Writing recently for Diet Doctor about the low-carb ketogenic diet for polycystic ovarian syndrome, fertility, pregnancy and gestational diabetes, I couldn't help but reflect on my own reproductive history and my two pregnancies, now more than 25 years ago. Would a low-carb ketogenic diet have helped me back then? Would it have made a difference to how events unfolded? I think it would have.
You see, 26 years ago I almost lost my first daughter in childbirth. She had "macrosomia" meaning I had grown a baby in my womb who was too big for me to deliver. Macrosomia usually means the fetus is getting too much glucose. "Fetal-pelvic disproportion" was another term used to describe my situation.
Many events led up to her difficult birth. But suffice to say Kate was born lifeless and blue, her heart had stopped and she was not breathing. Her Apgar score was zero at both 1 and 5 minutes and just 1 at 7 minutes. She spent the first two-and-a-half days of her life in the NICU - neonatal intensive care unit - fighting for her life.
Kate was feisty, thank God, an 8 lbs 13 ounce (4000 g) heavyweight, and she pulled through. To this day as a healthy young woman she has a resiliency and can-do spirit we marvel at. But her birth was one of the most traumatic events of my life. I checked my diary from that time this past week, just to make sure my memory had not somehow altered or magnified events. I needn't have bothered. The details have been irrevocably burned into my brain. Nothing has been forgotten.
PCOS and an inability to handle carbs
In the final weeks of pregnancy, and during the labour, one thing after another went awry. Back then they had no explanation for the series of complications, but I believe now that it was all related to my underlying polycystic ovarian syndrome (PCOS) and my life-long, hidden, inability to handle carbohydrates. Women with PCOS have three to four times the risk of complications in pregnancy and delivery compared to pregnant women without the condition.
Evidence that carbohydrates didn't agree with me - wheat products for sure - started early. I was diagnosed with celiac disease at 14 months after recurrent digestive troubles followed eating anything with flour. It was a time before celiac disease was detected by blood test or confirmed by intestinal biopsy, but I had the classic infant symptoms of bloating and diarrhea. Somehow by age 10, however, I seemed to grow out of it and wheat products were added back into my diet. Pasta was one of my favourite foods.
Outwardly, I seemed healthy but I had recurrent crippling stomach aches and irritable bowel syndrome (oddly to foods other than wheat - fruits and poultry mostly). I had delayed menarche, periods of patchy hair loss, and a diagnosis of PCOS by age 19. I was a skinny PCOSer, with a BMI of 18 and nary an ounce of extra fat. Back then it was never diagnosed, but now I know that I also had significant reactive hypoglycemia, which some studies have found is much more common in lean women with PCOS.
Four or five hours after a high-carbohydrate meal, like a breakfast of juice, toast and jam, or dinner of lasagna with garlic bread, I would be shaky, light-headed, dizzy, irritable, and so ravenous that I thought I would die if I didn't eat something immediately. Sometimes my blood-sugar lows made me feel so confused and foggy that I felt unsafe to drive a car. I would keep a bag of potato chips or granola bars in my glove box in case a low hit when I was behind the wheel.
The reproductive endocrinologist, who viewed my swollen ovaries covered in cysts and my hormone profile with too high androgens, diagnosed my PCOS and told me that since I rarely menstruated - two to three periods at most a year, some years no periods at all - that it would be very difficult for me to get pregnant. If fertility medicine was going to be able to assist me, he said, I better not wait too long. "What is too long?" I asked. "Thirty" he said.
My late twenties therefore were full of concern over my fertility - what was wrong with me? Why wasn't I normal? - and my fear that I would never be a mother. At age 29, up against the biological wall imposed by the doctor, I took a year off from my job as the medical reporter at a large Vancouver newspaper to research and write a book about infertility.
It was a great way to help the legions of women and men who struggle to conceive by providing the most up-to-date medical information. And it was a great way to help myself to understand what was going on in my own body, especially for the chapter on PCOS. The underlying insulin resistance of PCOS and the effectiveness of a low-carb high-fat diet for reversing the condition were not yet known. (I would radically re-write that chapter now.) When I had finished the book, however, I did know how to chart my basal body temperature, watch for signs of ovulation, and know when I was potentially fertile even if my cycles were 70 to 90 days long.
I knew precisely, therefore, the moment I conceived at age 32. I was tracking my fertility and knew I was ovulating. Usually conception and gestational age for the fetus is calculated two weeks from the mother's last menstrual period but that didn't help for me, as my periods were so wonky. My first maternity doctor dismissed my graphs and wrote "dates unknown" on my chart. Fortunately, I moved cities during my pregnancy and my second doctor believed my dates. "You are having a big baby," she said as she measured my fundal height. At 28 weeks I was borderline gestational diabetes, but had gained only 22 lbs (10 kg). It was all going to build Kate. I was given no dietary advice so I scarfed down pasta and potatoes.
A dramatic delivery
At 41 weeks gestation, they began to worry and follow me closely with ultrasounds. I was very low on amniotic fluid, called oligohydramnios, a common complication of a post-term pregnancy. Kate's head had not descended nor engaged with my cervix, which was hard and closed, not "ripe" or effaced. "That baby is high and dry," the ob/gyn said. "Time to get her out of there."
I was admitted to the antenatal ward for induction of labour, a fetal monitor almost constantly on my belly. Kate's heart rate, fortunately, was strong and steady. For three long days prostaglandin gels were applied to my cervix to try to ripen it. When it finally opened to 0.5 cm (0.25 inch), at 42+3 weeks gestation, they ruptured my membranes and only a dribble of amniotic fluid came out. Oxcytocin was then run through an IV to bring on contractions. After nine hours of hard, unproductive drug-induced labour, my cervix was still just 0.5 cm (0.25 inch) dilated. Kate's heart was still going strong. "You are in for a long haul," the ob/gyn told me and my husband. We decided for an epidural in the hope it might help my labour progress.
That is when disaster struck. The sweet relief of the epidural was just setting in, the bulb for the catheter being inflated in my bladder, when suddenly Kate's heart rapidly decelerated. She was in significant distress. I learned later they believed the umbilical cord became compressed between the catheter bulb in my bladder and her unengaged head, still high out of the cervix.
All I knew, however, was that something was terribly wrong. Lights were thrown on; the fetal alarm was sounding. People were running into the room. I was being rapidly transferred onto a gurney and stripped of my hospital gown. Someone was painting brown antiseptic on my belly. We were running down the hall to the OR. The ob/gyn, was straddling my belly on the moving gurney, pushing on it in rhythmic thrusts like a form of CPR, to try to take pressure off the umbilical cord.
A pediatric resuscitation team was waiting in the OR. Since the epidural was so new, they feared I wasn't numb enough yet for the incision. The OB/Gyn was pumping my belly while someone was running an ice cube over my skin as the anesthetist upped the dose until I couldn't feel the cold. The block was so high I found it hard to breathe, adding to my sense of panic and fear. I was masked with oxygen. As they removed a lifeless blue Kate from my belly in an emergency C-section, they passed her to the team who began suctioning meconium from her lungs and trying to restart her heart. My husband remembers the profound silence of the OR, filled with people working feverishly; the surgical team sewing me up, the pediatric team working on Kate. No one was saying a word.
We heard no cry, not even when they whisked her out of the OR into the NICU. "I can't hear her cry," I kept saying. But I was crying.
"She had us all scared," the pediatrician said. When a fetus is stressed by lack of oxygen it can pass meconium -fetal poo - which can be aspirated into its lungs. Kates lungs were full of it. "I must have sucked a gallon of meconium out of her lungs," the pediatrician said. They estimated she was close to 15 minutes without oxygen, a significant period of perinatal asphyxia. We were told it was as if she had experienced a massive newborn stroke and in the rewiring of her neural networks she might experience deafness or cerebral palsy or other neurological complications. She was followed with neurological and hearing check-ups for two years. While she has had significant life-long asthma - likely a result of the meconium aspiration - as well as severe allergies, ADHD and subtle learning differences, she has never been hindered by her dramatic entry into the world. She is our wonderful miracle child.
A second pregnancy
When it came time for my second pregnancy, two years later, however, I was scared witless. I felt my body was very flawed. I didn't understand why I'd had so many problems. I was frightened it would happen again. I saw a midwife, along with my maternity doctor, and both tried to convince me that I was a strong, healthy woman and this time pregnancy, labour, and delivery would be fine.
Yet, once again at 28 weeks, I had borderline gestational diabetes. My baby, Madeline, was big - even bigger than Kate. At 40 weeks I had oligohydroamnios, again. At 41 weeks my cervix was hard and closed, and her head had not descended. The rapidly diminishing amniotic fluid meant the placenta was failing. It was exactly the same scenario. "I am not inducing you again. The last one was a near disaster," said my OB/GYN who booked me for a planned C-Section the next morning.
I will never forget the insensitive nurse who shaved my belly and swabbed me prior to the operation. "So you decided you didn't want to go through labour, eh?" she said in a judgmental tone, as if I were too posh to push. I was almost speechless, but managed to sputter: "You have no idea what I've been through."
Madeline was 9.3 lbs (4 kg), so big that they had to use forceps to extract her through an incision that they had to widen from hip bone to hip bone. The surgeon stood on a stool for leverage, prying her from my womb while OR staff held my body down on the operating table. Madeline gave out a hale, hearty, red-faced, indignant wail. Relief flooded my body.
So in reflection, how might a low carb ketogenic diet have helped me years ago? Many ways. It would have helped correct my PCOS, my non-existent periods, my infertility and my reactive hypoglycemia. It would have evened out my huge blood sugar spikes and falls. Doing ketogenic eating during my pregnancies likely would have reduced the amount of excess glucose going to build my too big babies. I might have been able to deliver them vaginally if each had been closer to the norm of 7.5 lbs (3 kg). We might have avoided the trauma of Kate's birth. Then, years later, I might not have developed pre-diabetes - which women with PCOS and big babies are much more likely to get.
I thank my lucky stars everyday that I have been blessed with two healthy wonderful daughters when for 12 years of my life I felt I might never have children at all. I thank those same stars that Kate survived her horrible birth, and that I did, too. In another era we would have likely been a mother and child lost in childbirth.
But that underlying story is one of the reasons I am so passionate about spreading the word about low-carb ketogenic eating. If I can help more women avoid PCOS and its complications in pregnancy, if I can help more people improve their health, if I can help women and their babies prevent traumatic entries into the world, the experiences I have been through will have been worth it.
