AMA and Pregnancy

My chart said AMA.  Not just on one page, but on quite a few of them.  I must confess, when the OB stepped out of the room, I looked at my chart.  It’s my info – right?  As a nurse, I understand a medical record and as a curious about-to-be-mom, I wanted to know what it said.  I claimed not one feeling of guilt for looking, but I was incensed to say the least about the AMA abbreviation.

AMA in medical lingo meant “Against Medical Advice”.  Whaaat????!!!!!   I was the perfect patient!  I was going above and beyond to keep my blood sugars normal.  I wore several watches to help me to remember to check every 2 hours during the day and at 3 am every morning.  Yep, I tested at 7 am, 9am, 11am, 1pm, 3pm, 5pm, 7pm, 9pm and 3 am nearly every day while trying to conceive, while pregnant and while breast feeding.  My A1C was in the 5s.  What the heck was I doing that got me labeled as “AMA”???

Curious

I let it slide for a few visits, but finally my curiosity and indignation got the best of me and I had to fess up to the nurse that I had peaked into my chart and seen they had flagged me “against medical advice”.  She literally cracked up laughing!

“Oh no!  You are such an ER nurse!  In OB/Gyn practice AMA isn’t Against Medical Advice, it is Advanced Maternal Age!!”.  Great I am not a rule breaker, just old!

The definition of Advanced Maternal Age is women giving birth over the age of 35, also referred to as “Geriatric Pregnancy”!  Pah- leeze!  In my clinical practice the geriatric label was applied at age 65.  But alas, I was 39 with my first pregnancy so I met the criteria.

Diabetes, Risks & Babies

When I married, I was 36 and turned 37 the next month.  My husband and I knew at our age if we wanted children we shouldn’t dally.  So 2 months after our wedding ( some time for holidays and honeymoon) we were planted in my OB office learning all about the risks.

I knew them and wasn’t in the least concerned.  My husband, not so much.  He is the furthest thing from clinical you can image.  Discussions about genetic risks, miscarriages, and Down’s syndrome, nearly had him running for the door.

But I knew my socioeconomic status, access to healthcare, education and health status put me in a position of less risk.  My fear was not diabetes, but old “eggs” and the possibility of conception issues.  I was confident I would do what ever I could to keep my blood sugars in line and I minimized the genetic risk.  All of this was a bit over hubby’s head.  But we wanted a family and I convinced him I had it all under control.

Pregnant

A month later we conceived!  It took a few more weeks for me to miss a period and do a pregnancy test that was positive!  It was amazing!

Since I knew I was high risk because of my diabetes, I immediately contacted my OB.  She was very aggressive in my management so In a few days we were in the office for a sonogram.   It confirmed there was a heartbeat!  So exciting!!

The heart rate was in the 70s which didn’t seem normal to me.  Also the embryonic sac was tear drop shaped instead of round/oval.  The report was “too early to tell since we were only 6 weeks in” and we were asked to come back next week.

As I mentioned earlier, I was checking my blood sugar like a mad woman and there was absolutely no dietary cheating!  I clearly understood the importance of glycemic control and the early stages of fetal development.  The lower than normal heart rate and odd shape were very concerning, but all my positivity was in full force.

A week later, the embryo had a heart rate of 50 (very low and not a good sign) and did not have significant growth (another really bad sign).  The feedback as that most women didn’t typically have sonograms in the first early weeks, so who knew what could happen.

It wasn’t good and I knew it.  I had to have weekly sonograms until there was no longer a heartbeat and then a D&C (dilation and curettage),  a procedure where they open the cervix and remove the “products of conception” from the uterus. My baby didn’t survive

The hardest part was walking around waiting for this life inside me to die.    It just sucked.

Sam

The medical advice was to wait several months before trying to conceive again.  Time was not on our side, so we recovered from the miscarriage and let nature take its course.  Same drill blood sugar checks every 2 hours and at 3 am.  By late summer we were pregnant again!

This time sonos, checks, and tests were all 100% WNL (within normal limits).  I remained diligent about checking my sugars.  I saw my OB monthly for sonograms for the first 5 months.

My endocrinologist pretty much just cheered me on. I was on top of food, blood sugars and keeping ridiculous records.  He really didn’t have much to offer, but praise for how I was managing my diabetes.

We had to do some obligatory genetic and risk screening.  For me unless there were deformities discovered deemed incompatible with life, I was prepared to mother my child.  On the other hand if the child was not viable, I didn’t want risk my life, kidneys, etc  for naught.  The sonogram revealed all the parts were forming as they should, and I declined an amniocentesis.  A need to know test, for me, was not worth the risk of a procedure induced miscarriage.

Leap Year?

So onward we marched, testing, testing and testing to keep my sugars as normal as possible. During the last few months, I had sonograms weekly to keep check on the health of my baby and the placenta.  Since diabetes impacts circulation, there was special care to constantly assess the blood flow.

MY OB didn’t want me to go past 38 weeks.  In her words “nothing good happens after 38 weeks”.

Because my son was breach (head up, not down) and I wasn’t willing to do an “external manipulation” – that means trying to rotate my baby by pushing on my stomach and if things didn’t go well, it meant an emergency C-section.  I opted for a schedule C section on March 3^rd.

My Sam had other ideas and on February 29^th my water broke.  On the toilet no less (again – Thank God for small favors!)   We headed to the hospital, my husband excited to have a Leap Year baby.   The thought of my baby only having a real birthday every four years did not excite me.

Luckily timing, the nurses,  and my OB had other plans so Samuel Donald Daiker was born on 03/01/04 just 53 minutes after midnight.  Important to note; I stayed on the pump during the procedure and throughout the hospitalization, unwilling to let someone else control my lifeline.

He was perfect, not over weight, no time in NICU, no hypoglycemia.  This 39 year old AMA Momma defeated the odds.

No only child

Despite the first pregnancy failure, we were thrilled to be parents!  He was perfectly healthy.  I was perfectly healthy.  Despite the effort to manage diabetes, the risk was very worth the reward.  Neither of us wanted an only child

Between Sam’s birth in March and Sophie’s conception 7 months later, we experience 2 positive pregnancy tests that miscarried before we could see a doctor and one confirmed on sonogram, but without a heartbeat.  We did extra studies to look for physical issues, but most likely it was genetic problems or issues with my eggs.

4 miscarriages were not fun.  At all.  But we stayed positive and were grateful that we weren’t having trouble getting pregnant and our issues were most likely due to my age and not diabetes.

The every 2 hour and nightly blood sugar checks continued during all these months. I wish I would have kept track of how many test strips I used during that time.  Fear was my motivation as I couldn’t live with my self if I caused harm to my children.  To say I was a little obsessive would be a hug understatement, but in a world where I had no control for so  many things,  knowing my blood sugar was something I could do.

Sophie

Joyfully we did conceive and bring to our lives another child.  A daughter – Sophia Evelyn.  When she was born, I was 41.  This time I knew what AMA meant!  Ha!  Once again, my A1C during my pregnancy was 5.4-5.6.  The plan was the same, close monitoring of sugars, monthly checks initially that became weekly sonos further along.  All proceeded well.

Because Sam’s birth was a c-section and I was high risk we opted for another c-section this time as well.  Once again, my child had her own mind and we didn’t make the scheduled date.  This time I had one of the worst headaches in my life.  I don’t get migraines, but I imagine my pain felt similar to what migraine suffers experience.  Horrible.

Dehydration

My weekly OB appointment was the next day and I begged her to go ahead with the c-section that day.  She wasn’t willing to do that, until the sono report showed that since the last week I had lost all my amniotic fluid.  Not sure how I missed that???!!

We headed to the hospital that afternoon, where I was rehydrated with at least 3 liters of fluid while I waited my turn for the OR suite.  We are still not sure how I got in that state, but the dehydration was likely the cause of my headache.

Sophie was also born that evening, healthy and kicking requiring no special care.  We were home in a few days.

Reflecting

I realize how fortunate I am to have 2 healthy pregnancies at my age and with Type 1 diabetes.  Many are not.  I am grateful for this gift.  My obsessive blood sugar checks may have been over the top, but my heart and head demanded that knowledge.

My advice if you are in my situation now?  Get on a continuous glucose monitor and pump so you can manage as tight as you can. Trust your gut and listen to your body.  It will let you know what it needs.  Use your voice, ask questions, demand answers, understand your options and believe that it is possible. Lastly, you will have the opportunity to let something that you cannot see influence you: fear or faith.   Choose faith, fear will keep you from your best.

Peace,

Patricia