month now, and that placenta must finally be doing it’s thing because the spikes after my meals are higher and more stubborn. And the lows, while still severe, are fewer and farther between.

The dietitian asked me to keep a food log for three days and to bring it along to the appointment. I was embarrassed with what I had to show her. Besides my carb-laden meals, I also documented an alarming number of trips to the vending machine for things like donuts and Rice Krispies treats. Yikes.

Luckily, she was one of the “good dietitians” — you know, the ones who realize that we live in the real world with real world temptation and real world schedules. She did not try to beat me up over my bad choices, and instead offered a few suggestions for how I could do better.

She put together a pregnancy meal plan based on the old-fashioned exchange system  and it is very reasonable. But the suggestions for better choices were probably the best take away. For example, I am struggling with a ravenous appetite in the mornings. It starts when I wake up and doesn’t die until after lunch. Mid-morning is when I spend most of my time at the vending machine … hello donuts.

Instead of donuts, she suggested a sandwich. Or, if I just can’t give up the donuts, half of a sandwich and half of the package of donuts. That is a pretty basic idea, and  I probably could have come up with it myself, but it sure helps to have the reassurance from an “expert.” Plus, it really helps that she did not try to tell me that I absolutely could not have the donuts. Because the craving center in my brain has been on fire lately and there is no telling what I will feel like I “need” to devour next.

We also talked about my ketone issues. Like the High Risk OB, she thinks I can get away with moving the 2AM snack to before bed, but she disagrees with him about the protein. She thinks I need the protein to keep my energy level up overnight to prevent going into “starvation mode.” I tend to think she is right, and proteins are starting to sound better now, so I think I will take her advice. She suggested string cheese and a box of juice for my pre-bed snack because it is quick and easy and has the requisite number of protein and carb exchanges. I think I will give it  a try.

Sidenote: My Endo thinks that moving the 2AM snack to before bed is a recipe for disaster. I have not been able to test this change yet, because my BGs are bottoming out every night at 3AM, so I’ve had to eat then anyway. Hopefully I can get him to change my basal rate and then I can give this snack time change a try. Just goes to show you that even the experts disagree on these things!

Another idea she had was with my boluses. In the past, I have used the dual wave bolus to offset my slow digestion, but recently, I haven’t needed it. She suggested that I experiment with the square wave instead of the dual wave when I eat a higher-fat meal. She said to start with a duration of an hour or so and see how it goes. I have noticed in the last couple of weeks that my digestion is really slowing down again … another of the side effects documented in the book … so I think this could be really helpful, too.

All in all, I am really glad that I finally found a dietitian. She made some good suggestions that I think I can use to improve my diet and she gave me the tools I need to make better decisions. Perhaps most importantly, though, she has given me the information I need to at least partially relieve my diet-based anxiety. Whew!

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!

Ketones!

I wrote recently that my Endo instructed me to eat a snack around 2 or 3 in the morning in an attempt to eliminate the ketones I have been observing first thing in the morning.

I was not happy about this early morning chore, but I am just trying to kep my eye on the prize: a healthy baby. I’ve been eating the snack all week and so far my ketones in the morning have dropped to negative or trace, so the snack seems to be working.

But then I got to wondering … what is the big deal with a couple of ketones, anyway? Just because I am burning a little fat overnight instead of sugar, as long as my BGs are good, what’s the problem? I mean, I started this journey in the overweight category, so it is not like I am wasting away to nothing here. There is plenty of nourishment in the form of fat to be had for my growing baby.

So I started researching. Naturally, Google was my first stop. I found surprisingly little about ketones short of a couple of very generic explanations of what ketones are and why we spill them. This article by Joslin, in particular, has a good basic explanation.

As a refresher, when the body burns fat for fuel, ketones are produced and “spilled” in the urine. For us diabetics, this usually happens when we do not have enough insulin in our systems to convert the sugar in our blood to energy. Instead we burn fat and spill both the ketones and the sugar in our urine.

This was not news to me. And because my blood sugars were good, the ketones were apparently due to a shortage of energy stores. That is, my baby was using up all of my excess energy stores and then some. As a result, my body was burning fat to keep up.

What I really wanted to know, though, was how these ketones are affecting my baby? Sadly, there just does not seem to be much out there. The best I could find is this account from a  mother who had gestational diabetes during pregnancy. She calls herself Kmom, and the piece is well-written and seems to be well-researched.

She references two studies that showed a correlation between increased ketones and decreased IQ in the baby. However, she also points to further studies that reviewed the first two and were not able to confirm their findings. She pulls an excellent quote from the Journal of American College of Nutrition, which I requote here:

Even if the ketonuria in GDM were associated with lower IQ in offspring, it seems more likely that the overall poorer diabetic control resulting in ketonemia is more responsible for the lower IQ than an effect of ketone bodies per se…In any case, there is no consistent epidemiologic link between maternal ketonuria per se and impaired fetal growth and development.

That information eases my mind a bit, because I know that I am generally under good diabetic control. But I am still a little concerned.

Kmom says, “To prevent ketones in general, you should be eating every 3-4 hours in pregnancy, so that your body has a constant supply of energy and never needs to access the fat stores.”

Her reasoning seems sound and fits with the rules I remember learning back in my ADA diet days as a kid. And it made me realize that I am probably not eating often enough. In fact, after lunch at noon I often don’t eat until dinner around 7 pm or so. Last night before dinner I tested for ketones and found that I was spilling LARGE ketones. Not just trace, small, or even medium amounts, but LARGE. I was frantic. How long has this been going on??

So my new resolution is to eat at least every four hours and to try to include protein and carbs in every meal or snack.

This is not going to be easy. I have already upped my caloric intake thanks to an extra mini-breakfast as soon as I wake up and that 2 am snack, so I am simply not hungry most of the time. My stomach feels full pretty much constantly.

I am also a little aggravated that none of my doctors have bothered to explain all of this to me. When I was just in my 6th week or so, I asked my Endo for a referral to a dietician and he hedged, stating that the local dietitians would not be very helpful for someone who has had diabetes as long as I have. But I knew that my diet was less than healthy and I wanted some tips for ensuring that my baby was receiving adequate nutrition and energy.

Now that I know about this whole ketone thing, I am even more concerned. What other nutritional requirements am I missing? I see the high-risk OB this week. Maybe he knows a dietician who can help me get my head around eating right for my baby.

Fourth Month Endo Appointment

This morning I had an appointment with my Endocrinologist. Now that I’ve been doing this monthly thing for a while, I am starting to know what to expect, and that helps with the nervousness, but the clammy palms and queasy stomach never go away completely. What if that one high blood sugar spike this week hurt my baby? I know it is not really a reasonable thought, but I am pregnant, so I am allowed to be unreasonable, right? I blame it on the hormones.

Actually, the visit went pretty well and, as usual, helped ease my mind a bit. My A1C is still 5.3 (Amazing) and my weight is up about a pound since last month. My blood pressure was still awesome, too (120/75).

On the down side, my overnight visits from the ketone fairy are coming too often. Last week I had two mornings with small ketones, two mornings with trace ketones and one morning with moderate ketones. I think it was that one moderate day that set off the warning buzzers. The doctor instructed me to eat a snack around 2 am. Crap. I just got my bladder and BGs adjusted so that I can sleep through the night, and now I have to get up to eat. To eat! Who would’ve thought?? Oh well, I guess this is just a prep course for the sleepless night that are on the horizon, huh?

We also drew blood to check my thyroid. I have been absolutely freezing lately, and I don’t think it’s just because of the freezing temperatures and blowing snow. The Endo says it is normal for the thyroid level to change over the course of a pregnancy, and my dosage was a smidge low last time, so we will check it out.

We also talked about the high risk OB. The Endo says the local guy that my regular OB recommends is great, and that they work well together, so I guess I will give it a go. He was not 100% clear when I asked how the communication will work (i.e.; how will they stay on the same page given that they will both be making changes to my therapy and who is “in charge” of my diabetes), which leaves me a little uneasy, but I guess we will just have to let that one work itself out. So today on my lunch I made my first real appointment with the high risk guy. It’s next week.

On the agenda for this weekend: shovelling out from the huge snowstorm we’ve been receiving ALL week, and investigating snow blowers. This fall, we bought two new snow shovels in anticipation of this winter, but mine sits unused in the garage and it has been snowing like mad since Christmas. By the end of the day when I get home from work, I am just so exhausted and achy that when my husband says he’ll take care of the driveway, I let him. It takes him two hours, and by the time he gets in and warms up, I am nearly asleep. I feel like we hardly see each other anymore! So I am counting our pennies to see if we can’t squeeze a snow blower out of this month’s paychecks.

That’s all from here today. It has been another whirlwind week of testing, treating, and visiting doctors.  Only 25 weeks to go!

Real (Pregnant) People Sick

I’m still struggling with nausea and the remnants of that stupid H1N1 flu shot.

Yesterday I called the OB to ask if there is anything else we can do besides the Zofran. It seems that my love affair with that little pill was very short-lived. It turns out the only other thing we can do is IV fluids … which I would have to receive at the ER. Yuck. So I am forcing the fluids and testing for ketones. Luckily I’ve only had negative to trace amounts so far.

I read Lee Ann’s post over at the Butter Compartment this morning about guilt and I could really relate. My husband had planned to stop at Walmart last night to pick up some things for his lunch this week. I asked if he would pick up some Ketostix, Pedialyte popsicles, and chicken broth. He went to three stores, never found the popsicles, and forgot his lunch items altogether. I am so glad to have him. What would I do without his help at a time like this? But it is definitely hard to let him accept some of my burden. The guilt is indescribable. I have been building a post about this topic in my mind for some time now, but I want to give it the time it deserves.

That’s all from here for now. It is taking all of my energy just to get out of bed this morning.