What is the best next step in managing a 26-year-old gravida 2 para 1 woman with a 10-week intrauterine pregnancy, hyperglycemia-free urinalysis, and normal cardiac activity, presenting with nausea, food aversions, and an enlarged uterus, with a history of irregular menstrual bleeding and no prior prenatal care?

From the Guidelines

The best next step in managing this patient is to initiate a 75-gram oral glucose tolerance test (OGTT) at this initial prenatal visit. This patient presents with symptoms such as nausea, food aversions, and an enlarged uterus, which are common in early pregnancy, but also has a history of irregular menstrual bleeding, suggesting potential hormonal imbalances that could increase the risk of gestational diabetes mellitus (GDM) [ 1 ]. Although the patient does not exhibit hyperglycemia in the urinalysis, early screening for GDM is crucial, especially given the lack of prior prenatal care, which might have otherwise identified risk factors or complications early on. The 75-gram OGTT, as recommended by the International Association of Diabetes and Pregnancy Study Groups (IADPSG) and supported by the American Diabetes Association (ADA), involves measuring fasting blood glucose, followed by administration of a 75-gram glucose solution and subsequent measurements at 1 and 2 hours [ 1 ].

Diagnostic Criteria and Management

Diagnostic criteria for GDM include fasting glucose ≥92 mg/dL, 1-hour glucose ≥180 mg/dL, or 2-hour glucose ≥153 mg/dL [ 1 ]. Early detection and management of GDM can reduce complications such as macrosomia, birth trauma, cesarean delivery, and neonatal hypoglycemia. Management may involve lifestyle changes, which are an essential component of gestational diabetes mellitus management and may suffice for the treatment of many women [ 1 ]. If necessary, medications like insulin, metformin, or glyburide may be added to achieve glycemic targets, with insulin being the preferred medication due to its minimal placental transfer [ 1 ].

Additional Recommendations

Additionally, the patient should be started on prenatal vitamins, particularly folate supplementation, to prevent neural tube defects, and counseled on proper nutrition and weight gain during pregnancy to minimize risks associated with excessive weight gain or malnutrition [ 1 ]. Regular follow-up appointments should be scheduled to monitor the patient's condition closely, given the lack of prior prenatal care and potential risks associated with untreated GDM.

Prioritizing Morbidity, Mortality, and Quality of Life

Prioritizing the patient's morbidity, mortality, and quality of life, it is essential to take a proactive approach in managing potential gestational diabetes, given its implications on both maternal and fetal health. The most recent and highest quality study [ 1 ] supports the use of the 75-gram OGTT for early screening of GDM, emphasizing the importance of early detection and management to improve outcomes.

From the Research

Patient Assessment and Prenatal Care

• The patient is a 26-year-old gravida 2 para 1 woman with a 10-week intrauterine pregnancy, presenting with nausea, food aversions, and an enlarged uterus, and a history of irregular menstrual bleeding and no prior prenatal care 2.
• Given the patient's symptoms and pregnancy status, it is essential to initiate prenatal care as soon as possible, as care initiated at 10 weeks or earlier improves outcomes 2.
• The patient's hyperglycemia-free urinalysis and normal cardiac activity are positive indicators, but further evaluation and monitoring are necessary to ensure the health and well-being of both the mother and the fetus.

Nutrition and Supplementation

• The patient may benefit from prenatal supplementation, as sub-optimal intake of vitamins from preconception through pregnancy increases the risk of many pregnancy complications and infant health problems 3.
• Folic acid supplementation (400 to 800 mcg daily) is recommended to decrease the risk of neural tube defects 2.
• However, the association between folic acid supplementation and gestational diabetes mellitus (GDM) risk is not entirely clear, with some studies suggesting a potential protective effect 4.
• Iron supplementation in pregnancy may increase the risk of GDM, particularly in women who are already iron-replete, and should be considered on a case-by-case basis 5.

Screening and Monitoring

• The patient should be screened for asymptomatic bacteriuria, sexually transmitted infections, and immunity against rubella and varicella, and receive recommended vaccinations, including tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap), influenza, and COVID-19 vaccines 2.
• Screening for gestational diabetes between 24 and 28 weeks is recommended for all patients, and the patient's risk factors for GDM should be assessed and monitored throughout the pregnancy 2.
• Close maternal and fetal evaluation is essential, with the type and frequency of evaluation depending on fetal gestational age, severity of maternal condition, and presence or absence of intrauterine growth restriction (IUGR) 6.