Pregnancy & Diabetes

My name is Nurul Athirah Naserrudin. I have been living with Type 1 Diabetes Mellitus since 3 years old. I was diagnosed in Nagoya, Japan. During that time, the treatment for diabetic patients is by using insulin injections. I was admitted for more than 2 weeks, almost a month in the hospital. As a kid, my parents helped me a lot in giving me injections, deciding healthy foods, and I only got to eat ice-cream one a month. My parents are my strongest supporter, I know they have the strongest mental, emotion and inner-self too, as having a 3 years old and diagnosed with diabetes is not a comforting fact. A lot of stigma surrounds my family, about me being a T1DM, complications, problems at school, even not able to get pregnant. We faced it by reading more about type 1 diabetes mellitus, went for paediatric endocrine clinic reviews and sharing stories with other parents with T1DM children.
Living with diabetes from the day I was diagnosed until my adolescent years was not easy. It is the moment in life where teenagers love to try new things, go for adventures, activities, travels, and having fun with peers. Eating out was occasional and I always have to bring the insulin pens with me.

At 19 years old, I went to study medicine in Ukraine. Being far from family, have thought me a lot of things. Having peer supports and close friends are very important. Stress and emotional disturbance were parts of being a student. Assignments, classes, exams were part of the factors that contribute to blood sugar ups and downs. But that did not stop me from having fun with my friends. We went for celebrations, birthday parties, and even travelling To Europe, Egypt and others during winter breaks.

Being a diabetic and a medical doctor
At 23 years old, I successfully graduated and received my Bachelor in Medical Degree. That was one of the happiest moment of my life and to both my parents. My mom and dad came all the way to Ukraine to share the graduation moment with me. Earlier that year too, my sister graduated and received her medical degree from the local university. Their second child is now a medical doctor. A Type 1 diabetic and a medical doctor.
Working as an intern in the tertiary hospital in Kuala Lumpur was rather hectic. All those wards rounds, blood taking, learning process, and no proper meal and sleep times were considered part of an intern life. In Malaysia, this is called the “ Houseman years”. Houseman years are years that newly graduated medical officers need to pass. HO need to go for 4 department rotations before they can be a permanent medical officer. I started my Ho years doing Paediatric, then Orthopedic, Obs and Gynea, Medical and finally Emergency Department as my final rotation. I never had a Diabetic Ketoacidosis (DKA) episodes throughout my life, saved for one during my ED rotation. I was working at my night shift. I realised that I have frequent urination since the early morning (polyuria). After a few hours of starting the shift, I felt something was not right, thus I checked my BG level. Tt was 24mmol/l. As we were short of staff, I told my colleagues and nurses that I can still help them, and one of them helped me to put the cannula in, took my bloods and gave me a saline bolus. Being a doctor, I always put my colleagues and patients first. And myself being second. Not when one of my colleague reviewed my blood and noticed that I am already acidotic and I need to be observed and managed as a patient. Then as far as I can remember, I was pushed to the Red Zone and monitored till the next day. Afterwards admission for 5 days, I was given MC to rest, before getting back to work.
After I completed 2 years of horsemanship, I was sent to Sabah in 2013 to work as a permanent medical doctor. Both of my parents were quite worried when they knew I was posted there. Sabah is situated at East Malaysia, economically less developed, less infrastructure, and most of the area are hard to reach especially the interior part, and fewer resources as compare to West Malaysia. Truly, I’m contemplating too. But I really wanted to go Sabah since I was a high school student. This was based on Geography textbooks at school where it pictured the beauty of Sabah, their culture, beautiful forests, islands, and geography attracted me a lot.

Now after 6 years since started working in Sabah, I’m still providing my service to the community there. I even graduated with my Master in Public Health in Universiti Malaysia Sabah ( UMS). I had to defer my study due to complications and medical issues after my second caesarian delivery. Currently, I am working as a medical doctor in Kota Marudu district, a district at the North Divison of Sabah. It is situated two hours from Kota Kinabalu, the main city of Sabah. In Kota Marudu, there is no specialist handling Type 1 Diabetes, and there is no hospital with a specialist. Every endocrinologist follows up, I have to drive down to Kota Kinabalu, specifically Queen Elizabeth Hospital for my T1DM review, with the one and only endocrinologist in the whole Sabah. Driving is tiring, not including waiting at the clinic before being called for a review. The endocrinologist, Dr Fung was the one who helped me during my initial journey using insulin pump. I was really into insulin pump after I went back to Malaysia from the International Diabetic Congress in Melbourne, Australia in 2013. I was the representative for Malaysia, and during the “Young Leaders in Diabetic “programme, I met a lot of peers with diabetic from a wide range of professions. Everyone was so energetic and enthusiastic, and willing to share stories. That is when I leant about insulin pump and knew its benefits and advantages in making life less miserable and easier in controlling the BG levels.

Pregnancy and being a type 1 diabetic
I was married to my friend, now my husband in the year 2015. Being a medical doctor in primary care, I have seen a lot of diabetic ladies trying to get pregnant, and I knew the difficulty and stress having to control the BG levels. A lot of them having problems to control their BG levels. Some of the successfully got pregnant, and delivered. Some ladies got pregnant, but end up with miscarriages, stillborn or early neonatal death. But the difficulty doesn’t end there. Some of them have to spend more days at the hospital due to complications of hypoglycaemia of their baby, even problems occurred during delivery due to big babies and having a traumatic birth. Most of them ended in caesarean sections.

Now, all of these stories really make me be very careful before pregnancy. Being a T1DM for more than 30 years, I knew risks are possible. I made sure that my HBA1c levels were always good even months before we had our wedding reception, it was around 5.4 – 6.2mmol/l, and I took folate 3 months before conception. I even stopped taking my statin medication as it is teratogenic. Folate is an important supplement as offspring to a diabetic mother has increased risk of congenital anomalies, including neural tube defects. I did take 5 milligrams (mg) every day until I had positive urine pregnancy test (UPT) , and I continued until I was around 14 weeks pregnancy. Other issues that I am really concerned about was other organs anomalies like heart defects. I was also worried about risk to get diabetic retinopathy. Pregnancy is associated with increased risk of development and progression of diabetic retinopathy. Despite I did not have any complications (yet) after being a diabetic for 30 years, I tend to be more conscious about the complications that might occurred.

During pregnancy
For both of my pregnancy check-up I was under the review of the one and only maternal-foetal-medical specialist in the whole Sabah, at Women and Children’s Hospital Likas, Kota Kinabalu. Again, like my endocrinology follow-up I have to drive down to Kota Kinabalu for 2 hours for my review. During each pregnancy check, there will be a detail scan done by MFM. Mine was done at 20-week gestational period. After 4 weeks, I have to drove down again, for the detail scan of the baby’s heart. And as the continuation for the following check-up with MFM, I have to drive down every 4 week.

First trimester
Every pregnancy journey is different. Every trimester has its own stories. It was smooth sailing during my first pregnancy, but not for my second. I had my first hypoglycaemic coma at 6 weeks of pregnancy and another at 11 weeks each require urgent Emergency management and hospital admission. I had very frequent hypoglycaemic unawareness episodes that I can get as low as 2.0 mmol/l and still feel OK. Despite cutting down the basal levels, and insulin sensitivity, I still had the hypoglycaemic episodes. I tend to be very conscious every day as I did not want it happen again. The BG tend to get better when I reached my second trimester.

Second trimester
At the second trimester, I have very bad acne breakout that some people give predictions that I’m carrying a boy. It’s the old wives’ tales about gender. I never had the pregnancy glows like what people are always wishing for. I did not have morning sickness too. To me it’s all myth rather than reality. To add on, I had severe lower limb swelling which started around 25 weeks during my first trimester. Even my MFM told me that “It was the largest swelling he has ever seen ever throughout his practise”. Being a medical doctor, I knew the risk of probably having preeclampsia, or pulmonary oedema and thus, I went to the Occupational therapist and he measured my “big lower limb” and provided me with TED stocking.

Reaching the third trimester, I knew that my baby and I can do this. My BG was way easier to handle, with less hypoglycaemia events. My colleagues were very supportive from the beginning, and they’re also get excited waiting for my delivery day. My husband was my strong supporter too. Although I did not have requested for any special celebration before delivery, he was the one who always ask if I need anything during the day, or even ask me if I want to eat something before bed. Being someone who loves to travel, I dragged my mother and husband to Bali, Indonesia during both of my pregnancy. We also went travelling to islands as I love the island and sea very much. As scuba diving is not advisable during pregnancy as it can cause decompression sickness and risk to the baby, I went for snorkelling. Being in the water is very good, as it moves the joints, and helps me to improve my breathing. I tried to avoid high-risk activities, and I opted for low-pace hiking, and went for brisk-walking.

Before delivery
According to Sabah Obstetrics and Gynaecology Guideline which is being practise in Sabah, pregnant ladies with pregestational diabetic have to be induce at 38 weeks of pregnancy. This is due to many complications that might happened if the delivery is delayed like stillbirth, early neonatal death, big babaies, birth trauma, and others. Of course, if there was no guideline, I would like to get to 40 weeks and delivered normally. Both of my pregnancy ended up with Caesarean sections. During my antental check at 37 weeks, I was diagnosed to have oligohydramnios. My amniotic fluid was only 5. My MFM advised me for induction as low amniotic fluid levels are dangerous for the baby. It can cause a lot of labour complications such as cord compression, meconium stained fluid, misscarriages, stillbirth and the best management was to delivery the baby. I was admitted straight from the clinic. I was given cervagem for my first delivery induction, but it has to be taken out as I was having hypercontractility. I chose VBAC for my second delivery, and the MFM suggested for balloon catheter for the induction, and it pop-out after 17 hours insertion.

After delivery
My 1st and 2nd babies ended up in NICU as they’re born to mother with diabetes. The first baby weight 3.75kg ( 8.27 oz) and the second 3.4kg ( 7.5 oz). Both were boys. After being monitored for 24hours and able to breastfeed, they’re discharged and put into “rooming-in” with me in the postnatal ward. But The pregnancy journey did not end there. Even after delivery, close monitoring BG is required as breastfeeding tends to bring the BG down. I tried my best to breastfeed my babies, but end up having to give formula milk. Am I stressed? Well, maybe. After my first caesarean, I had my final Master exam in 2 weeks. After my second caesarean, I was admitted to the hospital due to infections one week after I was discharged from the ward. Breastfeeding has many health benefits and I do wish that I am able to provide milk to my baby. But different individuals will end up with either a successful pregnancy journey or not.

Mental health
Having a successful caeserian, and holding my baby – that was one of the most wonderful moments being a mother. Truly, I cant do it alone. There were a lot of supporting factors and demotivating factors through the months but to me, always believe in own self. Mental health is very important, as stress always bring negative emotion not myself, but with the surrounding people, my colleague, family and spouse. I believe the baby also could feel the emotions of the mother thus I tend to always be positive throughout my pregnancy months.

Always believe that everything is possible. Even a T1DM can get pregnant, and deliver beautiful babies. The most important thing is to have a good BG control before pregnancy, and a good HBA1c levels. Stop any drugs that is teratogenic to the baby’s development, and consume folate preconception. Be around positive circle of people, and with good supports, pregnancy months will be among the best moments in life.

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