With Diabetes in Mind

This post shares my thoughts and a review of my second trimester of pregnancy with type 1 diabetes. This is my own personal experience except where a source is cited. If you are pregnant or planning to become pregnant, please only take diabetes management guidance from your personal diabetes healthcare team, but feel free to let this help inform what questions you may ask your care team and how you advocate for yourself in your medical care.

Symptoms

I didn’t realize how bad I felt during my first trimester until second trimester hit, and when I say “bad,” I mainly mean fatigue, nausea, and loss of appetite which is still much better than some pregnant women have it during the first trimester and even after. I think my symptoms gradually worsened over the weeks (weeks 6-10 were the worst!) that I didn’t quite realize the extent of it until about week 13/14 when I seemed to snap out of it, and I was like wow, I feel like myself again, have energy, and want to eat.

In terms of food, I’ve had aversions to meat here and there, especially beef, and the smell of seafood. However, my aversion to the smell of seafood has not been as severe as the first trimester when just the smell made me want to gag. I haven’t had any super strong cravings, but certain foods just sound good all the time. I’ve craved “kid food” like Mac and cheese, string cheese, peanut butter and jelly sandwiches, pickles, goldfish, and peanut butter pretzel nuggets. I was definitely wanting saltier foods, but the later half of second trimester I started wanting sweeter foods, especially breakfast carbs, like muffins, donuts, French toast, pancakes, etc.

One thing that has surprised me throughout pregnancy so far is how few headaches I’ve had compared to pre-pregnancy. I used to have fairly frequent headaches and I think I’ve had 1 since being pregnant. I have had better blood sugar control which could be why, but I also attribute the change in hormones as I think my pre-pregnancy headaches were hormone related. I’ll be interested to see what happens with headaches postpartum.

Diabetes Management

Now for the hot topic of, “how have your blood sugars been?” The reason I say it like that is because that is the first question I get asked at every OB, endocrinologist, sonogram appointment I’ve had. My response each time is doing my best! Early second trimester, there weren’t really any changes from the first trimester, but I did transition into less low blood sugars which was nice. One of the first things I noticed as far as changes was that I started needing more than the 15 minutes of time for a pre-bolus for insulin to start working. I started needing 20-30 minutes, even a little longer especially in the morning. I found and continue to find that drinking at least 8oz of water first thing in the morning before consuming anything seems to help with the insulin resistance.

“Around 16 weeks, insulin resistance begins to increase, and total daily insulin doses increase linearly ∼5% per week through week 36. This usually results in a doubling of daily insulin dose compared with the pre-pregnancy requirement. The insulin requirement levels off toward the end of the third trimester with placental aging.” [1]

This statement comes from the American Diabetes Association’s Standards of Care so based on this, I started paying extra close attention to my insulin needs at week 16, but week 18 was my first “jump” in increasing basal and insulin to carb ratios with more frequent adjustments occurring since then. With such increases in insulin amount, it’s hard not to get caught up in “wow, this is a lot of insulin” and the fear of hypoglycemia in taking so much insulin. Similar to removing the emotion in addressing blood sugar as I discussed in my first trimester blog post, I have to remove the emotion behind amounts of insulin and think that I’m just providing what my body needs. If I didn’t have diabetes, my pancreas would be increasing its insulin output to match what my body needs to maintain glucose homeostasis. There is no “good” or “bad” when it comes to the amount of insulin used. It’s just simply giving your body what it needs. I started my second trimester using about 18 units a day in basal insulin with carb to insulin ratios of 7-8 grams per unit of insulin (depending on time of day) and ended second trimester using about 30 units a day in basal insulin with carb to insulin ratios of 4.5-6 grams per unit of insulin (depending on time of day). With the increase in insulin usage, my Omnipods which last for 72 hours are now only lasting me about 48 hours as it holds a max of 200 units of insulin and my total daily insulin usage has been 80-100 units.

At my endocrinologist check up at 23 weeks pregnant my Hemoglobin A1C was 5.6% and very shocking to hear! My Dexcom Clarity report was showing an estimated A1C of 6.3% so the 5.6% was very surprising.

“Due to increased red blood cell turnover, A1C is slightly lower during pregnancy in people with and without diabetes. Ideally, the A1C target in pregnancy is <6% (42 mmol/mol) if this can be achieved without significant hypoglycemia, but the target may be relaxed to <7% (53 mmol/mol) if necessary to prevent hypoglycemia.“ [1]

Physiological increases in red blood cell turnover and alteration in red blood cell kinetics are what cause the lower A1C during pregnancy. I did some research on what physiological changes are actually occurring in the blood cells to cause this as wanted to do my traditional “nerd alert” explanation of why this occurs. However, there is A LOT going on to try and explain it that it would take up this entire blog post so short answer here…the lifespan of a red blood cell is roughly 2-3 months. That is why a hemoglobin A1C provides a 2-3 month average blood sugar. An increased red blood cell turnover rate means the red blood cells now have a shorter lifespan giving them less time to become glycated (attachment of sugar) and new “clean” red blood cells are entered into circulation more often. If you want to learn more about hemoglobin A1C, check out a previous blog post I wrote discussing Hemoglobin A1C and time in range.

I’ve always heard how women with type 1 diabetes have maintained an A1C below 6% in pregnancy and have wondered how in the world they could do that, but now I know that pregnancy itself contributes to a lower A1C. Not to discredit the incredible amount of work and discipline it takes to maintain such a tight glucose range in pregnancy, but for anyone with type 1 diabetes who is planning for pregnancy and is intimidated by a low A1C goal, just know that pregnancy itself will help you get there!

“As A1C represents an integrated measure of glucose, it may not fully capture postprandial hyperglycemia, which drives macrosomia (large birth weight). Thus, although A1C may be useful, it should be used as a secondary measure of glycemic outcomes in pregnancy, after blood glucose monitoring.” [1]

Due to the changes that occur with A1C during pregnancy, blood glucose monitoring takes more importance and precendence as an indicator of overall blood sugar management which then brings up the topic of blood glucose targets and time in range (TIR). Here are the recommended target ranges during pregnancy from the American Diabetes Association’s Standards of Care:

• Target range 63–140 mg/dL (3.5–7.8 mmol/L): TIR, goal >70% [1]
• Time below range (<63 mg/dL [3.5 mmol/L]), goal <4% [1]
• Time below range (<54 mg/dL [3.0 mmol/L]), goal <1% [1]
• Time above range (>140 mg/dL [7.8 mmol/L]), goal <25% [1]

I recently decided to change the target range upper threshold in my Dexcom Clarity app to be 140 instead of the defaulted 180 so that I could have a better idea of the percent of time my blood sugars are in the 63-140 range.

The most challenging thing for blood sugar management this trimester was a combination of increased insulin resistance and lack of absorption and irritation from the Omnipod sites. I started having excessive irritation around the cannula insertion point where it would feel sore, itch, and swell up which in turn affected speed and efficiency of insulin absorption. I would bolus and an hour later my blood sugar still hadn’t budged when that 1 hour mark is peak insulin active time. I had one night where in the end I had bolused a total of 20 units in corrections, but my blood sugar was flatlined in the 160s. It just seemed like I couldn’t get enough insulin no matter what I did. It was also frustrating that since I’ve been using more insulin, my meal time boluses are larger amounts, and since a bolus can only be delivered from an Omnipod in 0.05 increments, it would take 10 minutes to get my full meal time bolus. One week I actually pulled out my historic minimed paradigm pump that I still had and wore that for a few days to take a break from the Omnipod. I also still had an insulin pen on hand and used that for some meal time boluses which seemed to work much better from an absorption and timing stand point.

After discussing all this with my endocrinologist, I’m trying a new management approach of using my Omnipod for basal insulin, corrections, and small boluses, and then I have a Fiasp insulin pen to use for larger meal time boluses instead of using my pump. This combination seems to be working well so far as it stretches my Omnipod a bit longer and I seem to be getting better insulin absorption through an injection. Fiasp is considered a rapid acting insulin and should start working quicker than a fast acting insulin like Humalog which I use in my pump so this has cut down on the time I have to wait between bolusing and eating. With my pump I am needing to bolus 30-40 minutes in advance, but with Fiasp I can take it about 10 minutes before I eat for the same effect. We’ll see how this approach continues to work as I just started it in my second to last week of my second trimester.

Pregnancy Care

This systematic review from 2005 states that those with insulin dependent diabetes have quadrupled risk for preeclampsia [3], but the reference for this statistic references 3 studies from 2000, 1990, and 1998. Not to discredit the accuracy of those studies, but the diabetic population in the 90’s is much different than the diabetic population today when we think of the advancements in technology with insulin pumps and continuous glucose monitors in addition to pharmaceutical advancements in various types of insulins and diabetic medications. The overall risk factors in a 90’s diabetic populations may not translate well to today’s population. A study from 2014 which is another systematic review of research done on low-dose aspirin to prevent adverse outcomes from preeclampsia questions this exact statement as it states that very little new evidence has been accrued since a large number of studies in the 1990s [4]. While this study supports that low-dose aspirin does reduce preeclampsia risk in those at a higher risk for preeclampsia, it may only be about a 10% reduced risk, but there was no evidence for adverse outcomes from taking aspirin [4] so in a sense it’s like what’s the harm in taking it. These studies also mention some specific risk factors that increase the risk for preeclampsia in the presence of insulin dependent diabetes which are nulliparity, advanced maternal age, previous preeclampsia, hypertension, a longer duration of diabetes, microalbuminuria, nephropathy, retinopathy, poor glycemic control [2]. The only risk factor I have in this list is the longer duration of diabetes. Overall, I feel this research shows that medical providers need to make sure they are using up to date evidence that applies to the person they are treating, and treatment should be individualized per patient and not automatically generalized into a “high risk” bucket based on only 1 piece of the person’s medical picture as I’m not sure I really need to be taking aspirin. It’s always important to be an advocate for yourself in your medical care!

Final Thoughts

As I go into the third trimester and home stretch, I’m thankful for good health, having a fairly “normal” pregnancy thus far, and for a loving and supportive spouse to do this with me (special shoutout to Chris!). I also think of James 1:17, “Every good and perfect gift is from above, coming down from the father of heavenly lights, who does not change like shifting shadows.” Through the everyday changes with pregnancy and life as we prepare to welcome baby L, we have a steadfast Father who is blessing us with a good and perfect gift.

References

1. Nuha A. ElSayed, Grazia Aleppo, Vanita R. Aroda, Raveendhara R. Bannuru, Florence M. Brown, Dennis Bruemmer, Billy S. Collins, Marisa E. Hilliard, Diana Isaacs, Eric L. Johnson, Scott Kahan, Kamlesh Khunti, Jose Leon, Sarah K. Lyons, Mary Lou Perry, Priya Prahalad, Richard E. Pratley, Jane Jeffrie Seley, Robert C. Stanton, Robert A. Gabbay; on behalf of the American Diabetes Association, 15. Management of Diabetes in Pregnancy: Standards of Care in Diabetes—2023. Diabetes Care 1 January 2023; 46 (Supplement_1): S254–S266. https://doi.org/10.2337/dc23-S015; https://diabetesjournals.org/care/article/46/Supplement_1/S254/148052/15-Management-of-Diabetes-in-Pregnancy-Standards
2. Weissgerber TL, Mudd LM. Preeclampsia and diabetes. Curr Diab Rep. 2015 Mar;15(3):9. doi: 10.1007/s11892-015-0579-4. PMID: 25644816; PMCID: PMC4317712. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4317712/
3. Duckitt K, Harrington D. Risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies. BMJ. 2005 Mar 12;330(7491):565. doi: 10.1136/bmj.38380.674340.E0. Epub 2005 Mar 2. PMID: 15743856; PMCID: PMC554027. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC554027/#ref12
4. Henderson JT, Whitlock EP, O’Connor E, Senger CA, Thompson JH, Rowland MG. Low-Dose Aspirin for the Prevention of Morbidity and Mortality From Preeclampsia: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Evidence Synthesis No. 112. AHRQ Publication No. 14-05207-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2014. https://www.ncbi.nlm.nih.gov/books/NBK196392/