Sunday, January 08, 2012

Hello 35 weeks

Really, I've been meaning to be better about updates, but life has a way of keeping me busy! I've got much more time now (for the next few weeks, anyway), so I'll try to update in bits and pieces. Today, it'll be the pregnancy update, with the med school/residency search following soon (I hope).

I'm 35 weeks today, which seems a little nuts. I haven't detailed this pregnancy nearly as much as the other two, thus fulfilling all of those third children assumptions that people have, but really, after doing this twice already, I kind of know what to expect. Interesting differences this time:

-I've gotten sicker for longer with each pregnancy. With this one, I was still nauseous and sick until almost the end of the second trimester. I actually lost about 10 pounds early on, and I started gaining about 22 weeks. Considering my starting weight, this is completely fine and no problem at all--I have plenty of reserves :) I'm 35 weeks and up about 10 pounds from my pre-pregnancy weight. Considering the baby is estimated to be around 6 pounds right now, plus all that extra blood volume/uterus/placenta/etc, I'm hoping I'm mostly baby. I also tend to accumulate tons of water weight in the third trimester, which is true this pregnancy as well. Even my loose socks leave 1/2 inch dents in my legs by the end of the day. I have been around 1+ pitting edema by my morning OB appointments, and it's worse by the end of the day. My blood pressure has been fine, so there isn't really any worry about pre-eclampsia (none of the other criteria for that have been issues either).

-The gestational diabetes has been a challenge. It's been tough in different ways: early on, it was tough checking sugars 4 times a day (especially during rounds) and trying to eat on a schedule. That got to be easier (though not fun) as time went on. My sugars had been very well controlled until about 6 weeks ago; my AM fastings were in the 80s, and my 2 hour after meals were usually in the 90s. I was on 4 units of NPH insulin at night, with nothing at meals, until recently too. Despite the lack of weight gain and the good sugars, my 20 week ultrasound suggested we were going to have another big baby; the abdominal circumference was good (a concern for diabetics), but the arm length was >95th percentile, and he had a big head.

-That's right: another boy! We are glad that he looks completely healthy, and we would've been happy with either gender, but at the time of the ultrasound, I have to be honest and say I was a little disappointed we weren't having a girl. I thought it would be a boy, just by the way the pregnancy was going, but I was hoping I'd have another opportunity to use some of the adorable girl stuff we had stowed away. Honestly, Josh was going through a tough developmental period at that time too--his lack of interest in snuggling and his desire to harm himself in any way he could made the prospects of doing boy rearing part two rather daunting.

-Since then, I've come to think having another boy will be good. We had both boy and girl stuff ready to go, so that was no big deal. This way, the boys will be close in age and get to play. Josh has since become a ton of fun; he's becoming much more verbal, which decreases the tantrums. He's also very affectionate, usually happy and playful, and he and Sophie are absolutely adorable together. I think having another little boy will mean the two of them will tire each other out. And Sophie loves being the little mom, so she'll enjoy having two brothers to boss around :)

-Basically, this pregnancy (other than being wicked sick forever) was going along similarly to the other two in terms of OB visits and such. I did have two high risk OB visits with maternal-fetal medicine, in addition to a meeting with a nutritionist, in the first trimester. Since everything was going well, I was on the normal schedule for ultrasounds and follow up. That changed at my 32 week visit.

-I had been having absolutely no fluctuations in my blood sugars until the beginning of December. Even when we were in Florida for 9 days over Thanksgiving, my sugars were fine. I ended up with a head cold when we got back, and my sugars went up a little bit. My OB said that was to be expected. Problem was, they never really went back down, even after I felt better. I was about 30-31 weeks when the creep in sugars started. This isn't unexpected; the insulin resistance in pregnancy worsens as time goes on, which is why women aren't screened until 28 weeks usually. We had discussed in the first trimester that my insulin requirements would go up as time went on.

-Despite knowing all of this, I was pretty emotionally down on myself at my 32 week visit. At that point, I was only up a few pounds (measured at my previous 28 week visit). Despite the fact that my home scale hadn't shown much of a change, my weight showed a 3 pound gain at the office between 28-32 weeks (note: 3 pounds in 4 weeks is usually no problem, but we were really trying to limit the rate of gain to less than 1/2 pound per week so as to prevent a giant baby). Add together the weight gain, the increase in sugars, and the fact that I had 90 minutes in the waiting room to percolate, and I actually had a few tears in the exam room in front of my OB. I told her, "Sorry, I'm not usually a crier," to which she responded, "I know!" Even though I was her last appointment of the morning, and she was 90 minutes behind, we spent a few minutes going over my expectations and how we could keep things in perspective. She told me that even though my fasting sugars had crept into the high 90s-low 100s, this was still better than most gestational diabetics had in the 3rd trimester, especially on a low dose of insulin. So even though I felt like a failure in my management, it was part of the disease--not something personal.

-It also didn't help that I had fallen the day before my appointment and couldn't really do much activity, which could help keep my sugars under control. I had been carrying Josh into daycare, and it was a bit icy. I slipped and fell forward, landing with one knee on the pavement and one in the mud. It was a slow motion fall--I was able to protect Josh and my belly so that I didn't land on them--and under regular circumstances, I would've walked away with just a skinned knee. Unfortunately, since I landed on two different surfaces, I tweaked something right in the front of my pelvis. It was likely a muscle, though we couldn't exclude a small pelvic separation (it's likely I had a minor separation after Sophie was born, and this gets reaggravated from time to time). I knew I had an OB visit the next day, and I had the luxury of being home to study for boards, so I made sure the baby was moving, and then I slept for the rest of the day. My OB wasn't worried when I told her about it, but I could barely walk (and couldn't do any stairs), so she just told me to rest it. It's better now, almost 4 weeks later, except that I still have a hard time finding a sleeping position that doesn't cause tons of sharp, burning pain.

-After that 32 week OB visit, we re-consulted maternal-fetal medicine to see how we should tweak my insulin. I really like the doc I see--he's very chill and realistic--and he almost laughed at me when I told him how concerned I was about my sugars. He said most of his patients were on 40-80 units of insulin at night and reminded me that pregnancy dosing was much different that adult diabetic dosing--so I shouldn't mentally be comparing myself to the patients I treated in the hospital or as outpatients. He recommended gradually increasing the dose to 16 units (from 4) at bedtime over the next week, and then I should come back to discuss. No need for mealtime insulin either, which was good news.

-I also had my first non-stress test (NST) at that visit. That's basically just sitting on the fetal heart rate and contraction monitors for a while. At that appointment, the baby was so active he kept kicking off the monitors. We called that test reactive :)

-I followed up a week later with MFM--at the shortest visit ever. Even though my fasting sugars weren't down to what they had been before, the doc was happy with them. In two minutes, he said we were good, and I didn't need to come to the high risk clinic again unless something changed.

-This was good news, since I was basically living at the hospital. Most of the gestational diabetics have weekly visits with the high risk clinic, plus the regular schedule of OB visits. I was thrilled to have one fewer appointment every week. Already, I had 34, 36, 37, and 38 week appointments with my OB, a 34 and 38 week ultrasound for growth, weekly NSTs until 36 weeks, and then biweekly NSTs from 36 weeks out. Thank goodness I was only facilitating small groups at the med school in the morning! I have no idea how people with a full time job manage to take enough time off for all these visits--and imagine adding in weekly high risk appointments...

-My 34 week ultrasound was good. The baby was estimated to be about 53rd percentile for weight, but his head circumference was >99th percentile. Both the tech and the doc must've measured 10 times. They couldn't find any abnormalities in the brain, and when they looked back and saw Sophie and Josh's measurements, they were less concerned. They did temper the weight measurement by saying that the femur length measured at a smaller percentile than it had previously, and the view wasn't great this time, so he might actually be a bit bigger than 53rd percentile. We'll take a second shot at the 38 week scan...

-The MFM doc did look at the ultrasound, the fact that it is my third, and that it is a boy--and said he will probably be my biggest yet. Hooray...

-My OB considers me to be average risk, despite the diabetes diagnosis, since my sugars have been so well controlled. Because of that, the plan is to let me go to term. She did say she would consider induction at 39 weeks based on my cervix, not the size of the baby. I completely respect her position: she follows the American College of Obstetrics and Gynecology recommendations. No woman wants to be pregnant any longer than necessary, but there are tons of studies that have shown late preterm babies (34-37 weeks) do have higher risks. From uptodate.com:


               -Compared with term, late preterm infants had longer hospital stays (5 days vs 2.4 days) and higher rates of neonatal intensive care unit (NICU) admissions (56% vs 4%), feeding problems (36% vs 5%), hyperbilirubinemia (25% vs 3%), and respiratory complications (20% vs 5%).
               -In a study of singleton infants born in Florida in 1996 to 1997 with a gestational age between 34 and 41 weeks, children who were born late preterm compared to those born at term had an increased risk for developmental delay or disability when evaluated in early childhood (4.2 versus 3 percent), prekindergarten at three years of age (4.5 versus 3.9 percent), and prekindergarten at four years of age (7.4 versus 6.6 percent)
                -Brain immaturity may play a role in the observed long-term neurodevelopmental disabilities in some individuals who were born late preterm. Although data are limited upon the brain maturation of late-preterm infants, autopsy and magnetic resonance imaging demonstrate that at 35 weeks gestation, the brain weighs 65 percent of a full term infant's brain
 
So even though the absolute risks are still low, I'd rather bake this baby until his brain is fully developed. Although at >99th percentile, his head seems to be well on the way to being big enough!!
-I was induced at 39 weeks with Josh, even without gestational diabetes, both because he was measuring big and I met the Bishop criteria. And he was 8 lbs 13 oz. I'm hoping things will work out as well this time.

-I have been having contractions for weeks now. The last few weeks have gotten more painful and frequent. The discomfort of the Braxton-Hicks contractions has worsened with each pregnancy--I barely noticed them with Sophie, they were noticeable but just irritating with Josh, and they are uncomfortable with this pregnancy. When I was on the monitors for my most recent NST last week, I had about 8 contractions in an hour. They are definitely noticeable, but they are irregular and last only a minute or two. There was one instance of a late deceleration after a contraction, but the heart rate didn't drop to a scary level, the NST was otherwise reactive, and late decels are less ominous when you aren't actually in labor. Again, since I contracted regularly with the other two (they were actually 4 minutes apart and regular when I had the external cephalic version at 36 weeks with Sophie), we weren't worried. I'm just hoping all these contractions show some productivity and help me get to a good Bishop score when she checks me...I'm pro-induction at 39 weeks!

-So, today I am 35 weeks. I'm having wicked heartburn, though somewhat better than I had been about 6 weeks ago. I don't really have any cravings, and I am tired to death of eating the same high protein/low carb stuff all the time (seriously, eggs and cheese may have to come off the menu for a while). I'm tired, I have insomnia, and when I can fall asleep, I only sleep an hour or two at a time due to pelvic pain. I have to drink a ton of water to keep the contractions under control, but all that water makes me swell.  Despite sounding like a miserable time, it's actually been fine. I was home most of December "studying" for my boards, and now I've got facilitating/precepting for between 7-20 hours per week (except for the next two weeks, when I am cramming in as much as I can before the delivery). I spend many hours a week at the doctor's office, which means I am still basically driving to the hospital/med school every day. But overall, I think things are going well.

-We haven't prepped anything for the baby yet. We did paint Josh's room (thus continuing my streak of painting rooms when I am >30 weeks pregnant). Theoretically, he can move out of the crib and into his toddler bed any time. Since he is still active, and the baby usually stays in the bassinet until about 3 months old, we do have time in the crib remaining. Beyond that, I need to wash up the bouncer/car seat/bassinets and bring up the baby clothes. That's about it. Oh, and pick a middle name--we have a first name, but the middle name is still elusive. Eh, we've got at least 4 weeks...amazing how much more relaxed we get with each baby.

-And despite the fact that I previously mentioned wanting a girl, this is it for us. The high risk OB said the fourth pregnancy is usually easier, but I don't want to have to go through anything rougher (or higher risk) than this pregnancy. And with starting residency in July, I don't know how I could possibly squeeze in the number of visits I've had this time into a resident's schedule.  Plus, we're good with three: they can each have their own bedroom, they'll be close in age, and we'll be done with all of the sleepless nights sooner rather than later. We will have to upgrade my 10 year old Civic into a minivan in the coming months/years, but other than that, we're set for three. I think we're content with three. Never say never, but I'd say the odds of a fourth are slim to none. Especially with the possibility of twins that exists in both of our families...

-I do usually take a 36 week picture, so we'll see if that is up for posting or not. This pregnancy, I wore regular clothes until about 20 weeks or so, and no one commented (they would occasionally throw a glance that said, "Is she getting fatter, or is she pregnant?"). Once I transitioned to maternity wear and the built-in bump enhancement, it was instantly, "Are you having twins?" or "How sure are they about your due date?" I've had many strangers comment on how big they think the baby is. I am carrying far out in front, like I did for Josh, but still--trust me on this, no pregnant women wants to hear about how large you think she is. Friends/family I don't mind too much, but cashiers, secretaries, and total strangers passed in store aisles? Please keep the gigantic comments to yourself. Thanks.

-In summary: rough pregnancy, tired of diabetes, having a giant-headed boy in 4-5 weeks. Otherwise, things are good. Now, I'm off to chug some water to try and stop these contractions, check my sugar, and take some Tums for the heartburn. I'm looking forward to having a baby, but I can't say I'll miss pregnancy! Ok, maybe I'll miss the elastic pants...

2 comments:

  1. Hi

    I stumbled on to your blog while looking for new people to follow. I first want to congratulate you on the new addition coming soon and then I want to commend you on the path you are taking despite the different tribulations that have risen in your life. It is truly a miracle to stop school and then go back! And to Med school!?!? It is inspiring. So, keep pushing on and I wish you and yours all the best.

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  2. Hi, I saw your blog through "Next Blog". Congratulations on baby #3. You seem like a very busy woman! Well done :-) I had gestational diabetes in my pregnancies too, such a pain. Hope all goes well for you in the next few weeks.

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