Pregnancy hypos: how low can you go? by Helen German
When I was diagnosed at the age of nineteen, I knew nothing about diabetes. I was completely ignorant and in the dark. So, in order to help me understand what had happened and what was going on with my body, I read as much as I could about this autoimmune disease.
With me, education is the key to understanding. Reading all about the pancreas and the damaged islet cells and my body’s non-existent production of insulin or blood glucose monitoring, I found I could accept the disease more. Despite never fully knowing why the pancreas attacks itself, I could at least understand the science behind the sudden situation I found myself in.
Jump forward ten years, and my approach to pregnancy has been no different. I am now in new diabetes territory and if I thought this autoimmune disease was complex and complicated before, now it is like trying to dodge the cracks in crazy paving!
Blood glucose is affected by all aspects of life: food, exercise, stress, and the biggest one for us women, hormones. And pregnancy loves hormones! I read and researched as much as I could about Type 1 diabetes and pregnancy before we even starting trying for a baby. I knew the importance of having good management prior to conception – a HbA1c of 6.5% or lower – and how this positively impacts foetus development in the first six weeks. I’d read that once pregnant, women typically find they have more hypos in the first trimester mainly due to the tighter target ranges for blood sugars. This was certainly the case with me.
Prior to conception, my HbA1c was 7% or 53 in the new measurement terms. This worried me beyond belief as all the healthcare literature will recommend a lower result in order to lower the risk of miscarriage and developmental problems. However, when my HbA1c was 6.7% I was having up to six hypos a day and lost all my hypo awareness. I was still fully coherent and functional for example on a 1.5 blood sugar reading! So when I fell pregnant at 7%, given my personal diabetes history, this was considered a healthy HbA1c to conceive on.
After adjusting the basal (background) rate on my insulin pump in the first few weeks of pregnancy, I got myself into a regular routine of testing my blood glucose: before each meal and then one hour after each meal; before driving and before bed; and then during the night when I wake up to wee. And then of course whenever I felt hypo or sometimes even hyperglycaemic. The problem I found in the early stages of pregnancy is that I was drinking more, weeing more, and felt very tired all the time. Sound familiar? Yes, all the symptoms of high blood sugars! Throw in that horrible fear of hyperglycaemia killing my unborn child, then I found myself testing my blood every two to three hours. The general early pregnancy symptoms do disguise hypo and hyper signs very effectively. Those early pregnancy hormones matched perfectly my low blood sugar irritability and agitation. Spotting the difference was impossible! So when in doubt, my finger-pricker came out!
Because I was (and still am at week 22) testing so frequently, I rarely miss my hypo warning signs. I am very in-tune with my body and recognising when I just don’t-feel-quite-right. However, during my first trimester, I had a few plummeting sugar levels. Some hypos came on suddenly and unpredictably. On one particularly bad episode, I had tested my blood sugars and they were 5.1. There was no quick-acting insulin still working in my body and all was fine. Within half an hour I couldn’t concentrate. I felt weak and detached from my limbs, like I was having an outer-body experience. Then the thin glaze of sweat appeared on my brow and rolled down the side of my face and I was hot. I walked with wobbly legs to the kitchen and my hands shook as I fumbled with my testing kit and struggled to apply my blood to the thin line on the test strip. Five seconds later and there was my answer, a hypo at 1.7 mmol. Guzzling from a Lucozade Energy bottle I slumped to the kitchen floor hugging its cold tiles while enduring the long slow fifteen minutes back to normality.
But then the real fight begins. The post-hypo hunger battle! Prior to being pregnant, hypo hunger was a force not to be reckoned with. It takes control of your entire being and you can’t stop eating an entire pack of Rich Tea biscuits, or loaf of bread, or just gnawing the doors off your kitchen cupboards. Once it passes, you are left with only the shameful devastation of crumbs and wrappers and empty jars of jam or chocolate spread. Oh the guilt! And the realisation your blood sugar is now going to be sky high…
Add pregnancy hunger to this and basically your entire neighbourhood best be advised to keep all their food under lock and key. It’s not safe from the ravenous, pregnant and hypo-hungry beast that lives down your street!
The trick is to try to eat no carb snacks – celery, cucumber, carrots. I find drinking a pint or two of squash can take the edge off the hunger. Some people find a digestive or two rich teas help to stabilise blood glucose and stop a return hypo. I find 200ml of Lucozade is enough to treat a hypo. Everyone is different and will have their own hypo hits that work.
I am very prone to hypos. In fact this was one of the main reasons why I was eligible for pump therapy, having previously lost my hypo awareness when my HbA1c was below 7%. In a week I would on average have about five or six hypos. Ideally, my diabetes nurses wanted to reduce this to one or two. Since being pregnant however I’ve fallen into the trap of gratefully accepting my frequent hypos; hypos don’t harm my baby, they only bother me. It’s a twisted logic I know, but I’ve taken hypos as a much better and safer state to be in! Luckily I’ve had no more hypos below 2.0 and I usually catch my blood sugars when they are between 3.0 and 3.5 due to my regular testing.
At the start, the diabetes team at the hospital gave me a very tight target range for my blood glucose. Before meals it should be between 3.5-5.9 and one hour after meals between 3.5-7.7. Any blood sugar reading that was now 8.0 or above was considered a high reading. Given my hypo history, I asked the DSN (Diabetes Specialist Nurse) if I could be given 4.0 as my lower target level. I knew that anything below 4.0 would leave me feeling hypo. I was told these are national guidelines and that I only feel hypo below 4.0 because my high blood sugars are too high. I went fourteen weeks with this target range and feeling terrible every time I was between 3.5 and 4.0. Finally, the DSN admitted that the national guidelines are only to be followed according to the safety and wellbeing of the individual. My lower range level has since been moved back to 4.0!
Any diabetic ultimately knows their body, how they feel, and where their ‘floor’ is before they begin to feel hypo. The lesson I’ve learned from this is to still listen to your instinct. Even though my body is having an overhaul of changes as I go through this pregnancy, the signs are still there. They may be well-hidden but I still know best when it comes to knowing how I feel. But it’s very easy to be pulled along by a healthcare professional. They may have all the medical certificates, but we have all the experience of managing diabetes first hand. The fact I can still trust and rely on this experience is what has surprised me most so far, despite being in unknown territory with pregnancy and diabetes.
Hypos, much like hypers, are inevitable. I am trying to reduce the number of hypos I have, but this is the delicate balancing act that is diabetes, trying to manage the swinging pendulum from low to highs. A friend of mine gave me some advice in the first trimester. She is Type one diabetic and has a son. She said to take it easy right from the start – the baby, as it grows, will take what it wants when it wants. Hypos will happen and for me the scary part was how suddenly they appeared. Hypos are draining, physically and emotionally. Add to this the general pregnancy tiredness and it’s very easy to become drained and exhausted beyond belief. So I tried to slow myself down in the first trimester, if I had a bad run of hypos then I gave myself time to recover.
The other piece of advice she gave me was to eat a biscuit, every two hours. Just one digestive. It’s only 9.8g of carbohydrate and it’s a balance of high and low GI (glycaemic index) so it can stabilise blood sugars without sending them too high. I carried around with me a small tub of digestives and always a bottle of Lucozade just in case.
Hypos are unpleasant. Not just for you, but for friends and family too. Especially being pregnant, it is extra worrying all round. I have a glucagon pen in my fridge should I ever fall unconscious with a hypo. I also carry around a glucose tube that can be given to me safely without me biting down on anyone’s fingers if in my hypo state I’m being uncooperative. Thankfully, neither of these have been used and hopefully never will be.
The good news is I lost my morning sickness and tiredness around week fifteen. And the hypos became more predictable in relation to my insulin profile. With small adjustments to my insulin I was able to go three or four days without hypo’ing and I began to feel much better. In fact, I felt that ‘glowing’ feeling pregnancy brings in the second trimester! It does actually exist…but the diabetes clouds occasionally roll in and dampen it. And with me, hypos never rain, they pour. Today, at 22 weeks, I’ve had four!
But onwards and, quite literally, upwards I go.