A 23-year-old woman, gravida 1 para 0, comes to the office for an initial prenatal visit. She had a positive home pregnancy test 2 weeks ago and started taking a daily prenatal vitamin at that time. The patient had some light vaginal bleeding 3 weeks ago, which has resolved. She has had no nausea, vomiting, or pelvic pain. The patient was diagnosed with type 1 diabetes mellitus at age 5 and is on an insulin pump. She has no other chronic medical conditions. Blood pressure is 120/74 mm Hg and pulse is 80/min. BMI is 22 kg/m². Pelvic examination shows an enlarged uterus and a closed cervix. Ultrasound shows a twin intrauterine gestation; both twins measure at 7 weeks gestation and have normal heart rates. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

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Explanation: 11ec25c8_da6f_f58d_bc81_d1c85ce8b40e_MD0003_00 Patients with type 1 diabetes mellitus (T1DM) are at risk for diabetic nephropathy (eg, proteinuria) and vascular disease (eg, hypertension), which are independent risk factors for preeclampsia (hypertension of pregnancy with associated proteinuria and/or signs of end-organ damage). Therefore, T1DM is one of several conditions that increase the risk of preeclampsia; others include chronic hypertension, systemic lupus erythematosus, and multiple gestation (eg, twins). Patients at high risk for preeclampsia are started on daily aspirin beginning at 12 weeks gestation. In addition, high-risk patients require a 24-hour urine collection for total protein at the initial prenatal visit to establish a baseline (prepregnancy) proteinuria assessment. The ability to evaluate changes in proteinuria levels helps determine whether blood pressure elevations later in pregnancy are due to gestational hypertension or preeclampsia, which affects antepartum management and delivery timing: Patients with gestational hypertension have blood pressure elevations with no significant changes in proteinuria. These patients are typically managed as outpatients and delivered at 37-39 weeks gestation. In contrast, patients with preeclampsia typically have blood pressure elevations and worsening proteinuria. These patients may require inpatient care and possible preterm delivery (<37 weeks gestation). A 24-hour urine collection also identifies patients with nephrotic-range proteinuria (>3.5 g/day) who are at risk for thromboembolism and require anticoagulation during pregnancy and postpartum. (Choice B) Cerclage placement decreases preterm delivery risk in patients with a short cervix (<2.5 cm) on ultrasound or those with a prior preterm delivery due to cervical insufficiency (ie, painless cervical dilation). (Choice C) Hemoglobin electrophoresis is indicated for patients with anemia (ie, hemoglobin <11 g/dL in the first trimester) to evaluate for hemoglobinopathies (eg, sickle cell trait, thalassemia). This patient's hemoglobin level is normal. (Choice D) Intramuscular hydroxyprogesterone is indicated in patients with a prior spontaneous preterm delivery to decrease the risk of recurrence. This is the patient's first pregnancy. (Choice E) Quantitative β-hCG levels are measured in patients with a pregnancy of unknown location (ie, suspected ectopic pregnancy) or gestational trophoblastic disease (eg, hydatidiform mole) to aid diagnosis and treatment. β-hCG levels do not affect management in patients with a viable intrauterine pregnancy (singleton or multiple gestation) on ultrasound. Educational objective: In patients at high risk for preeclampsia (eg, type 1 diabetes mellitus, multiple gestation), a 24-hour urine collection for total protein at the initial prenatal visit establishes baseline renal function and dictates management (ie, delivery timing) if hypertension develops later in pregnancy. References: Prediction of preeclampsia in type 1 diabetes in early pregnancy by clinical predictors: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/28574296) Determinants of preeclampsia in women with type 1 diabetes. (http://www.ncbi.nlm.nih.gov/pubmed/28975446) ACOG committee opinion no. 743 summary: low-dose aspirin use during pregnancy (http://www.ncbi.nlm.nih.gov/pubmed/29939936)

A 23-Year-Old Woman, Gravida 1 Para 0, Comes to the Office