Sixth Appointment a.k.a. the 'booking appointment'

So, this morning I had my first appointment at the clinic since I found out I was pregnant. It's been a beautiful late summer's day, so I parked the car about 20 minutes walk away from the clinic and enjoyed walking in. Nice to get some exercise, but actually not the best idea I've ever had, since by the time I arrived at 8.30 I was already hypo, and had to treat twice before my sugars came back to normal. Ah well, if you're going to do it there's probably no better place than the diabetes clinic!

I waited for about half an hour before I was seen (could have stayed in my lovely comfy bed a little longer!) by two new faces, a lady endocrinologist called S, and a DSN (Diabetes Specialist Nurse) called D. They had a really good look at my monitoring diary, suggested that I might be taking a unit too much insulin at each meal, but especially lunchtime, and then hit me with a tsunami of information! The researcher in me totally geeked out ;) Rather than try to capture it all as it happened I'm just going to try to pull out the essentials! Thank goodness for my trusty notebook, which is allowing me to reconstruct what was said. They both said they could see why my sugars have been so good and my HbA1c has come into line so well - I'm obviously a control freak! (Maybe the list of questions I'd brought with me gave it away?)

• Contrary to what I'd understood before my care will actually be shared between the clinic and the community midwife team (sorry to my lovely GP who was right on that score). The lines are still a little blurry to me though, as some of my scans and suchlike will not be organised by the midwife but rather by the obstetrics team at the hospital clinic. I guess we'll just have to see how it all works in practice, but attention from two different sources can't hurt! Apparently the community midwives have more time than the hospital based ones, so that's the rationale for the split.
  
• There is no set schedule of appointments for a diabetic mum-to-be - it very much depends on how things are going and how well controlled the person is. Some people go into the hospital every single week, others might not be seen for three or even four weeks at a time earlier on in the pregnancy. Apparently I'm doing brilliantly at the moment so the dynamic duo thought that I'll probably be able to keep on top of changing insulin requirements pretty well on my own behalf, and can use the clinic appointments as more of a safety net. Nice to get the praise, but also nice to know that there is a safety net! One thing they said was that my sugars have been so good recently that my risks of problems are likely to be no greater than those of a non-diabetic woman of my age. Hurrah!
  
• I'm likely to be induced at 38 weeks rather than going into spontaneous labour. The received wisdom (which I already knew from fossicking around on the internet) is that diabetic mums can have problems with their placentas in the last couple of weeks - presumably linked to the other vascular issues we all have - so as a precaution T1s are made to deliver early. When I'm in labour I'll be put on a sliding scale, although I'll still be able to monitor my own sugars as well, if I wish (can you say control freak!?) I'm on MDI, not a pump, so this makes sense to me (although the last time I was on a sliding scale, when I had my wisdom teeth out, it was so mismanaged that I ended up discharging myself in order to get my sugars back down to a number that wasn't in the twenties - that's mmol/l for my friends in the US - or about 360mg/dl plus!)
  
• Delivering early also takes account of the fact that diabetic women can have big babies (macrosomia) if their sugars are high in the later trimesters. We all know that there's also a greater risk of having a C-section, but I was relieved to hear that this particular clinic doesn't push people into having unneccesary C-sections. They'll see how things are going and make a decision based on the evidence at hand.
  
• I don't have the option of a home birth, since it's important for the baby to be monitored closely in the first couple of days - even if my sugars are good there's still a risk that baby's pancreas will be working overtime at birth with consequent low blood sugars. I'm totally at peace with this one. I know some people don't like the idea of a hospital birth, but frankly I'm all about the big old safety net.
  
• I need to keep taking the high dose folic acid until I'm 13 weeks. Once I reach that point all the benefit will have accrued and I can revert to just taking a maternity vitamin with the 'normal pregnant lady dose' (ie. twice the normal RDA).
  
• My blood pressure will be monitored closely as T1 ladies face a higher risk of pre-eclampsia. Both the hospital clinic and the community midwife should be all over this one. I also have a BP cuff at home, so I can keep an eye on this myself. Mum had pre-eclampsia with me, so I'm wary about this possibility.
  
• My thyroid function tests at my last appointment were fine. I am on the edge of what's normal, and have been warned that a pregnancy might just tip me over into having an underactive thyroid, but at the moment all is okay, and they'll watch me closely.
  
• My eyes will be checked once a trimester for any signs of retinopathy. So far I've been extremely lucky and have had no trouble in this regard (retinopathy still terrifies me even though I know most T1s will experience it at some point in their lives and that treatments have improved a hell of a lot since I was first diagnosed back in 1991). I'll be having my eyes checked at my next appointment, which will mean not driving (expensive cab time) and taking the day off work (as I won't be able to get in later in the day, what with the 40 mile commute).
  

I was also able to ask some of my long list of questions (at least the ones which hadn't already been covered in the information tsunami):

• I wanted to know if I should have some ketostix. Honestly I don't think I've clapped eyes on these since I was first diagnosed, and being pregnant I wanted to reacquaint myself! The answer was a resounding yes, and I left the appointment with a prescription.
  
• I also wondered about how much weight I should be gaining in this pregnancy. As those who've read my earlier posts will have realised I'm not a svelte little person. No, I'm what my Dad once described as 'dense'. My BMI is hovering around the 29-31 level, and I'd read that I should try to restrict my weight gain to about 6 kgs (15 lb) instead of the recommended ideal of 11.5-16 kgs (25 lb - 35 lb) suggested for people with a 'normal' BMI. The doctor told me not to worry too much about this. With my levels of control and the kind of doses of insulin I'm taking I will be likely to gain, apparently, but she didn't think that I was in a worrying category weightwise. The trick is to eat for one (with 200 cals extra in the last trimester) and stick to healthy foods. I've been trying to do that for months now, so I hope I won't struggle. So far I'm not really experiencing any morning sickness, food aversions or weird cravings, so that makes things simpler. Fingers crossed that I stay this way!
  
• I've recently been invited for an annual flu jab (all T1s in the UK are considered to be in an 'at risk group' and get routinely invited). I was told that having this is fine whilst pregnant, and in fact is a good idea.
• My final question was 'when should I worry?' I know that the odd high blood sugar is fine (although I'd prefer not to see any!), and that the real concern would be soaking this embryo in persistently high sugars, but I wanted to know if there was any guidance on when I should be worrying more. Apparently pregnant women can be at greater risk of DKA, and if I'm vomiting, not eating or drinking, and have ketones of 3+ (hence the ketostix), I should call the hospital and come straight in. I should also start to worry if my insulin requirements start to tail off (instead of increasing rapidly) in later pregnancy, as this can be a sign that all's not well with the foetus.
  

The first part of my appointment finished with S, the doctor, saying that she'd order a full set of blood tests so we can know exactly how things were when I conceived, and D, the DSN giving me an updated version of the sick day leaflet, and providing me with a couple of extra telephone numbers that I can call if anything goes awry - this included her number, and the antenatal mobile telephone which is with her or with L, the dietician, at all times.

Once I'd seen the diabetes duo, I waited in the same room to be seen by one of the obstetricians. L, the dietician, popped her head round the door for a chat and to congratulate me, so I was able to thank her for the ovulation sticks tip. Turns out the reason she knew they're so great is that she's 18 weeks pregnant herself! I'm thrilled for her, and we had a little mums-to-be gossip for a few minutes, which was nice. I think it might be catching, as I noticed that the clinic receptionist is also pregnant! :)

My next caller was A, one of the obstetricians, who took a detailed history from me to add to my notes, and explained some more about what will happen on the obstetrics side. (I don't have the fabled 'yellow file' yet, which all UK pregnant ladies carry around with them. This is the pregnancy medical notes which will be started by the community midwife and given to me for safekeeping.) A briefly went over the diabetes-pregnancy 101 stuff - bigger babies, risks if sugars are high, possible c-sections, early delivery (although she said that it could be 38-39 weeks, not a blanket 38. It will depend on baby's growth and my sugars). Then she ran me through the various different scans and tests that I'd be offered. These include:

• early viability/dating scan - which will happen in 4 weeks time.
  
• Downs screening. The usual blood tests aren't valid for T1 ladies, so they offer the nuchal scan instead. This usually takes place at 12-14 weeks.
  
• A detailed 20 week anatomy scan.
• Regular growth scans from 24 weeks onwards.
  

I'd already agreed with the diabetes duo that I'd keep my appointment for 23 September when I'd have my eyes looked at. A checked with the sonographer and was told that the earliest they'd do a dating scan was 10 weeks, so I also had to make an appointment for a week later for my dating scan. (The reason they don't do it earlier is that it can cause anxiety if people don't see what they expect to!) It's going to start getting challenging to find reasons for all of these medical appointments before I can tell my colleagues at work what's up. They're used to the eyes thing, so maybe I'll take a strategic flexi day the next week and that way no-one will know I'm back at the hospital.

Once I'd seen both the diabetes and obstetrics teams all that remained was to have some bloods taken and produce a urine sample (no worries for me these days - my bladder's already working overtime). On the way to have my bloods taken I ran into Dr I, who stopped for a 5 minute chat to offer me his congratulations and see how things are going. All in all I was at the clinic for two and a half hours, and everyone is so great it's almost like being in a parallel universe (certainly compared to the clinic I used to attend for many years in another big city).

Once I'd booked my next appointment and confirmed the one I already had booked (and changed its designation from pre-pregnancy to pregnancy) I headed home, with the notes A had made tucked in my bag for inclusion in the yellow file once it's been started. This afternoon I went to arrange my first appointment with the community midwife at my GP surgery (which involved some form filling and sharing of dates I can and can't do). She'll apparently call me to set a time to meet sometime between weeks 8 and 12. I also had my prescription dispensed, so I'm now the proud owner of a box of ketostix that I hope I never have to open :)

So that was my day. Pretty busy, and I'm feeling tired now. I also had a busy day yesterday visiting my friend L, her son J, and her new baby daugher L. We went on a long walk in the sunshine and had a lovely time, and I told her my news. L's a hugely trusted friend who's been through a lot pregnancy-wise, and she's going to be my pregnancy buddy and mentor. That was supposed to be it for the telling people - I don't want to spread the news too far and wide just yet as it really is early days. S has told one friend (his best man), I told L, we've told both sets of parents and when we see my brother this weekend we'll tell him. However, another extremely good friend, J, rang out of the blue last night for a chat and to invite us to go and stay with her and her husband and meet her 6 month old daughter. I can't wait, and I'm afraid I cracked and told her too! Obviously it's still early days, and things could go wrong for me, but S and I agreed that if we were going to tell a select few people it would be in the full knowledge that we'd have to be able to face telling them we've had a miscarriage if anything does go wrong. L and J are two of my best friends, and I'd tell them anything, so I feel comfortable with telling them this news. We share stuff. However, I'm now drawing the line around my inner circle. Anyone else who asks (and actually J did ask outright) will be told 'we're working on it' - which is not untrue, just not the whole truth either!

Wow. Just realised I've been typing away for ages. S has arrived home from work whilst I've been tapping the keyboard. Must be time to check the old sugars and see what's for dinner. Bye for now!