Thursday, July 31, 2014

Things I will not miss about being pregnant

Turning over in bed is complicated. I definitely have to wake up fully to do it and sometimes I need to get half out of bed to turn over.

Relatedly, not being able to lie on my back. I sleep on my side mostly, but I do generally spend some time relaxing on my back when I first get into bed. I can't do that at the moment!

Being a pin-cushion. With 2 injections and 4 blood glucose finger pricks a day, that's a lot of sticking needles into myself. Fortunately, I'm not squeamish about needles, but I won't miss having to stick myself multiple times a day.

The effort of getting up out of a chair or bed. Usually accompanied by an involuntary "Oof!".

The pain at the bottom of my ribs on the right hand side. Apparently this is common in pregnancy, something to do with the ligaments between the ribs relaxing and the bottom ribs bowing out to make more room. I'm not sure why since my torso is long enough that Zarquon doesn't really reach that high. But the pain is there, most of the time, especially at night when I lie on my right. I hope it just goes once I give birth. (I did ask an obstetrician about it since it can be a sign of something more serious like a liver infection or HELLP, but he was happy that I didn't have any other symptoms of anything serious and it should be nothing to worry about).

Being hyper cautious about what I eat. Not so much the normal diet restrictions of pregnancy (though I do have the occasional craving for Eggs Benedict) but the specific ones for gestational diabetes. I do think it's been good for me to be forced to eat healthily for the last couple of months and I hope some of my good habits (like salad wrap lunches and plenty of veg with my dinner) will stick after the GD has gone. But I do miss muesli for breakfast and sometimes I would love a bowl of ice cream!

Central heating! I'm so hot, all the time. It has been very hot for the last few weeks: 27C most days and sometimes up to 30 or 31C. What with that and the little furnace in my belly, I've been pretty sweaty, especially at night. Of course, once Zarquon's born, her temperature won't be being regulated by mine anymore and we'll have to make sure she stays cool enough/warm enough. But at least I won't feel so overheated all the time. I hope!

Wednesday, July 30, 2014

Things I will miss about being pregnant

The little kicks and wiggles from inside. I love feeling Zarquon moving around.

The bump. I like being bump-shaped! I feel feminine, fertile and womanly. I'm a little waddly, but I don't feel that enormous, just curvy.

Being looked after. No-one minds giving up their seat to a heavily pregnant woman. People ask if I'm OK, how I'm finding the heat.

Afternoon naps on my schedule! Once Zarquon's here, naps and everything else will be on her schedule, at least at first.

Zarquon is very portable and easy to look after right now. I don't have to think about how to carry her or feed her.

Tuesday, July 29, 2014

36 weeks, 6 days

So, the decision has been made. I will be induced at 38 weeks.

To back up a bit: I had a 36 week growth scan on Tuesday and saw the obstetric and diabetes teams. The scan looks fine. Zarquon is consistently on the 50th percentile line and doesn't look to be getting too big or too fat round the middle. I've done a good job with keeping my blood sugar under control, but need metformin over night. It's because of the need for medication that I'm being induced early. If I were well controlled on diet alone, I could probably go to 40 weeks. I think this explains the disparity between the first and second obstetrician I saw. At the time I saw the first one, I was controlling my blood sugar by diet alone, but by the second I'd started on metformin.

It's quite hard finding good information on why early induction is better for GD. The NICE guidance, as far as I understand it, looks at the numbers of early inductions (typically 38-39 weeks) and the outcomes but doesn't really address the underlying reasons for early induction. It's more a case of this is what happens and it seems to be safe. A relevant passage says:

"The NICE induction of labour guideline recommended that women with pregnancies complicated by diabetes should be offered induction of labour before their estimated date for delivery. Although the guidelines reported that there were insufficient data clarifying the gestation-specific risk for unexplained stillbirth in pregnancies complicated by diabetes, the GDG [Guideline Development Group] that developed the induction of labour guideline considered that it was usual practice in the UK to offer induction of labour to women with type 1 diabetes before 40 weeks of gestation." p120

Early induction for macrosomia (baby over 4kg or 4.25kg depending on who's defining it) is the most commonly cited reason, because of the associated risk of shoulder dystocia. That doesn't seem to be the case for me and Zarquon. There is still a risk of still birth (one study found a rate of 26.8 stillbirths per 1000 live and still births for women with all types of diabetes, not just GD, versus a national rate of 5.7 per 1000 live and still births), although it's unclear if it's actually a larger risk for well-controlled GD.

I have the impression if I ask an obstetrician pointblank why I should be induced early, they're either going to say "because that's standard practice for GD" or say something about the increased risk of still birth, which is probably scary enough for most women to agree to an induction on that basis. But I need to remember I am not an expert at interpreting scientific evidence and medical guidance.

Anyway. I am being induced at 38 weeks or soon afterwards. I am OK with this. I'm not completely convinced it's necessary, but I'm willing to trust the obstetricians' judgement. It did help that the last obstetrician I saw was helpful and friendly, explained why the previous two gave different answers and gave me a thorough explanation of the process of induction, with all of its if-thens and what happens if steps.

Of course, I'd love to know how long it will take to get labour going, but that really is something no-one can tell me. It all depends on how I respond to the drugs. I'm hoping it's fairly straightforward, that the prostaglandin pessary and gels work for me and I don't need syntocinon to get things going. I will have continuous fetal monitoring. I may need a glucose and insulin IV once I'm in labour if my blood glucose doesn't stay in my target range. I'd like to get through labour with my TENS machine and gas and air, but I'm open to the idea of an epidural if I need one. Especially if I do have to have syntocinon. I think I'm more open to having an epidural than to pethidine, because the latter seems to have more side effects for the baby. All these unknowns! And I might still manage to go into labour spontaneously, you never know. We will find out soon.

Friday, July 18, 2014

Maternity clothes - what I wore

I have lived for the past 8 months mostly in a variation on my pre-pregnancy wardrobe of leggings and dresses. Pretty early on I switched to over-the-bump maternity leggings. Even before there was much of a bump, anything around my waist felt too tight and uncomfortable. The ones I had came via my sisters. One pair was from Mothercare, another from a brand called Miki, who seem to be based in Malaysia, so goodness knows how they ended up in this country. I also had a bunch of maternity t-shirts from Next. Along with my usual jersey dresses, that kept me going for a good while. In fact, I can still wear a good proportion of my pre-pregnancy stretchy dresses, the ones that are more or less empire-line, flaring out under the bust.

Things I bought

Jeans from Simply Be: These are useful, but not as well fitting as I thought they would be. Only now at 8 months pregnant are they not baggy and in danger of falling down. Perhaps the sizing is a little generous? To be fair, I was probably nearer a size 20 that 22 (at least at Simply Be) before I got pregnant, thanks for losing almost 10kg over the autumn. I ordered several things from Simply Be as they're one of the few places that does size 18+ maternity clothing. Sadly, I sent most things back again. Some just didn't fit well, others, the fabrics weren't good quality. The range looks good, but I was disappointed by the quality and I wanted things that would show off the bump, not try to camouflage it in baggy shapelessness.

Leggings from Bon Prix: shorter than the ones I've linked. I got a two pack with one pair grey and one pair black. I wear them a lot. Again, I tried other garments from Bon Prix as they have a good stock of larger sized maternity clothes, but sent them back as I didn't like them, for the same reasons - too shapeless or low quality fabrics. I like cotton! I do not like polyester and nylon. This is a common failing in plus size clothing.

Wrap t-shirt by Isabella Oliver: not at full price, I hasten to add! I bought 2 of these on eBay (in size 6, equivalent to about size 20, though IO seem to have stopped making things in that size) for a total of £30, one in red and one in brown. I have worn the red one a few times and the brown one not at all. They are a fun garment to put on, though need adjusting throughout the day. I think they make stylish workwear, which is rare in maternity clothing. I probably should not have bought the brown one, as brown isn't really my colour. I haven't tried wearing them recently as I think I'd be too hot and I'm not completely sure they'd fit anymore. The wrap style is quite forgiving, but I'm rather at the top of the size range. A nice treat and I enjoy them. I will definitely hang onto these for the future. And actually, they'd probably work as breastfeeding tops too, though they might be fiddly.

Dress and t-shirt from H&M: I adore this dress! It's my favourite thing to wear as it shows off the bump beautifully, as does the t-shirt. I don't think that's quite the same style as the one I have, but it's more or less right. I like H&M's maternity range. Lots of good jersey basics in sizes up to XL (which they describe as 22-24, though I think it's more like 20-22) and it's all good and long in the body and sleeves. I've continued to wear a lot of non-maternity H&M stuff too - vest tops which are long and stretchy enough to go over the bump and jersey mini skirts which are just about bum-covering enough that I can wear leggings, a mini skirt and a t-shirt and not feel underdressed. They do nursing tops too. I've got a couple of second hand ones in a drawer waiting for that stage, so I'll see how they suit me when I get there. I suspect they may not quite work for me as I'm pretty large busted and therefore shelf-bra type arrangements under tops tend not to be big enough, but we'll see. Good work all round H&M.

Project D London Victoria Dress: this was the eventual result of my search for a suitably glamorous dress to wear to a posh wedding in Cyprus at the end of June. I did feel fabulous in it, though it was a leetle bit too low cut. I meant to take double sided tape with me, but forgot, so my bra was on show for most of the occasion. Oops. The dress I desperately wanted was the Tilda Maxi dress by Isabella Oliver. But it was last year's and extremely popular at the time, and now nowhere to be found. The Project D Queens Maxi looked like a good second choice, but I never found anywhere that had it in stock. (I wish I had discovered Project D before they ceased to be. Some of the dresses are gorgeous and all go up to big sizes).  I tried to find specifically maternity evening dresses, but couldn't find anything I liked that went to big enough sizes at a price I could afford. I love Seraphine's dresses, particularly this colour block maxi, but with sizes only going up to 18 and priced as you might expect for a silk evening gown, this was never really a realistic option. I've had good results with empire line-ish maxi dresses though. A greenish print jersey one I got from BHS of all places has had good wear, as has this striped t-shirt maxi from Taking shape.

Minted Rose dress from Taking Shape: I bought this as a bump-friendly dress for weddings. I'm not sure it's as successful as I'd like. It looks a little shapeless on. Again, perhaps I wanted a 20 rather than a 22. It definitely needs a camisole underneath to stop it gapping and the netted petticoat shown in the photo, which it needs for shape, is sold separately. I will wear it again I suspect, for the next wedding we'll shoot in November. For one thing, the wrap top should be easy to breastfeed in.

Zoggs Mallacoota Maternity swimming costume from Marisota: spent ages trying to find a maternity swimming costume in my size. This was pricey, but it looks good. I like the adjustable bust and side ruching. It does ride up a little in the water as the top layer is only anchored at the top. This is bearable as I don't do a lot of serious swimming. So far I've worn it in the hotel pool in Cyprus and the hot tub at my mother-in-law's. I do want to do some swimming as it's so hot. Now that I'm officially on maternity leave I should schedule some swimming sessions.

There are a couple of other things. T-shirts from New Look. One from their maternity range (which annoyingly only goes up to size 18) and one shapeless t-shirt in a funky print from their Inspire range. I think I've spent a lot of time browsing clothing websites and ordered and sent back more garments than I actually bought. H&M are definitely my favourite for maternity clothes, though it probably helps that I don't need to be particularly smart for work. If I had a job which required smart work wear, I think I would be very stuck to know where to look for maternity clothes in my size. Possibly Next might have been my saviour.

Wednesday, July 16, 2014

35 weeks, 2 days

Oops, how did that happen? I've been neglecting the blog again. So, what have you missed?

Zarquon is a girl. Pretty definitely. She wasn't exactly co-operative at her 20 week scan though. We had to go away for half an hour in the middle and do some walking around to get her to move so that the sonographer could get a measurement on the blood vessels of her heart. Then, finally, I had to empty my bladder to get her into the right position to see her gender. But Rob was right all along. She is a girl. :)

Things progressed pretty uneventfully for a while after that. I got bigger, the bump showed more, I needed more actual maternity clothes (planning a post about my favourite places for buying those). Then, at 28 weeks I had a glucose tolerance test (GTT) which is standard practice for someone with a 30+ BMI. Women with a BMI below 30 get a glucose challenge test, which takes an hour. GTT takes 2 hours, but essentially both are measuring similar things - overnight fasting blood glucose and how well your body processes sugar.

I didn't expect it to show anything unusual. After all, I didn't feel unwell, or extra thirsty or like I needed to wee a lot. I had no reason to think I might have gestational diabetes. But, according to the test, I did. My results were borderline, only just into the range where they flag you for follow-up. But it was enough to need monitoring.

I was pretty upset the first day I found out. This was the last nail in the coffin of my ideal birth preferences. With GD, continuous monitoring during labour is standard practice and induction at 38-40 weeks is also standard. There's a risk of the baby being large (macrosomia) and of shoulder dystocia, where the baby fails to once the head is born, resulting in her getting stuck in the birth canal. Basically, zero chance of a water birth and a pretty high chance of needing further interventions. Plus I was worried about flying to Cyprus at the end of June. I already needed a fit to fly letter to say I was safe to fly and had no complications and here was another complication.

The midwife I saw that day was reassuring. The GD was controllable, whether with diet alone or with medication. I should be ok to fly, at least. And my birth plans? Well, I had a while to think about them and get used to the idea at least. And knowing there was something wrong was the first step to making it right.

So, since then, I've had an awful lot of hospital appointments. I have extra scans, the first at 32 weeks, the next at 36 and one more at 40 if I get that far. Every couple of weeks I see the obstetric diabetes team and an obstetrician. I had an assessment from an anaesthetist, who talked me through what an epidural would involve if I wanted one. (Right now, I don't think I do, but I've never given birth before, induction has a reputation for making labour more painful and it's good to know the option is there if I need it). Not forgetting the haematology clinic I've been going to every 8 weeks or so since the beginning. It all adds up to a lot of time at the Rosie, mostly in the antenatal outpatients clinic.

The good news is we got my blood sugar levels (which I have to measure 4 times a day with a finger prick blood sample) under control fairly quickly with diet and metformin. The day time ones were pretty easy to get right by changing my diet - limiting sugar, cutting out refined carbs and replacing them with wholemeal bread and pasta. I've had to forgo my usual bowl of muesli for breakfast, which I miss, because I can't cope with oats and milk and yoghurt and banana first thing in the morning. Instead I'm having scrambled eggs on wholemeal toast, which is nowhere near as good, but doesn't do bad things to my blood glucose. Over night took longer to stabilise. I'm now on 2 tablets (1g) of metformin, which makes my body more sensitive to insulin, so the amount my body makes can work more efficiently processing stored glucose overnight. I got a bit frustrated when I had to increase the dosage (and worried about having to go onto insulin if it didn't work) but the diabetes team reassured me that really, there wasn't anything else I could do if my daytime control was good, apart from take medication at night. I am controlling my levels well with diet during the day. Also, my weight gain is good (7.5 kg above my booking weight) which helps. I've not put on any weight since I changed my diet to control my blood glucose. I lost a little (maybe 0.5 - 1kg) initially, which worried me, but it soon stabilised.

The bad news is I don't yet know if I'm going to be induced early or at 40 weeks, or not at all. The first consultant I saw on the day of my 32 week scan was happy that Zarquon's growth looked normal, particularly her head circumference to belly circumference wasn't large and because of that, he was happy for me not to be induced early and have the offer of induction at 40 weeks, though the choice was up to me. The evidence for early induction in my kind of case - borderline GD, well controlled by diet without insulin, baby not looking large - is inconclusive. It happens to lots of people since the standard route for GD is early induction at 38 or 39 weeks, but it's possible women who are well-controlled don't need it. Though of course, it's possible they do. (Also, growth scans are notoriously unreliable for predicting birth weight. I'm therefore not sure why they bother measuring so much, but I suppose having a look and trying might tell you something?)

Then, at my last obstetric clinic appointment I saw a difference obstetrician who said they wouldn't let me go to 40 weeks and I'd be induced around 39 weeks. I challenged this by repeating what the previous obstetrician had said (though, annoyingly, he hadn't put any of that in my notes) and pointing out that I was well controlled, not on insulin and the baby wasn't looking big. She did back down a bit after asking colleagues about my results and we agreed we'd make a decision at 36 weeks, after my next growth scan.

I think I basically ran into the problem of varying degrees of risk-averseness among medical professionals. I think the first man was more senior, with a better understanding of the evidence and the second women was going by standard procedure. The potential complications associated with GD are serious - placental abruption, still birth, foetal death because of getting stuck in the birth canal, though the absolute risks are small and hard to calculate accurately. It's easy to be scared by the prospect of still birth and I don't want to put my daughter at unnecessary risk. But it's hard to quantify risk exactly. I would rather not be induced because of the increased risk of further interventions. But I'm not completely sure that I'm not being selfish, trying to avoid discomfort for me at the expense of increasing the risk of damage or death for my baby.

Right now, I hope I'll be booked for an induction at 40 weeks, but actually go into labour spontaneously before that. Unfortunately, there's nothing I can do to make that happen! I don't want an early induction. Maybe if I can convince the hospital to book me for induction towards the end of week 40, have a membrane sweep at my 40 week appointment and hope that starts things off? I don't know. We will see what my 36 week scan and appointments bring next Tuesday. I am trying to remain calm and trust God.