A 27-year-old woman, gravida 1 para 0, at 25 weeks gestation comes to the office for a follow-up visit. The patient was diagnosed with gestational diabetes mellitus a week ago and was started on an appropriate diet. She has a history of infertility due to polycystic ovarian syndrome and conceived via ovulation induction. The patient's pregnancy has been complicated by excessive weight gain. She has no other chronic medical problems and has had no surgeries. She takes a prenatal vitamin daily. The patient's mother has type 2 diabetes mellitus and her father has hypertension.
Vital signs are normal. Fetal heart rate is 150/min. Fundal height is 25 cm. On examination, the skin on the axilla and back of the neck is notable for acanthosis nigricans. The remainder of the examination is within normal limits.
Hemoglobin A1c is 7.3%. Home blood glucose levels for the last 5 days are as follows:
Which of the following is the best next step in management of this patient?

Question

A 27-year-old woman, gravida 1 para 0, at 25 weeks gestation comes to the office for a follow-up visit.  The patient was diagnosed with gestational diabetes mellitus a week ago and was started on an appropriate diet.  She has a history of infertility due to polycystic ovarian syndrome and conceived via ovulation induction.  The patient's pregnancy has been complicated by excessive weight gain.  She has no other chronic medical problems and has had no surgeries.  She takes a prenatal vitamin daily.  The patient's mother has type 2 diabetes mellitus and her father has hypertension.
Vital signs are normal.  Fetal heart rate is 150/min.  Fundal height is 25 cm.  On examination, the skin on the axilla and back of the neck is notable for acanthosis nigricans.  The remainder of the examination is within normal limits.
Hemoglobin A1c is 7.3%.  Home blood glucose levels for the last 5 days are as follows:
 Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Gestational diabetes mellitus requires tight glycemic control to prevent maternal and fetal complications (eg, preeclampsia, macrosomia); glycemic targets are lower than in nonpregnant patients with diabetes. The glycemic targets during pregnancy recommended by the American Diabetes Association are: Fasting <95 mg/dL (5.3 mmol/L)1 hour postprandial <140 (7.8 mmol/L) OR 2 hours postprandial <120 mg/dL (6.7 mmol/L) Fasting <95 mg/dL (5.3 mmol/L) < 1 hour postprandial <140 (7.8 mmol/L) OR 2 hours postprandial <120 mg/dL (6.7 mmol/L) < < Although hemoglobin A1c measurements may be helpful, there are no clear guidelines for monitoring, and values tend to be lower in pregnant women. Patients monitor their glucose levels at least 4 times a day (fasting and 1-2 hours postprandial). Those with moderate hyperglycemia may initially attempt dietary modification. Insulin or oral anti-hyperglycemic medications are started if patients do not achieve glycemic targets (fasting and postprandial) within a week (Choice A). First-line management of patients with gestational diabetes mellitus is a combination of short-acting and mid- or long-acting insulin. Insulin detemir (long-acting analog) and intermediate-acting neutral protamine Hagedorn (NPH) are considered safe during pregnancy. Insulin detemir is associated with less hypoglycemia compared to NPH insulin. Human regular insulin, insulin lispro, and insulin aspart are short-acting insulins that are safe during pregnancy (insulin glargine and insulin glulisine are not approved by the US Food and Drug Administration for use during pregnancy). (Choices B and D) Glyburide (not other sulfonylureas) and metformin are acceptable alternate therapies for patients who are unable or unwilling to take insulin. However, both medications cross the placenta, and long-term safety is less established than with insulin. (Choice E) The long-term safety of dipeptidyl peptidase-4 (DPP-4) inhibitors (eg, sitagliptin) and glucagon-like peptide-1 (GLP-1) receptor agonists (eg, exenatide) in gestational diabetes mellitus is not well established, and they are not currently recommended. Educational objective: Hyperglycemia during pregnancy is associated with adverse fetal outcomes. First-line therapy for glycemic control in patients with gestational diabetes mellitus is dietary modification; if that fails, insulin is the preferred treatment. __________ References: Diabetes and pregnancy: an endocrine society clinical practice guideline. (http://www.ncbi.nlm.nih.gov/pubmed/24194617) Practice bulletin no. 180: gestational diabetes mellitus. (http://www.ncbi.nlm.nih.gov/pubmed/28644336)

A 27-Year-Old Woman, Gravida 1 Para 0, at 25 Weeks