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.

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