A 29-year-old woman, gravida 1 para 1, comes to the office for a routine postpartum visit. Six weeks ago, she delivered a 4.2-kg (9 lb 5 oz) girl by cesarean delivery for cephalopelvic disproportion. The pregnancy was complicated by gestational diabetes mellitus, which was controlled with diet and exercise, and preeclampsia without severe features. Since the delivery, the patient has been feeling well but continues to have daily light vaginal bleeding of dark red or brown blood. She is breastfeeding exclusively and is not on contraception. She has no chronic medical conditions and has had no other surgeries. Her last Pap test 2 years ago was normal. Blood pressure is 122/78 mm Hg and pulse is 87/min. BMI is 30 kg/m². The lower abdominal incision is well healed. On speculum examination, there is a small amount of scant brown discharge in the vaginal vault and no cervical lesions. The remainder of the physical examination is normal. Which of the following is the best next step in management of this patient?

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11ec25c8_da5f_7aac_bc81_91095c929852_MD0003_00 This patient had gestational diabetes mellitus (GDM), a common disorder due to placenta-mediated increases in peripheral insulin resistance. Patients are universally screened for GDM at 24-28 weeks gestation, and management varies from diet/exercise to insulin therapy, depending on the ability to achieve target blood glucose goals. After delivery of the placenta, maternal insulin resistance decreases and blood glucose levels typically return to normal. However, all patients diagnosed with GDM are at increased risk for developing type 2 diabetes mellitus (T2DM) due to a proven predisposition toward insulin resistance. In addition, some patients diagnosed with GDM may have had undiagnosed (ie, preexisting) T2DM before becoming pregnant. For these reasons, all patients with GDM require postpartum screening with a 2-hour (75-g) oral glucose tolerance test performed 6-12 weeks after delivery. If screening is negative, repeat screening should occur at 3-year intervals. (Choice B) A 24-hour urine total protein collection can assess for preeclampsia, and an antepartum diagnosis of preeclampsia (as in this patient) increases the risk of persistent preeclampsia and eclampsia up to 12 weeks postpartum. However, this patient is currently normotensive, making these diagnoses unlikely and further testing is not required. (Choice C) This patient's daily, scant brown vaginal bleeding is consistent with normal lochia, a gradual process of endometrial shedding and regeneration which can last up to 8 weeks after delivery. Therefore, further evaluation with endometrial biopsy is not indicated. (Choice D) In women age <30, routine cervical cancer screening occurs every 3 years with a Pap test only (ie, no HPV cotesting). This patient's Pap test was normal 2 years ago. (Choice E) Urine culture screening is performed routinely during pregnancy to identify and treat asymptomatic bacteriuria to help prevent acute pyelonephritis and preterm labor. In contrast, asymptomatic postpartum patients do not typically require urine culture screening because it does not change outcomes. Educational objective: Patients with gestational diabetes mellitus are at increased risk for developing type 2 diabetes mellitus. Therefore, these patients are screened with a 2-hour (75-g) oral glucose tolerance test at 6-12 weeks postpartum. References: ACOG practice bulletin no. 190: gestational diabetes mellitus. (http://www.ncbi.nlm.nih.gov/pubmed/29370047)

A 29-Year-Old Woman, Gravida 1 Para 1, Comes to the Office