Pregnancy with type 1 diabetes: The constant calculation

I have lived with type 1 diabetes for most of my life. At this point, so much of diabetes management happens almost instinctively. I count carbs. I dose insulin. I watch my Dexcom. I make adjustments. I respond to highs and lows.

Diabetes is always there, but most days, it doesn't get to be the main character.

Pregnancy changes that.

I have two healthy boys, and now I am pregnant with my third baby, a little girl. With each pregnancy, I am reminded just how much pregnancy changes my relationship with type 1 diabetes.

The Targets Are Different

When I'm not pregnant, I work hard to manage my blood sugars. During pregnancy, there is another level of intensity.

The glucose targets during pregnancy are tight. My medical team wants my fasting blood sugar below 95 mg/dL, my one-hour post-meal blood sugar below 140, and my two-hour post-meal blood sugar below 120—all while avoiding hypoglycemia.

Living within those ranges is much harder than simply listing the numbers makes it sound.

During my pregnancies with both of my boys, my lowest A1C was 4.9. I didn't maintain a 4.9 for nine straight months, but I did for a good portion of both pregnancies.

Getting there required an enormous amount of attention.

Right now, one of the biggest challenges is how aggressively my blood sugar responds to food. I typically need to pre-bolus 20 to 30 minutes before eating, depending on where my blood sugar is when I start.

If I don't, it almost doesn't matter what I eat. My blood sugar doesn't gradually climb—it heads straight up.

I've even started giving insulin for about 20 grams of carbohydrates before I've completely decided what I'm eating. It gets some insulin working while I figure out the rest.

Then comes the constant calculation.

Where am I now? Where am I headed? When am I eating? How many carbs? How much insulin is already working? Did I wait long enough after bolusing?

And all of those calculations are happening while the rest of life is happening, too.

I'm managing a career, leading a nonprofit and raising two boys who are 3 and 6. There are meetings to get to, school schedules, activities, dinners, bedtime routines and all of the normal chaos that comes with having a young family.

Diabetes doesn't politely wait until I have time to pay attention to it.

I can be in the middle of a meeting while watching an arrow start to climb. I can be getting my boys out the door while thinking about whether I pre-bolused early enough for my own breakfast. And more often than I'd like, I'm standing in the kitchen preparing dinner for my family while drinking juice to correct a low blood sugar of my own.

Most of the time, no one around me would even know I'm doing it.

That's part of what makes pregnancy with type 1 diabetes so mentally demanding. You're working constantly to prevent blood sugars from going too high while also trying not to push so hard that you end up low. And all of that management is happening alongside the rest of your life.

Pregnancy doesn't make the rest of life less demanding to make room for diabetes. It simply asks you to carry more.

And pregnancy keeps changing the answers. What worked last week—or sometimes yesterday—may suddenly need to be adjusted.

Not Every Hour Is Equal

Interestingly, fasting blood sugars have been one of the easier pieces for me during this pregnancy.

After some trial and error, my overnight patterns have become fairly predictable. Keeping my overnight blood sugar safely above 70 while waking up below 95 has been relatively manageable for me.

Then the day gets harder.

My most challenging stretch is lunch through dinner. Those hours require much more attention, more pre-bolusing, more watching trends and more adjustments.

Some days I feel like I am constantly looking at my Dexcom and thinking three steps ahead.

That's probably the biggest difference between pregnancy and my everyday life with type 1 diabetes.

Pregnancy makes diabetes feel louder.

The Weight of Every Number

There is a reason I take all of this so seriously.

Keeping my blood sugars within the range recommended by my medical team is important for both my health and my baby's development.

Knowing that changes the emotional weight of a blood sugar.

Outside of pregnancy, a high might mean, "Okay, I need to correct this."

During pregnancy, that same number can quickly become: How long have I been high? Why did this happen? How quickly can I get it down? Is the baby okay?

And you can do everything right and still see a number you don't want to see.

That's important to acknowledge because I don't want sharing an A1C of 4.9 to suggest that my blood sugars were somehow perfect.

They weren't.

There were highs. There were lows. There were meals I didn't time correctly. There were unexpected reactions to foods. There were adjustments that worked beautifully until suddenly they didn't.

An A1C is one number representing thousands of individual moments.

Pregnancy with type 1 diabetes is lived in all of those moments.

Diabetes Moves to the Forefront

I've spent years learning how to make diabetes fit into my life rather than building my life around diabetes.

Pregnancy shifts that balance.

For these months, diabetes moves closer to the forefront. I think about it more. I watch it more closely. I plan around it more carefully.

And while I take that responsibility incredibly seriously, I don't want to pretend it isn't exhausting sometimes.

Type 1 diabetes already asks us to make hundreds of decisions every day. Pregnancy raises the stakes of those decisions while simultaneously making your body less predictable.

I've already had the privilege of doing this twice.

I have two healthy boys who remind me that all of those pre-boluses, alarms, corrections, finger sticks, calculations and frustrating numbers were worth it.

And now I'm doing it one more time for their little sister.

If there is a woman with type 1 diabetes reading this who hopes to become a mother someday, I don't want my story to make pregnancy sound easy or perfect.

It hasn't been either.

But I do want her to see that type 1 diabetes and motherhood can exist in the same story.

There are other parts of pregnancy with type 1 diabetes that deserve their own conversation—navigating a medical team with different levels of type 1 expertise, advocating for yourself in the hospital, and what it actually looks like to manage diabetes while delivering a baby. Those are stories I'll share separately.

Type 1 diabetes may require more of me during pregnancy.

It has never been allowed to decide whether I get to be a mom.