From Denver, Colorado, USA:
I have had Type 1 diabetes for 23 years. I just turned 40 and am 8 weeks pregnant. Almost immediately upon becoming pregnant, I started showing high levels of ketones in the morning, followed by high blood sugars. 3 A.M. blood sugars are usually around 90. Ketones usually start showing by about 5 A.M. with blood sugars around 120-150 and then the blood sugars rise dramatically and can go over 300 if not caught. I can clear the ketones within 1.5 hours with insulin. Knowing the dangers of high blood sugars in the first trimester, I have frantically been trying to get rid of this problem. I saw the exact same pattern in a pregnancy 4 months ago that ended in a very early miscarriage, so I know that this is not a coincidence. There is something about the pregnancy that throws me out of control as early as 4 weeks.
I was taking 20 units of Regular insulin before meals (7 at Breakfast, 6 at lunch, 7 at dinner) and 10 units of NPH at bedtime.(I weigh 120 pounds.) About the same time as conception, coincidentally, I switched from Regular to Humalog to correct post prandial highs. Now I take the same number of units as above, only in Humalog, plus I have increased the bedtime NPH to 14 and added 8 units of NPH in the morning.
So far I have tried the following to fix the ketone problem:
This seems to say that the ketones are not being caused by starvation or by lack or insulin. I do not usually have very low blood sugars at 3 A.M., so I don't think the ketones are being caused by a rebound from a low. The only thing I have found to help is to wake myself up at 3 A.M. and 5 A.M. and take 1 unit of Humalog if I see even a trace of ketones. If I don't catch it that early, the levels skyrocket and my blood sugars soon follow.
- Increased NPH to 14 units at bedtime: no effect on the ketones, though I have lower blood sugars.
- Increased my diet from 1500 calories to 2000 calories: no effect.
- Tried a bigger bedtime snack: no effect.
So, is there any explainable connection between development of ketones and very early pregnancy? Is there any other way to treat early am ketones besides waking yourself up all night? I have some very good CDE's and doctors here in Denver, but none of them can explain what is going on here! I am afraid that I am causing great harm to my baby. Thank you very much for any insights you can provide. I really appreciate it!
I am not exactly sure why you are have ketones in your urine, but I would be willing to bet it is due to high blood sugars and not enough insulin. You are probably having big swings in your blood sugar values based on the information you provided in your letter. It might be worthwhile checking a hemoglobin A1c to get an idea of what your overall control has been like.
Erratic control of diabetes can be a problem in early pregnancy. The only solution is close monitoring and appropriate use of insulin.
Ketones in the urine during pregnancy are not worrisome. This will happen in nondiabetic mothers as well who have missed a meal. Ketones in the blood are more concerning and can theoretically have an impact on the fetus's metabolic status.
Additional comments from Dr. Lebinger:I think you have noticed a common problem in pregnancy when you have diabetes - you sometimes sleep more at night after the baby is born than before the baby is born! If you are spilling ketones first thing in the morning and are not running high blood sugars, you may not be getting enough calories during the night (during the pregnancy, the baby "eats" all night even if the mother doesn't.) Eating extra food at bedtime may not last all night. You might find that your only solution is to eat a snack during the middle of the night. You may also want to consider increasing the protein content of your bedtime snack or trying uncooked cornstarch found in NiteBites or mixed with some yogurt, milk or pudding. If you are unable to adjust your evening insulin to prevent high blood sugars when you wake up, you may also need a little extra insulin during the night. Of course, do not make any changes without first discussing them with your own physician.
Good luck and don't get frustrated. You are getting good practice for "night call" for when the baby is born (hopefully the baby will sleep through the night at a young age).
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