You've made it 9 months


(katie.clark) #1

What to expect in the delivery room.   I'm interested in hearing how labor and delivery went for you with type 1.


For both of my pregnancies, I was induced at 38 weeks.  The first time was low amniotic fluid (not a normal type 1 diabetes issue).  With the 2nd, I begged the doctor hysterically for them to get the child causing the lows out of me at 37 weeks and 3 days pregnant.  My doctor bargained with me to get me to 38 weeks.  I was NOT in a good place with blood glucose control (that was right around when I hit 5% on the A1C) (or mentally)  and had a 20 month old at home to take care of.  I was going through jugs of orange juice like crazy.

Anyway, I was induced at 38 weeks for not real "diabetes" related medical reasons.  They had me take my insulin pump off right at the start of getting settled in the hospital.  They put an IV with insulin and glucose to take care of diabetes.  Every hour on the hour they came in and checked BG levels with a finger poke.  I was in labor 24 hours for each, so had 24 BG checks.  In both labors, I had two bouts of low BG but was for the most part - pretty steady. 

It wasn't until AFTER I gave birth that the BG control went haywire.  I was low from about 30 minutes after giving birth, until around a day or two later.  The doctors at the hospital (note - NOT the endo or the perinatologist - but the doctors doing rounds) wanted me back on my pump.  So I did that, for about an hour.  Then I took it off and didn't need it again for about 20 hours.  After that, I needed it but only at about half the amount of insulin I was on before I got pregnant.  At about 48 hours after giving birth, I was back on the amount of insulin I was on before getting pregnant.

Expect to have doctors and nurses who have no clue about type 1 diabetes management.  Be ready to stand up for yourself and explain to them that you know your body and your type 1 management.  Insist upon it. Prepare yourself with information from your endo about what to do after childbirth, get it written down and stick with it.  (I didn't with my first, I did with my 2nd).

I will tell you that after my 2nd daughter, I checked us both out of the hospital about 24 hours after giving birth (with her doctors blessing, of course).  I had been through it before, had a better support system at home and didn't have the constant interuption for "diabetes care" that I didn't need throughout the day and night.  I have come to realize that being type 1 in the hospital for anything other than type 1 care is not really a place to recover.


(Payton) #2

Thanks again for sharing your experiences! I dread being in the hospital for any reason - it really scares me (bad hospital experiences in the past). Having written orders from your endo is a great idea! Is 24 hours of labor typical, or is that long?


(katie.clark) #3

I was induced so that probably added on time to labor.  If the body can do what it wants, I don't think labor tends to be that long.  But, alas, I have no medical background or resources to back that up.  :-) 


(Gina) #4

Oh wow katie thanks for that information!


(DocHam) #5

24 hours is common. It can stretch to 48 hours.


(DocHam) #6

I'll share my experience with having kids as a person with diabetes with a little medical insight as well (I'm also a physician - albeit a new one!).

My A1Cs have always been <7 but my endo at the time wanted it <6.5. I was less educated my 1st pregnancy and CGM wasn't around so I did not fully appreciate the incredible post-prandial spikes that tend to occur in the latter part of the 2nd and throughout the 3rd trimesters. My insulin requirements did increase significantly - probably quarupled. One caveat about maintaining such tight control is more frequent hypoglycemia and that can add to weight gain. If you have a regular OB who says you are gaining too much weight - don't listen to them! For my first pregnancy my A1c drifted upward throughout the pregnancy and at the end was 7 or so. Rather than being cared for by a general OB/GYN I went to a perinatologist who specialized in diabetic pregnancies. While I realize that this is not available to most people, I highly suggest that people select a hospital that has a well-established NICU and a perinatology service. 

My 2nd pregnancy started with an A1c of 5.5 and it remained <6 throughout. I had a lot of bad lows and actually had to have glucagon 3 or 4 times. This was more of a function of my paranoia of high blood sugars (I had almost completed my medical training and had read all of the articles on dabetic pregnancies). In my 3rd trimester, I was particularly insulin resistent in the morning and could not keep my glucose from spiking post-prandially, even giving my insulin 1/2 to an hour in advance of eating. I elected to use symlin to prevent those spikes and it worked beautifully. MOST physicians will not prescribe symlin during pregnancy because - well everyone is afraid to prescribe anything that hasn't been studies and used extensively to a pregnant woman. However, it was the key to my great control the last 3 months. There was a published study that found the symlin did not cross the placental barrier but you'll find that obstetricians are over-cautious about things they don't know much about.

We tried to induce first baby at 37 weeks 3 days. This can be done if you get an amniocentesis to test for the fetal lung maturity. It didn't progress and I was impatient so we elected for a c-section. Now having delivered a number of babies myself and witnessed many, I'm so glad I did! He had significant hypoglycemia and was in the NICU for several hours. Weighed 8 lbs 11 ounces (both my husband and I are tall).

Second baby was elective c-section at 37 weeks 3 days. 9 lbs 10 ounces and not a single issue post-partum. He did have a VSD (ventriculo-septal defect. . . a very common heart defect). However, this occurs in 5-10% of babies overall and many close on their own (his did at 6 months). The pediatric cardiologist confirmed that it was not secondary to my diabetes.

I gained 80 lbs with the first (I was also REALLY hungry) and 60 lbs with the 2nd. I think I was just fat for the first. I lost all of the baby weight within 3 months of the 2nd birth.

So that's a long personal story but may be of use. I used the Dexcom CGM throughout the 2nd pregnancy and credit it (and symlin) for my incredibly tight control. It actually functioned much better for me while pregnant than it does non-pregnant (probably bc of the excess interstitial fluid).

If you have any questions - I'm happy to respond. I'm not sure if you can private post or its all general but I'm happy to do so either way. I'm taking the year off to be a mom then will start internal medicine residency in the summer so have plenty of time to chat!


(katie.clark) #7

Have you ever heard people say that women with type 1 require less insulin while pregnant?   I attended a research update by Dr. Richard Insel from JDRF (VP of Research) and he was talking about a study how beta cells produce more insulin women with type 1 are pregnant and that is why they require less insulin.  It was a study about how beta cells are always being produced, but the immune system continually destroys them in some people with type 1.  They found that MORE are produced in women with type 1 when they are pregnant.  (this is me totally paraphrasing and perhaps not even accurately)

I explained to him that I actually needed four times more insuiln by the end of my pregnancy and wondered if that meant my body was no longer producing beta cells.  Of course, he could't answer, but I wondered if anyone had experienced requiring LESS insulin when pregnant.


(DocHam) #8

Hi Katie.  Around week 10-12, the insulin requirement does tend to decrease. It is postulated that it is secondary to increased insulin sensitivity, possibly because of the decrease in the anti-insulin hormone progesterone. Conversely, as pregnancy progreses, contra-insulin hormones increase and cause progressively increased insulin resistance. I'm sure that the research  focused on the late first trimester. The decreased insulin requirement and thus decreased glucose levels of pregnant women with diabetes in the first trimester may be responsible for the tendency for us to gain weight earlier than most pregnant women. 

By the time I was finished with both pregnancies, my insulin dose had quadrupled as well. I was so resistant that the only thing I could do to keep from spiking was take Symlin.

With regard to the research, I am somewhat circumspect to believe that beta cells are continually produced as immunosuppression would halt diabetes. By the end of the honeymoon phase, most if not all patients with diabetes have no beta cells.

Does that answer


(katie.clark) #9

It does help.  Thanks.

 


(Jacki) #10

Thanks for all the great information.

I have one question.  Did you use the DexCom in your belly when you were pregnant or did you put it in an alternative location?

FYI:  I love my CGM and could never get my blood sugars or A1C as good at it is without it.


(DocHam) #11

Hi Jacki -

I used it on my belly in the first trimester as the belly fat accumulated (the stage of pregnancy where noone knows you're pregnant but notices weight gain). Once the abdomen starts to get full, its impossible - kind of like with the pump infusion sites. I put mine on my side/love handle area both front and back and it worked beautifully. In fact, my Dexcom was more accurate, worked better, and the sensors lasted longer throughout my pregnancy than they do now (likely due to the additional fat).

I even placed it on my back flank for D-Day and wore it into the OR (elective c-secion). The anesthesiologist was amazed by its information. It was cool to see what happens post-partum to my glycemic control. But I'm a nerd.


(AmandaStewart) #12

Today i'm just over 36.2 weeks.  I went to my OB who isnt a diabetes specialist but is a "high risk" OB so he's dealt with Type 1's before.  Anyways he's told me that my sugars arnt under good control, which to me is insaine, my last A1C was 5.6 and i wear a pump and a sensor so i'm always on top of my sugars.  I do go hight sometimes but i quickly adjust my insulin to bring anything that is high down to normal.   My fetal monitoring has been going good and i go 3times a week and they say the baby is doing well, my ultra sounds say that my baby is in the 97% for weight, so he says that i'm not in good control or my baby wouldnt be so fat. 

I feel horrible, like i'm not doing good and that i'm hurting my baby by what this doctor is saying.  He now says that he wants to induce me on Christmas Eve, and then he said but you'll end up with a C-Section becasue you're not ready and the inducing more than likely wont work.  

Should l listen to this guy?  He also said that he's worried taht the baby might not be develped enough next week when it comes out, because its not a full term baby, but its 37 weeks by that time.  I just dont understand why he is making me feel like crap.   I had two days last week where my blood sugars went high and i took tons of insulin to try to get it to come down and it took almost all day even though i hardly ate.   I have no idea why the sugars went up and it was almosmt like i was insulin resistant for 8 hours.   So this OB thinks that i'm not under control and that i'm not taking care of myself.  

Has anyone else has this happen?  is 37 weeks to early to be induced? He also told me and my husband that this should be our only pregnacy, so basically dont do this again. 

Thanks for any help or suggestions

 

Amanda


(DocHam) #13

Hey Amanda. So your doctor isn't crazy to suggest that you induce at 37 weeks. The larger the fetus, the greater the likelihood of post-partum complications for both you and the baby. He is not entirely accurate about the cause for the size of your baby. It is theorized that women with type 1 diabetes have larger babies despite excellent control because the placenta is larger. The larger the placental area, the greater the nutrient load the baby receives and thus, the larger the fetus. Granted, hyperglycemia will contribute to large fetuses as well, but don't beat yourself up. We have different mechanisms contributing to the large babies. Most perinatologists don't even know that unless their particular area of expertise is diabetes itself.

Another caveat of the diabetic placenta, however, is that it also tends to age more quickly. I was told I'd be induced at 38 weeks. I elected for the 37 weekss because I was sick of being pregnant. And that early on, it did not progress (I am SOOOOO glad it didn't) and I ended up with a c-section. I've delivered babies both ways and man, is a c-section more enjoyable for the mom and dad and produces much fewer complications long-term (many women who birth large babies suffer urinary incontinence when they reach 40 or so).

Bottom line, you aren't crazy and neither is your doctor. I highly recommend following his advice but you should DEMAND an amniocentesis prior to the induction/c-section to confirm fetal lung maturity (to make sure your baby's lungs are developed enough to work well outside your uterus).

Honestly, when I was in your shoes I was set on a vaginal delivery. I am so glad I went the other way. I'd have a c-section over and over and over again as opposed to delivering vaginally. Its probably based on what I've seen in the NICU, delivery room and morgue. I'm happy to answer any other questions - both medical and personal - regarding this issue. And congratulations!!! You're almost there!!!


(samaralily) #14

Hi Hayley,

  My name is Amanda as well.  I am newly pregnant (a little over 5 weeks) and have already found that I am becoming more insulin resistant (I had to up my basals by about 30% this morning).  This is my second pregnancy and I am hoping it will be much more uneventful than the first--I was diagnosed with type 1 at the same time that my pregnancy was confirmed by my OB...  This time I am on the pump (minimed) and am looking to go on the continuous sensor asap.  I have extremely good control--none of my A1C's have been over 5.5 since my initial diagnosis (I credit this to learning about the diabetes during a critical time and getting into good habits right away)--and I intend to continue that way throughout this pregnancy as well (although yesterday I had an almost impossible time getting below 150). 

   I am writing to you because although I am not a health care professional, I am extremely 'nerdy' and like to know as much about my condition as possible.  I want to ask you specific questions about the issue of the diabetic placenta aging more quickly than a normal one.  My first OB told me this as well, but couldn't give me any information about where that knowledge came from.  It also resulted in an early induction/c-section, although I managed to push it to about 39 weeks, much longer than he had let any of his other patients go (even still, I had really wanted to do a natural birth).  My questions are specifically, what is this information about the placenta based on--women with what kind of A1C's, what was the sample group, and when was this research done?  If it is not recent, and based on my own experience, I would question the results.  I also remember reading an article about a woman who had three children the natural way, and this was long before the type of control that is available currently.  I am not an expert, but I find it hard to believe that if a woman maintains her blood sugar at normal levels (for the most part), there should be no 'diabetic' effects on the baby or placenta???

  I am also a bit concerned because the soonest I can get in to see the Maternal Fetal doctor recommended by my Endocrinologist is towards the end of January, by which time I will be over 2 mo. pregnant.  I haven't seen a doctor for the blood test confirm, not that I need it for myself, but I'm wondering what they might be missing in me or my progression if they don't get early info on me.  Luckily, I will be going to see my endocrinological team at the beginning of the week after Christmas, at which time I will initiate getting the glucose monitor going as well...

  I hope this question/message is coherent--I am trying to write it with my 2 1/2 year old playing with me (who is still nursing, btw), etc.   

    Thank you for sharing your experience with us all!  Amanda


(DocHam) #15

Hi Amanda,

Congratulations on your  pregnancy! I must first preface my response with the caution that I am neither an Endocrinologist or Perinatologist and advise you to refer to your physician for any medical management decisions. That being said, based on your post, it sounds like your great control may be attributable to the honeymoon period. You were diagnosed 2.5 years ago and thus since diagnosis, your pancreas has produced some insulin, albeit the quantity gradually decreased. I've noticed that when people are diagnosed with type 1 later in life, their honeymoon period tends to last longer. It may be that the newer insulin analogues are beta-cell protective and those of us diagnosed as children who had a brief honeymoon period did not appreciate that benefit. However, I know that is not your question.

There is very little literature regarding the placentas of women with type 1 diabetes. However, it is known that pregnant women who were diabetic prior to pregnancy experience a greater incidence of placental vascular disease (preeclampsia, infarction). My perinatologist theorized that the process of placental aging is similar to the process of the damage to the microvasculature that pts with diabetes experience (retina, kidney, etc.) secondary to oxidative products. Physiologically, a healthy placenta ages also. Aging means that portions of the placenta are no longer working to provide the fetus with the O2 and nutrients it needs. This is the reasoning behind obstetricians inducing women at 42 weeks. Studies have determined that beyond that, the risk for poor outcome increases because of the aged placenta. Women with type 1 diabetes tend to have this process somewhat accelerated, particularly if their glycemic control is not optimal. Maintaining an A1C such as yours is important. Some data suggests that minimizing the glycemic variation (ups and downs) also limits the oxidative stress that the vasculature experiences. Hence why some people with great A1Cs develop complications while others with higher A1Cs do not. Does that make sense?

I can't remember my insulin sensitivity early on in pregnancy - I know it dropped around week 11 or 12. An article by Lois Jovanovic (an expert in diabetic pregnancy, if not THE expert) defines increased insulin requirements in the first 3-7 weeks of pregnancy. You can view this article at http://care.diabetesjournals.org/cgi/content/abstract/24/7/1130. 

Unfortunately, even with tight glycemic control as defined by an A1C, women with type 1 diabetes should not expect the pregnancy to be without risk. The A1C is an average - it does not describe how many highs and lows. Type 1 diabetes is more than simply islet cell loss.

As per your concern about the MFM not seeing you until January, you should not worry about this. Because the risk of miscarriage is greatest in the first 8 weeks, many wait to see their patients at that time. I presume your endocrinologist will be managing your glycemic control? That is the most critical component in the first 12 weeks. There is nothing that the MFM physician can do other than endorse the endocrinologist's recommendations for tight control.

Does this make sense? If its not particularly coherent - I too am in the midst of 2 major distractions (3 if you count DH). If what I wrote isn't clear, let me know and I can elaborate.

Out of curiosity, what was the size of your first child? I maintained an A1C <6 (usually 5.5 or lower) throughout my pregnancy and my second was 9 lbs 10 ounces at 37 weeks 3 days (both his dad and I are tall). There is a different theory about placenta and fetal size as well!!


(Jacki) #16

Thanks for the info.  It is good to hear that you wore you Dexcom during your C-sectioin as well.  That is interesting and pretty cool that your DexCom was more accurate and worked better.  I have the Navigator and the DexCom.  I liked the DexCom but the alarms weren't waking me up at night so I got the Navigator which works much better but the past few times I have been getting welts from it.  So, I put my DexCom back on yesterday and the accuracy has been horrible and I really miss all the data I get off the Navigator.  Oh well I am grateful to have something.  It really helps me and I find it facinating watching the numbers.  Before I got my CGMS I thought it was going to be magic and that I would never get high or low again.  Yeah right, I actually get lows more often now as it doesn't catch my lows and I have much better numbers in general.  and it tells me when I am raising but insulin takes 2 hours to work and somedays I am more resistant than others but it definately prevents me from a. overeating when I am low because I can watch it go back up.  and b.  not get as high or be high for as long because I can catch the highs a lot earlier. 

 

I can't wait to see what the CGMS systems look like in a few years when they are smaller and even more accurate.  Thanks again!

 

Jacki


(samaralily) #17

Thank you so much for the detailed and quick response!  I really appreciate all of the information.  You may be right about the honeymoon period (or it may just have been that I was using different insulins last pregnancy) because I find that I have to eat a lot less to correct the lows these days.  Although, by the end of my last pregnancy I was about 1:1 for breakfast.  I guess we will see what happens this time! 

  Thanks for the reassurance about the Dr., it does help to know that she would only be a cheerleader at this point...  As for my daughters weight--you think these are the things you will never forget, right?  I think she was about 7lbs+ when she was born, but I couldn't tell you the exact # unless I go look it up. 

   All the best, and Happy Holidays for you and your family!

 

       Amanda


(Rachel Y) #18

For my first pregnancy (I'm 6 wks pregnant now), everything was going fine, no problems until about week 32-33 when I had what seemed to be my water breaking (at work).  Went to hospital, lots of tests and sent home, it was determined that it was not amniotic fluid.  But- I continued to leak heavily for a week and 1/2.  I had ultrasounds almost every day for that week and 1/2 and the amniotic fluid level kept slowly decreasing but was never less than the acceptable range (though got damn close), so they deemed it all to be fine.  Finally after 9 days of leaking they re-did a test they had done the initial leaking day (can't remember name, predicts if you will go into labor in next 2 weeks).  First test had been negative, this one was not, so they decided to do an amnio and see how lungs were developing and insert dye to try to determine more about where leaking was coming from.  (And- as an aside, that test was redone after the perinatologist said "well, since you keep complaining of this issue...").  Anyhow, amnio came back lungs more than adequately developed (even for a baby on non-diabetic mother, they were impressed!) and dye came out immediately.  So, I was admitted and they started inducing, this was Friday.

Nothing happened Friday, no progression from first induction drug.  Saturday I was started on Pitosine (sp?) and things progressed very, very slowly- remember, I was 34 weeks.  Midnight Saturday night concern rose b/c baby's heartbeat going wrong direction after contractions and I was nowhere near dialted enough, so I had a c-section.

Bryce went to NICU, as I knew he would to have blood sugars checked, they were fine and stabilized quickly.  Unfortunately he had sucking/swallowing/breathing reflex problems and stayed in the NICU for 10 days, most of them with a feeding tube and also b/c he stopped breathing twice while trying to eat.  He was one of the healthier babies in the NICU and has been 100% fine and healthy since coming home 2 1/2 yrs ago.

Katie- I just reread what you wrote and have not been able to stop wondering all this time if mine was a leak of amniotic fluid.  My hypothesis is that it was and either initial tests were wrong or it became so and they couldn't say it once saying it wasn't. I wonder if ours were similar...

Eager to see what #2 will bring!