As I’m having a c-section at 38 weeks, the baby needed to have a shot of steroids before she’s born to make sure her lungs are nice and strong when she arrives. I was surprised by this as I thought 38 weeks was past the date when steroids are required, but according to the latest Royal College of Obstetricians & Gynaecologists guidelines, it’s generally recommended that all babies to be born by c-section before 39 weeks are given steroids. So that’s what we did.
The one advantage of the whole situation was that because everyone was so busy telling me “steroids will play havoc with your diabetes” it did stop them from telling me that all diabetics have massive babies for a short while at least, so that made a pleasant change. Unfortunately I was unable to locate the havoc prevention setting on my pump, so instead I took to the interweb and asked people via Facebook, Twitter and various forums to share their experiences of how steroids impacted their diabetes so I could make a plan.
The general consensus for steroids in pregnancy seemed to be that they make you really high from around 2 hours after you have the first injection up until around 48 hours after the last injection. And the peak insulin resistance seems to be between 9 and 15 hours after the injection. And helpfully, that varies from person to person. Great stuff, just what you need when you’re pregnant. The hospital kindly offered a sliding scale to manage this for me, you’ll be surprised to hear that a diabetic control freak like me declined that option. I decided to manage it myself on pump and CGM.
I find with any form of insulin resistance, once you let BGs get high it’s a mammoth task to get them down again. So I decided on an aggressive strategy of pre-empting BG rises and increasing basal rates well in advance so in theory I should be able to prevent any shocking highs. Overall, I’m very pleased with how it went if I do say so myself. Here’s the detail from day 1:
- 22.00, BG 5, temp basal rate (TBR) 100% (ie normal basal rate) – 1st steroid injection
- 23.00, BG 5, TBR 110% – increased basal in anticipation of BG rise starting 2 hours post injection
- 00.30, BG 5.2, TBR 110% – holding steady
- 02.30, BG 5.8, TBR 120% – CGM shows BGs starting to creep up ever so slightly, gamble that this is the steroids starting to kick and increase temp basal
- 04.00, BG 6.6, TBR 130% – increased temp basal in anticipation of peak insulin resistance starting in a couple of hours. Also took 1u correction as rate of BG increase was speeding up and I wanted to keep that as flat as possible.
- 05.00, BG 7.4, TBR 130%
- 06.00, BG 6.6, TBR 130% – temp basal seems to be holding things steady, stick at 130% and keep a close eye on it
- 07.30, BG 6.3, TBR 130% – bolus for breakfast 30mins before eating. Increase breakfast bolus by 30% to accommodate steroids (this was a complete stab in the dark, in hindsight I’d probably increase by 50% and bolus about 45mins before)
- 09.30, BG 11.4, TBR 130% – BG peaks post breakfast at 11.4, give a bit more bolus to try and get that down fast as I’m conscious the second steroids are due at 10.30 and I want to get it down before they start having an impact
- 10.30, BG 10, TBR 150% – final steroid injection. Increase basal early to 150% in anticipation of them kicking in around 12.30 and my BG already being higher than I’d like
- 11.30, BG 7.4, TBR 150% – BG coming down gently following aggressive post breakfast corrections
No, I didn’t get much sleep. And so it continued for a further 2 days. I kept monitoring and trying to anticipate the changes. And it seems being brave worked. Over the next 12 hours I increased basal rates to 170% and then eventually started reducing them back down as the resistance started to fade. I returned to normal basal rates about 36 hours after the second injection. I was expecting my aggressive approach to end up in me needing to eat to treat low BGs, but that only happened once when the resistance was starting to fade and I didn’t reduce my basal quick enough.
When I started thinking about how to handle steroids, this is exactly the kind of info I was looking for and I just couldn’t find it, so hopefully this might be of use to some other poor soul in my situation. In summary, I learned:
- Try to anticipate the rise and increase basals early – shifting a high once you’re up there is always going to be harder than preventing it
- I couldn’t have done this without a pump and CGM – the trend info on the CGM showing me whether I was rising or falling was invaluable. I gambled on basal rate increases based on tiny rising trends on the CGM – you simply couldn’t spot that on BG monitoring alone.
- My obstetrician wanted to give me the steroids 2 days before my c-section. After a bit of reading I asked that we did them earlier, so that they’d have time to clear my system before the surgery. He agreed. If you have any choice (ie it doesn’t endanger the baby), I’d recommend getting the steroids out of the way early – otherwise you risk the steroid highs still happening while you’re giving birth and then clashing with the post birth insulin requirement crash. That would be a complete nightmare.