By: Katherine Marple
A couple of factors lead to increased risk of insulin shock comas during the first trimester. For many, insulin sensitivity increases and the pancreas isn’t yet producing the hormones associated with insulin resistance. In addition, many type 1s will be taken off of their current basal insulin if it is not yet approved for use during pregnancy.
Before pregnancy, my A1C was 6.5% using Levemir as basal insulin and Apidra as bolus insulin. I maintained very stable glucose readings using this combination and was rarely out of range. However, when I met with my endocrinologist during the first five weeks of pregnancy, he informed me that Levemir wouldn’t be approved for pregnancy until possibly 2012, if ever. He added that Lantus wasn’t clinically approved for use in pregnancy because it sometimes affected fetal growth hormones.
We discussed at length my decision to switch back to NPH. I had left NPH behind in 2003 because its peaks and valleys were too extreme for me, and I often found myself out of range.
Even with my background knowledge and history with NPH, however, I found myself in eight insulin shock comas during the first trimester. Many times it was due to the sudden peaks NPH created in me. My peak on NPH came between four to six hours after injection. This two-hour span was difficult for me to grasp because every day it peaked at different times. Because of the pregnancy hormones and tight control, I was also battling hypoglycemic unawareness. I could no longer detect the early symptoms of low glucose and was unaware that I was going into shock.
To safeguard myself against insulin shocks, I took some steps:
1. I informed my husband about the symptoms in great detail. One symptom of mine was cold, clammy hands and cold sweat. Another was time urgency. I would be extremely anxious and speak very quickly because I felt as if time had suddenly slowed to a near-halt, putting me into panic. Acting out of character, like laughing loudly and out of context, screaming, rocking back and forth, and repeating the same sentence over and over were other symptoms. During pregnancy, my insulin shocks came in different forms than before pregnancy. In the first trimester, one of my insulin shocks occurred while I was awake and mid-sentence, yet I had no control over my body or my words.
2. I taught my husband how to check my glucose levels and what readings required treatment. We kept a spray nozzle can of cake frosting at my nightstand because if I was asleep during insulin shock, I wouldn’t be able to swallow any juice. This worked for me because I had adverse reactions to the glucagon kits, which would send me into extremely high and stubborn rebound glucose readings. I knew that the two of us could handle treating my shocks without medical assistance, so in all of our experiences we never called the ambulance.
3. I set my alarm clock every two or three hours throughout the night. I kept my glucose meter at my nightstand, next to a bowl of candy. When I woke in the night and a reading was lower than 50, I ate a few pieces of candy and then fell back asleep.
You should discuss your concerns about your diabetes treatment plan with your spouse and with your doctor. Make sure you are comfortable with your plan. Don’t be afraid to switch doctors if you feel yours isn’t supporting you enough, including your endocrinologist, your maternal fetal medicine team, and your OB/GYN.
I switched my OB/GYN at week seven because she refused to accept that it’s nearly impossible for a woman with type 1 to reach a 4.0% A1C. This is often the case because gestational diabetes is common in pregnancy, so many OB/GYNs become fixed in the gestational diabetes mindset.
In addition to your child’s health, your priority should be your own physical, mental, and emotional health. Seek support from your partner, your family, friends, support networks online, and your medical teams. They should be celebrating your successes in your diabetes control, and you should be able to discuss treatment ideas with them. You are in a partnership with your medical team. During the third trimester, you’ll be seeing your OB/GYN twice a week, your high risk maternal fetal medicine team twice per month, and your endocrinologist once per week. Your doctors should feel like a knowledgeable extended family. You will need all the support you can get.
Next, I will share my experiences with the second trimester complication of insulin resistance.