KEEP IT IN THE PHAMLY

When people find out I'm pregnant, there are one of two questions they will ask first:

1. When is baby due?
2. Do you know what you're having?

When is baby due? Well, nobody really knows because estimated due dates based on the start of your last menstrual period are based on a very non-inclusive formula some German obstetrician named Franz Nagele concocted hundreds of years ago, assuming all menstrual cycles are 28 days long and you conceived on day 14. This excludes most pregnancies because menstrual cycle lengths vary and you can conceive on a number of fertile days each cycle. In short, this method is stupid and I don't understand why we still use it.

Healthcare professionals realise this, which is why some medical practitioners use your Week 12 growth scan to estimate a new due date that they deem more accurate. But this method is also flawed because the angle the sonographer decides to take the measurement on any given day changes, your fetus's position could also be tricky to measure and you end up with a measurement that can be a little or a long way off the reality.

Lastly, we started the IVF process and my hormones were all over the shop when we became pregnant naturally. My menstrual cycle was a whopping 49 days or so the month before we became pregnant as opposed to my usual 28-day cycle. I tracked my body's symptoms and knew when I had spot bleeding, which I thought was my period coming in a few days, but it turned out to be Baby Pham in embryo form embedding into my uterus lining so if I use another formula that assumes the embryo implants 6-7 days after fertilization then my current estimated due date is off by over a week.

So when people ask me when baby is due, I say it'll be a summer baby.

This turned into a long rant, so I will talk about gender reveals in my next post.

Our fertility and pregnancy experience

There are three main ways that gestational diabetes seems to be managed:

1. Not at all - pregnant woman ignores medical advice, goes rogue and eats whatever she wants and doesn't test her blood glucose levels.
2. Diet-control and exercise - Moderating blood glucose levels through balanced meals and snacks, with moderate movement/exercise after each main meal to help process the blood glucose.
3. Diabetes medical intervention with insulin injections or Metformin pills, or a combo of both.

So far, I have been on Option 2: Diet control and movement. On bad days, I wish I could do option 1 and indulge in hot chips and ice cream without the crippling guilt I know I'd feel after. On exhausted days, I consider asking my diabetes team to stick me with multiple daily needles already so I can be less strict with my diet. Then I remember that I am doing option 2 for baby and get back to it!

Going on insulin, I'm told, risks placental deterioration while taking Metformin pills passes through the placenta and impacts baby's insulin production and growth. Both are safe enough to be used on pregnant women, obviously, but diet-controlled is what the medical teams prefer if you can to avoid further medical interventions that come from going on medication. Diet control doesn't always work especially towards the end of your pregnancy because of wild pregnancy hormones produced by the placenta.

I am writing this at Week 30 when the placenta starts to kick up its insulin-resistant hormones so I may write about insulin and metformin experience in future. But for now, I am diet-controlled.

I went from two meals a day, and an afternoon snack of fruit to:

1. 3 main meals a day - breakfast, lunch, dinner - 30g-45g carbs
2. 2 snacks - 2-3 hours after breakfast and lunch - 15g-30g carbs
3. Supper right before bed - 15g or less carbs

I focus on low-GI carbs that take longer to break down into blood glucose, and adding lots of veggies and protein will also help slow the conversion to glucose. Some women find it easier to go low-carb because there's little to no risk of spiking your blood glucose levels (BGLs), but my dietitian recommended 175g minimum a day for baby's development so that's what I target.

I have this with low GI brown rice that's not pictured

For those on diet control, this generous Melbourne dietitian is a godsend - Robyn Compton shares her GD expertise and I couldn't have figured out my new, balanced diet without her. Even my hospital dietitians recommended her to me after I'd found her through an online support group: https://www.instagram.com/gestationaldiabetes_dietitian/ The hospital dietitian's few pages of info on carb portions and whole foods vs processed foods is not enough to build meal plans for however many months until baby arrives. But with Robyn Compton here to save the day, I have plenty of meal and snack options from here until I deliver.

The Gestational Diabetes Australian Support Group on Facebook is also really helpful:  Lots of women sharing their personal experiences and supporting each other through this often baffling diagnosis and treatment. I don't normally have a good time with Facebook groups because I find people get catty, judgemental or sarcastic when they're allowed to post anonymously. But this group is full of pregnant women who genuinely care and are trying their best to navigate the murky areas of gestational diabetes management.

I also binged the Gestational Diabetes Club podcast by nutritionist, Helena. There is one particularly helpful Q&A episode with a GD educator that I wish they'd recorded a couple months earlier when I was starting my GD learning. It's super helpful: https://open.spotify.com/episode/1AaAKDKl7kOC1hOWQzzoLh?si=e0a1418b664b452b  

I've found my 'safe' meals after about 4 weeks of a crash course on how my body processes different food combinations. I'll occasionally try something new now I'm 11 weeks into my new diet but often I don't want the anxiety of eating something different and waiting two hours to test my BGLs to see if it's within limit. My diet is getting boring and I have another 9-11 weeks to go if baby arrives around the estimated due date, but better safe than sorry. I talk Baby Pham through our daily menu each morning so he's prepared for yet another bland day of eating.

I have a few 'cheat' meals coming up for Babymoon and over the holiday season where I'm pretty sure I'll spike so I want to avoid having too many spikes now. Consistent spikes over time is the real danger to baby whose body then gets used to producing more insulin to compensate for my high glucose diet so I don't feel so bad about the odd cheat meal I have coming up in the next couple months.

Our fertility and pregnancy experience

Not fun fact: There isn't a national standard for diagnosing gestational diabetes (GD), as stated on the Royal College of Pathology Australia's website and also by my gestational diabetes educator. She opened our education session by stating, "This won't help you ladies, but if you were having your baby next year you may not have been diagnosed with GD because they're easing the diagnostic levels." Great. Just great!

It gets dumber. Each hospital has varying blood glucose limits and guidelines. So you can be in the same city as another pregnant GD mumma and get different medical advice. For example, I am trying to keep my levels within:

1. Fasting - 5.0 or under

2. 1 hour after meals - 7.6 or under (only if I know ahead of time I can't test at 2 hours then I should test at 1 hour if I can)

3. 2 hours after meals - 6.7 or under

Other women's fasting numbers range in the 5.3-5.5 range that I've seen. Some women are told to test at the 1-hour mark, while others are told to test at 2 hours. Gestational diabetes guidelines are a bit of a joke, yet it impacts many pregnancies in Australia. I can see why they're loosening the GTT gestational diabetes diagnosis guidelines because it puts more strain on pregnant women who are already struggling with all the quick bodily changes. Though, let's face it - the motivator for diagnosing fewer women with gestational diabetes is probably the cost to the healthcare system. The number of appointments I had scheduled more than doubled when I was diagnosed with GD. 

Anyway, it's 2023 and they haven't changed the Glucose Tolerance Test (GTT) gestational diabetes diagnostic ranges yet so I am being treated for gestational diabetes. You can read about my GTT experience and results for a bit of background.

In my early pregnancy, I was counting down to Trimester 2 in the hopes that I'd feel less nauseous and fatigued. Though, once Trimester 2 arrived so did my gestational diabetes diagnosis. This has taken over my pregnancy and overshadowed sciatica and pelvic pain that seem like molehills compared to the mountain I'm now climbing learning how my body's insulin and blood glucose levels relate to the foods I eat, the exercise I do and stress factors like work, hot weather and poor sleep.

I'll be honest. Gestational diabetes management has put a huge dampener on my pregnancy. I can't sit back and enjoy not feeling nauseous for a few months before reflux and indigestion take over in Trimester 3. Instead, I have a tonne of daily logistics and duties to try and prevent my glucose levels from spiking and causing baby harm. I am juggling 3 meals, 2 snacks and 1 supper each day and testing my blood glucose levels (BGLs) 2 hours after every main meal, and my fasting level first thing when I roll out of bed. This is the most discipline I've had around body and health since... well, ever.

The diet isn't really a diet. It's basically healthy eating with a balance of protein, veggies, fruit and carbs that is recommended for all adults. The difference is I actually have to follow it strictly because straying into simple carbs and highly processed foods like white bread or hot chips spikes my blood glucose levels. Why is this bad? Because if I can't keep blood glucose in check, then my baby overproduces insulin to compensate for my high blood glucose levels. Why is that bad? Because insulin is linked with weight gain in adults and babies leading to macrosomic babies.

Why is big baby bad? They may be harder to birth vaginally, though I've heard of plenty of women birthing big babies who didn't have GD so I'm not worried about that. The main problem with having a big baby in our medical system is the hospital policies. They will want to induce you early (Week 38-39 at my hospital) instead of letting you go into labour naturally when the baby is good and ready to come out. What if they don't want to come out until Week 40-41? Women in my GD support group also seem to feel pressured into elective C-Section to avoid risks. In case you can't tell from my language, I plan to decline offers of early induction or elective C-section unless a good medical reason arises such as I develop preeclampsia or placenta deterioration or baby has health issues. I'm not scared of trying to push out a big baby.

What I am scared of is what could happen after birth if I don't control my BGLs and baby gets used to over-producing insulin. Once bub is earthside, they'll no longer have my blood glucose passing through the placenta to them, and could end up a severe blood glucose level crash, end up in NICU and we won't have skin-to-skin time in our first days together-apart. I want to do everything I can to be able to hold my baby even if it means going on insulin injections or taking metformin tablets. There's only so much you can do to manage your BGLs with diet and exercise. If my placenta decides to produce lots of insulin-resistant hormones as my pregnancy progresses, then medical intervention will be the way forward. 

So... this fear is how I am getting through the monotony, strict schedule and firm diet of gestational diabetes. Any time I've slipped up like eating mango, or having a late meal, my BGL has spiked to remind me to get back in line. On days when I don't feel like jabbing my finger for the two hundredth time or meal prepping yet again or eating another hard-boiled egg for supper, I either say my affirmation out loud or loudly in my head, "For baby!" I'm doing it all to give Baby Pham a chance at being as healthy as possible.

My dreams of an easy Trimester 2 before I got extra bloated in Trimester 3 is long gone. I'm now dreaming of Trimester 4 once baby is out and I can bite into a banh mi. Soft, fluffy, crunchy white bread and all the things I don't currently eat for risk of salmonella or listeria - deli meats, raw egg mayo, liver pate. Oh man... I haven't told The Phamly yet but whoever visits me from Brisbane's southside first has to bring at least two banh mi for me and maybe one for Boyfriend Pham.

I have roughly another 250 finger jabs to go before our due window. Sigh... For baby!

Our fertility and pregnancy experience

The glucose tolerance test (GTT) is a stress test on your body to see if your insulin is managing your blood glucose levels well when you consume 75g of glucose syrup on an empty stomach. All pregnant women are offered the GTT around Week 27-29 when the placenta produces more of the hormones that cause insulin resistance. High risk women like me who have a family history of Type 2 Diabetes and Chinese-Vietnamese descent are given the GTT around Week 14-16 once the placenta has formed. From what I've gathered, women who had gestational diabetes are given the GTT in Trimester 1.

If you're going for a GTT, make sure you follow the preparation guidelines carefully so you don't accidentally skew the results and get misdiagnosed. Your pathology lab should give you an info sheet specific to their testing requirements, but here is a general guide if you want to learn more: https://www.healthdirect.gov.au/blood-glucose-test

The irony is I was working in a product team building a pathology booking system when I got pregnant. Pregnant women are treated like pin cushions we are sent for so many blood tests in Trimester 1. I went from researching what pathology patients need to being a regular pathology patient.

The GTT is a 2 hour+ test. When you arrive, usually first thing in the morning as you need to fast for 8-12 hours. If you fast for longer, your body may do a glucose dump and cause you to fail the fasting blood glucose level test and be diagnosed with diabetes, pre-diabetes or gestational diabetes depending on why your doctor sent you for the test and your medical condition.

Some people abhor the test and feel sick from the glucose syrup. I was thankfully not one of these people. After my fasting blood vial was taken, I sipped my 75g of glucose in a 10 minute window without issue. The pathology collector set a timer for 1 hour from my fasting test and at the one hour mark, another blood vial was taken. Another 1 hour timer was set and at the 2-hour mark from drinking the syrup, my third blood vial was taken and after checking I was feeling OK, they sent me on my merry way with cotton balls taped to both arm nooks. They rotate arms for the GTT so one arm gets pricked twice at the fasting and 2 hour mark, and one arm gets pricked once at the 1 hour mark.

I failed my GTT at 16 weeks pregnant, and have been diagnosed with gestational diabetes due to my 1 hour test results based on the diagnostic criteria below, as I had a 10.7mmol/L result. My fasting and 2 hour results were fine.

International Association of the Diabetes and Pregnancy Study (IADPSG)

• 0 h ≥ 5.1 mmol/L
• 1 h ≥ 10.0 mmol/L
• 2 h ≥  8.5 mmol/L

Our fertility and pregnancy experience

When people say you're glowing in Trimester 1, it's the sheen of sweat that is reflecting light off your nauseated forehead. The good news is that for some of us, including me, this sweat does actually become a glow in Trimester 2 once you stop feeling sick all the time and are instead flushed with the 40%-50% extra blood circulating around your body, making you feel overheated, and putting you at risk of varicose veins, high blood pressure and other fun, potential pregnancy symptoms.

My early pregnancy symptoms in brief:

1. Sore boobs - a constant dull ache and they keep on growing
2. Sleep deprivation - I used to sleep like a log but no more
3. Frequent peeing - including at night, which added to lack of sleep
4. Fatigue - the most tired I've ever been in my life. Pulling all-nighters and 6-day camping music festivals have nothing on pregnancy fatigue
5. Gas - constantly bloated and gassy. Farting myself awake was a fun, new experience
6. Nausea - constantly needed plain carbs to settle my belly
7. Pimples - a smattering of hormonal pimples along my chin line
8. Sciatica in both legs - this is why they recommend sleeping with a pillow between your knees to alleviate pressure on the hips during pregnancy. Learned the hard way. D'oh.

I only vomited twice and that was before I knew I was pregnant. The first time I threw up was during a Diablo 4 gaming session. I don't normally get tension headaches but Boyfriend Pham does so we assumed I'd just been tense at the computer for too long. The second time I threw up was the night I found out from the GP via an email that we were pregnant. I went out to dinner for Girls Night, ate pho, had indigestion all night then finally threw up in the morning and took the next day off work.

This is what I craved early on:

1. Breakfast - must have cereal as soon as I get up to combat nausea
2. Oranges - 3kg bag nearly every week
3. Bananas
4. Kiwi - out of season so that was an expensive phase
5. Strawberries
6. Vegemite on toast
7. Eggs and toast
8. Plain crackers
9. Crackers and cheese
10. Hot chips
11. Cheese and butter sandwiches, later I craved pickles and cheese sandwiches
12. Vinegar - on salads mostly, but sometimes I'd drink a mouthful
13. Could not stomach red meat for 2+ months

Of the girls night crew, I had the worst Trimester 1 experience. In hindsight, I think it was the gestational diabetes / pre-diabetes because my pregnancy cravings were all high GI, mega blood glucose spiking foods like plain cheese sandwiches with butter and white bread, or plain hot chips soaked in tomato sauce. Fatty foods made me feel sick, flavoursome foods like curries made me feel sick. I somehow managed to not throw up, though, even when I thought I might. I was mega nauseous and plain carbs seemed to be the only thing to settle my stomach. But then I'd feel tired and exhausted after food and need a nap.

Our fertility and pregnancy experience

Our 2cm bean at 8 weeks.

For someone trying to get pregnant for a number of years, I sure was oblivious to what pregnancy actually entails. I knew that you did an at-home pregnancy test and then should get a blood test to verify any positive results. And then...?

I went to my regular general practitioner doctor (GP). He is very considerate and attentive when diagnosing general health problems but he is not an antenatal specialist so wasn't across the nuances of early pregnancy. I've since come across a checklist that would have been handy for both of us to know and work through together.

I am in Queensland, Australia and at my first public hospital midwife appointment, I was given a printed version of the Pregnancy Health Record and told to take it to every medical appointment from now on. Pages 12 to 13 are a handy breakdown of what you'll be chatting to healthcare professionals about during the different weeks of pregnancy. https://clinicalexcellence.qld.gov.au/sites/default/files/docs/clinical-pathways/pregnancy-health-record.pdf

A summary of my pregnancy scans and tests up to Week 20 (the halfway mark!):

1. Blood test to verify pregnancy.

2. Blood test to check immunities and potential risks if not immune.

3. Scan 1: Early pregnancy scan to check embryo growth. My GP recommended week 8-10 to also get bub's heart rate. 

4. Scan 2: The "Week 12 Scan" is a Nucheal Transparency (NT) to check the fetus' growth.
   
   This one is a biggy because your baby has developed vital body parts and functions and the remainder of your pregnancy is further developing what's been established. The risk of miscarriage dramatically drops if your baby has all its bits and bobs in order.
   
   Before your scan, you need to do a PAPP-A blood test 4-5 days in advance so the radiology team can get a copy of the blood results before your scan.
   
   Optional NIPT genetic screening blood test that is not covered by Medicare. Cost ranges from $500-$700 from the few pathology companies I looked up in Queensland. NIPT blood test needs to be done up to 7 days in advance as it's a specialist test and may take longer to process. I opted to pay for the NIPT for peace of mind but to also learn the baby's sex (finding out the gender is an opt-in tick box on the request form, you don't have to find out if you don't want to).

5. Hospital referral from your GP - You need to decide whether you're going public or private and nominate your preferred hospital.

6. Hospital care options - You need to choose a maternity care option. I was offered shared care with my GP and hospital midwives, midwives only, or specialist care. I went with midwives only since I was a fairly low-risk pregnancy. That, and my GP seemed glad to refer me away from his care because I had questions he sometimes couldn't answer. I later got bumped up to Specialist Care with a little more involvement from the hospital's obstetrics team. More on that another time.

7. Scan 3: The Week 20 Scan is the last major milestone for the first half of pregnancy.
   
   The scan checks baby's growth and takes measurements and images of the baby. You can also learn the baby's sex at this scan if you didn't learn earlier. If baby is healthy and mumma is healthy then I'm told women are mostly left to their own devices until the Week 26-28 glucose tolerance test (GTT). Then don't continue growth checks until Week 32+ onwards.

Me? Unfortunately, I got diagnosed with gestational diabetes in Week 17. I did my GTT early because being part Chinese put me in the high-risk category. I will write about gestational diabetes another time though, because it adds a whole new dimension to my pregnancy experience.

My left ovary that gave us two frozen embryos and our miracle 'natural' pregnancy embryo.

Our fertility and pregnancy experience