A 29-year-old woman, gravida 1 para 1, had an uncomplicated vaginal delivery 10 minutes ago. The patient underwent an induction of labor at 39 weeks gestation for insulin-controlled gestational diabetes mellitus. An insulin drip was utilized for glycemic control during labor. The patient was diagnosed with gestational diabetes mellitus at 26 weeks gestation and started on an insulin regimen at 29 weeks gestation when glycemic control via dietary modification failed. Her pregnancy was otherwise uncomplicated. She has no other medical conditions or previous surgeries. The patient is also taking a prenatal vitamin and folate supplementation. She does not use tobacco, alcohol, or illicit drugs. The patient currently has minimal vaginal bleeding; she has no fever, chills, or abdominal pain. Temperature is 36.7 C (98 F), blood pressure is 110/80 mm Hg, and pulse is 88/min. Prepregnancy BMI was 23 kg/m². Physical examination reveals a nontender uterine fundus that is 1 cm above the umbilicus. Bilateral lower extremities have trace edema but no calf tenderness. Blood glucose level 1 hour prior to delivery was 118 mg/dL. Which of the following is the best next step in management of this patient?

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Explanation: 11ec2b69_beba_b490_8f63_1d42bb735f73_MD0005_00 During the second and third trimesters of pregnancy, the placenta begins to secrete increasing amounts of diabetogenic hormones that increase maternal insulin resistance to promote fetal growth. However, women with pancreatic function that is inadequate to overcome this insulin resistance are at risk of developing gestational diabetes mellitus (GDM). GDM is diagnosed at the end of the second trimester (24-28 weeks gestation) by a 2-step approach (ie, glucose challenge test, glucose tolerance test). Typical initial pregnancy management includes dietary modification. If blood glucose levels are not adequately controlled by diet, then either insulin (first-line) or an oral anti-hyperglycemic (eg, metformin) is required. After delivery of the placenta, maternal insulin resistance decreases and glucose concentrations normalize to prepregnancy levels. Therefore, patients with GDM do not require anti-hyperglycemic therapy postpartum (Choices A and C). However, patients with GDM may have had undiagnosed preexisting type 2 diabetes mellitus. For this reason, patients with gestational diabetes are screened for 24-72 hours postpartum with fasting blood glucoses and at 6-12 weeks postpartum with a 2-hour oral glucose tolerance test. Patients with GDM should also undergo diabetic screening every 3 years as they are at increased risk of developing type 2 diabetes mellitus. (Choice B) Patients with insulin-dependent type 1 or 2 diabetes mellitus typically require half of their pregnancy insulin regimen during the postpartum period due to decreased insulin resistance after delivery of the placenta. An insulin sliding scale can be added for additional glucose control. (Choice E) Hemoglobin A1c levels are lower in pregnant women due to physiologic increases in red blood cell mass and cell turnover. Therefore, a hemoglobin A1c is a less sensitive screening test than a glucose challenge test for diabetes mellitus during pregnancy or the postpartum period. Educational objective: Patients with gestational diabetes mellitus (GDM) can discontinue anti-hyperglycemic therapy after delivery. However, patients with GDM are screened 6-12 weeks postpartum with a 2-hour oral glucose tolerance test due to the association between GDM and type 2 diabetes mellitus. References: Diabetes and pregnancy: an endocrine society clinical practice guideline. (http://www.ncbi.nlm.nih.gov/pubmed/24194617) Practice bulletin No. 137: gestational diabetes mellitus. (http://www.ncbi.nlm.nih.gov/pubmed/23969827)

A 29-Year-Old Woman, Gravida 1 Para 1, Had an Uncomplicated