With Diabetes in Mind

This post shares my thoughts and experience of my third 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.

A shot in the butt! That is how my third trimester started. At my 28 week OB appointment I received the rhoGAM shot due to me being rh negative and my husband being rh positive. This shot will help prevent my body from developing rh antibodies if the baby has a positive blood type. I will receive another one of these shots after delivery if the baby does end up having a positive blood type. If the baby has a negative blood type, I will not need another shot. However, I was not aware nor prepared that this shot is given in the butt! It ended up not being a big deal at all but did leave a decent bruise for awhile. Also during this appointment I got to hear the baby have hiccups on the Doppler in addition to the heartbeat. I hadn’t felt any hiccups up to this point so it was neat to hear them. I started feeling baby’s hiccups around week 30 and since then, this baby has hiccups a few times a day!

When I walked into the exam room for my 28 week OB appointment, the nurse tried to hand me the glucose drink saying I hadn’t had my glucose test yet. I asked if I still needed to do a glucose test since I already have diabetes, and she was like oh I guess not, so one nice thing about already having diabetes going into pregnancy is you do not have to do the glucose test. I can only imagine the havoc drinking that glucose drink would bring to my blood sugars! I wish the nurse would have already known that I didn’t need to do the glucose test, but it was easily refused, so know that you can do the same if you end up in a similar situation.

Pregnancy Care

At the beginning of the third trimester, my OB appointments switched to every other week instead of once a month. This is the normal cadence of appointments even if I didn’t have diabetes. At my 32 week appointment, we had an ultrasound and growth scan where baby weighed in at an estimated 4lbs 12oz putting he or she in the 75th percentile. I also received a TDAP vaccine to help lower baby’s risk of whooping cough in their first few months of life. Again, this was all standard week 32 protocol whether I had diabetes or not. Where things changed for me due to having diabetes was week 33.

Week 33 began a twice weekly monitoring protocol because of me having diabetes. I do not know if this is the same type of protocol used across all OB groups for people with diabetes or just mine in particular, but I’m sure all OB groups provide some type of increased monitoring for those with diabetes towards the end of pregnancy. My OB told me this protocol has reduced the number of still born babies. This monitoring protocol consisted of twice weekly appointments where the first appointment of the week (I would go on Tuesday mornings) is an ultrasound where a biophysical of the baby is completed, and the second appointment of the week (I would on Friday mornings) is a non-stress test (NST). A biophysical looks at the baby’s heart rate, breathing movement, muscle tone, and level of amniotic fluid among other assessments. The NST involves being hooked up to a heart rate monitor that records the baby’s heart rate for 20-30 minutes for any signs of distress. This test looks for heart rate variability between 110-160 beats per minute with at least 2 accelerations during that timeframe. These twice weekly appointments will continue until the baby arrives.

Also at 33 weeks we met with a maternity nurse navigator at the hospital where I will be giving birth. This appointment reviewed insurance, hospital registration, paper work, signing consent forms, discussing birth plan, and then a tour of the birth center to see the rooms and triage that we will be utilizing when the time comes. This was a very helpful appointment to get all the paperwork and administrative things out of the way and feel more comfortable with where I will be giving birth. I would highly recommend doing this if you are pregnant and the hospital where you are delivering has this option.

The 36 week appointment was the next growth scan during the ultrasound. This scan estimated baby’s weight at 7lbs 7oz which is the 90th percentile. While this is large, the main concern was that baby’s abdomen was measuring large rather than concern for their overall size. With a larger abdomen there is a higher risk of baby’s shoulder being dislocated during delivery or just getting stuck in the birth canal in general. Baby was also still breech, but not surprising as he or she has been head up most of the pregnancy and I had seen that on each week’s ultrasound. The 36 week appointment was also a cervical check where I was not dilated at all yet and a swab to test for strep B (which came back negative). If I had tested positive for strep B, I may have needed some antibiotics at the time of delivery to help prevent passing it along to the baby. After this appointment is when we started discussing with my care team what would be the best delivery options and when. More on this towards the end…

Diabetes Care

I continued once a month appointments with my endocrinologist through the third trimester. This cadence of appointments stayed the same for me throughout pregnancy. This most likely won’t be the same for everyone who is pregnant with diabetes as it depends on how well-controlled you are, if you are seeing a high risk doctor, etc.

At my endocrinologist appointment during week 30, my A1C was 5.7 (still surprising! Check out my second trimester blog post for more on why this is), and also did a blood test to check my thyroid since I have Hashimoto’s disease which thankfully came back normal.

I knew insulin resistance and my insulin needs could really ramp up in the third trimester so I had been mentally preparing for that. Week 31 is when I started noticing it in my morning blood sugars as I was waking up higher and then it seemed like I could not get enough insulin for breakfast. I knew I most likely needed to lower my morning insulin to carb (IC) ratio so that I was getting more insulin for what I was eating, but lowering that IC ratio meant lowering it to 3 grams per unit of insulin. This just seemed like so much insulin to me and the “fear” or maybe just how uncomfortable it felt kept me from making that change, but then I was just stressed and frustrated over how my blood sugars were not doing what I wanted them to. Finally, I lowered my morning IC ratio to 3 and that put my morning blood sugars back in the range I wanted them which ultimately reduced my mental load of managing diabetes during that time of day for me. I feel like I learned from this that the fear and stress and mental gymnastics of making a change is more work than the change itself. Long story short, if you feel pretty confident that you know what change you need to make in your diabetes management, just do it. You can always revert back and chances are you will spend less time stressing about not seeing the outcomes you want. Diabetes is pretty wild in that it is one of the only, if not the only, disease where you are the one dosing your own medication every day. This should all be done with the guidance from a doctor of course, but use your autonomy and free will within the boundaries of what has been prescribed by your doctor to try new things that may improve your overall diabetes experience as you are the one living with your diabetes every day and need to feel comfortable with it.

If you remember from my second trimester of pregnancy blog post, I had just started using Fiasp injections for my meal time boluses in addition to using my Omnipod 5 insulin pump. The update on this is that it has worked very well, and I have continued using the injections + insulin pump throughout my third trimester. I do believe this management strategy made meeting my time in range goal possible and I could not have done it using the Omnipod alone. While the Omnipod has still been great to use in terms of being able to have various basal rates, use the bolus calculator, and for corrections or small boluses, it just can’t keep up with the larger quantities of insulin needed in the later part of pregnancy. I wrote a blog post giving a more detailed look at my use of the Omnipod 5 during pregnancy so you should check that out if you haven’t already!

My last pre-natal endocrinology appointment was during week 36 where the main topic of discussion was reviewing my pre-pregnancy insulin pump settings so that I am able to revert back to those settings after giving birth. What is crazy is that I will go back to my pre-pregnancy insulin needs within hours of giving birth. The placenta is producing all the hormones that cause the increase in needed insulin so as soon as the placenta is delivered, hormone levels drop pretty quickly.

To give you an idea of how my insulin needs changed during pregnancy, pre-pregnancy I was using about 24 units a day in basal insulin with a 8 or 9 gram per unit IC ratio for a total of 40-60 units per day. At the end of pregnancy, I’m using 38 units a day in basal insulin with a 2-4 grams per unit IC ratio for a total of around 120 units per day.

Conclusion (of blog post and pregnancy!)

Due to baby being breech and the size of their abdomen and the risks those can cause during delivery, we have decided the best option for delivery for the lowest risk to myself and baby will be to have c-section. It has been nice to know this in advance to mentally prepare and it not being sprung on us in an emergency situation. It’s hard to believe my pregnancy is coming to end and baby L will be here before we know it, but at the same time I feel like I have been pregnant forever and it will be nice to take a deep breath and bend over!

Matt Redman has a song titled, “Your Grace Finds Me” where the very first line is, “It’s there in the newborn cry” so with that, we anxiously await experiencing God’s grace and joy in our newborn’s first cry.

Thank you for following along with me on this pregnancy journey and look forward to sharing the next post of managing diabetes during the labor and delivery experience of welcoming baby L to the world!