It may be time to revisit my insulin requirements?

I had a frightening morning today. I knew that in early pregnancy insulin requirements can reduce, and hypo warning signs can dull. Here's Gary Schreiner on the subject: 'During weeks 8 to 16 of pregnancy, insulin requirements tend to be lower than usual, followed by a gradual increase in insulin needs until the baby is delivered. Severe hypoglycaemia is three times more common during the first trimester of pregnancy than during the four months preceding pregnancy. This is partially due to the drive for very tight control during pregnancy, and partially due to the uptake of glucose by the growing fetus. Compounding the problem is a suppressed counter-regulatory hormone response to hypoglycaemia. Traditional hypoglycaemic symptoms tend to appear at lower blood sugar levels during pregnancy.' Gary Schreiner, Think Like a Pancreas, (Da Capo, Cambridge MA, 2004), p. 173.* So far I've had the slight dulling in hypo warning symptoms, but my insulin requirements have been holding up to usual levels (maybe even a little more). Until the last couple of days, that is.

Yesterday evening I came home from work and cooked a yummy spiced butternut squash and sweet potato soup, which I served with Irish potato farls on the side. This is an old faithful meal which keeps my sugars nice and level. I took the usual insulin for it, ate my dinner (a good sized portion) and then an hour later I had that horrible sinking feeling. I tested, and sure enough I'd plummeted to 4.2 mmol/l one hour postprandial. 8.0 mmol/l would be the target. So I started the cycle of treating, waiting 15 minutes or so, testing and repeating. Which went on for the better part of two hours. Here's how it went: 10.19pm - 4.2 (and dropping). 10.52pm - 3.3. 11.22pm - 3.4. 11.35pm - 3.9. 11.47pm - 3.7 (down again?) 12.50am - 7.1 (finally!) During this time I forced down a chocolate oat cake bar and half a packet of Dextro Energy tablets (ick). When I woke in the middle of the night to go to the loo ( a regular occurance these days), I did my usual test and found that I'd crept up to 10.7 (at 5am). Took a small correction dose, and by 8am I was sitting pretty at 4.1mmol/l, which is a good place to be.

I felt slightly crappy when I woke up (not surprising really), and decided that maybe this was the beginning of my changing insulin requirements, so I dropped my breakfast insulin slightly and ate a slightly larger than usual breakfast before setting off for my 40 mile drive to work. Here's how it went, and it was absolutely terrifying... 9.06am, test sugars at 3.4 mmol/l, eat five glucose tablets on top of my big breakfast and set off. 9.26am, pull into a layby in a country lane somewhere between Bristol and Bath because it feels like my sugars are going south. Test reads 2.6 mmol/l. Eat more glucose tablets and call work to say that I'm hypo and have pulled off the road so I'll be late. Wait and test again: 9.34 am - 3.9 (coming up - good). Wait some more, still feeling weird so eat more revolting glucose tablets. Test again: 9.48am - 3.3 mmol/l (going down - seriously? how??) Eat the remainder of the packet of glucose tablets. Wait, and test again: 9.55am - 4.3 mmol/l. Give it five more minutes then retest. 10.00am - 4.6. (Woo-hoo - safe to drive). By this time I've received a text from my boss telling me to head home as it's closer. 10.19 am, arrive home and test again - 4.1 mmol/l. Down again? Really? More glucose from the half packet left on the bedside table from last night's excitement. Head thumping by now, I lie down but don't dare to sleep. Set alarm on mobile phone for ten minutes time. Test again at 10.31am - 5.4 finally, and I can doze off for an hour. Test again at 11.51am, and I've reached the comfort of 6.6 mmol/l. However, I've eaten most of the day's calories in one go (and as glucose tablets - eeeew) and I've had enough carbs to put me in hospital under normal circumstances.

Hence my feeling that it may be time to revisit my insulin requirements! What has surprised me is just how fast this has come on, and how scary it is to be forcing glucose down and see your numbers continue to travel in the wrong direction. Looking back, I think this may have all begun on Saturday, when S and I spent the weekend with my parents and brother to celebrate my Dad's 65th birthday. We went out for a beautiful meal in a very posh restaurant and I took my usual insulin to cover this blow out, rather than increasing my doses. I was cruising at 5mmol/l two hours post-prandial. Just wrong really! So, as of today I'm going to start reducing Novorapid doses at each meal, and will also slightly reduce my background Levemir doses too. I'm home for the rest of the day (banned from coming into work by my very solicitous boss, whose wife is a T2, and hence who understands a little bit about diabetes), so I can check my sugars even more than usual and keep a close watch on what's happening. I was supposed to stay in London tonight but have contacted the people I'm meeting tomorrow to say that I'll be doing the meeting by teleconference instead. It's awkward, as no-one know's I'm pregnant yet. I'm planning to tell work once I'm safely through the first trimester, so when I was asked why this might have happened I couldn't say, 'ah, yes - this happens to pregnant diabetic ladies'. Instead I had to fall back on the oldie but goodie 'sometimes things happen to type 1s that don't make sense, it's just one of those diabetes things'. I guess I'm lucky that in almost 16 years I've never had a truly disabling hypo, never had to use a glucagon kit, and never had to call the paramedics. I hope that continues, and I'll be testing and altering my doses all the more to make sure that it doesn't. Oh, my poor fingertips.

This post has been a bit of a downer, all in all, but really I'm fine, and by applying all the 'diabetes rules' I got through my scary morning okay. I guess it's all part of the challenge of diabetes and pregnancy. I did have some good news yesterday though, so I'll finish on a high note. My last HbA1C, taken at the hospital on Thursday last week, was better than I expected. I'd been running a little higher than I would have liked for about a week around the time I conceived, so I was expecting a less good result than the previous two. Instead, I improved again! It was 6.3% - a number I haven't seen since my post-diagnosis honeymoon period. Not too shabby at all. So, my little passenger and I are doing fine, despite all the dramas of the last couple of days. Long may that continue. :)

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NOTES:

* Also see this fascinating article for more detailed information: L. Jovanovic et al, 'Declining Insulin Requirement in the Late First Trimester of Diabetic Pregnancy' in Diabetes Care, July 2001, vol 24, no 7, 1130-1136. Particularly interesting is the information that 'In pregnancies that resulted in live-born full-term singleton infants, a significant 18% increase in mean weekly dosage was observed between weeks 3 and 7 (P = 0.000), followed by a significant 9% decline from week 7 through week 15 (P = 0.000).' Might use these percentages as an initial guide for tweaking my doses since I seem to have experienced the increase in weeks 3 to 7.