What is the best next step in managing a 23-year-old gravida 1 para 0 woman with type 1 diabetes mellitus (T1DM), twin intrauterine gestation, and a hemoglobin A1c of 8.4%, indicating poor glycemic control?

From the Guidelines

The best next step in management for this patient is to optimize her glycemic control by adjusting her insulin regimen to achieve a hemoglobin A1c target of less than 6.5%. Her current hemoglobin A1c of 8.4% indicates suboptimal glycemic control, which poses significant risks for both maternal and fetal complications in her twin pregnancy. Poor glycemic control in type 1 diabetes during pregnancy increases the risk of congenital malformations, macrosomia, preeclampsia, preterm birth, and perinatal mortality, as highlighted in the standards of medical care in diabetes-2019 1.

The patient should have more frequent blood glucose monitoring, with target fasting glucose levels of 70-95 mg/dL and postprandial levels below 120 mg/dL. A multidisciplinary approach involving an endocrinologist, maternal-fetal medicine specialist, and nutritionist would be beneficial, as recommended in the management of diabetes in pregnancy guidelines 1.

Some key points to consider in the management of this patient include:

• The importance of achieving tight glycemic control to reduce the risk of congenital anomalies and other complications, with a target A1C of <6% if possible without significant hypoglycemia 1
• The need for frequent blood glucose monitoring and adjustment of insulin dosages to achieve target glucose levels 1
• The importance of counseling the patient about the increased risks associated with twin pregnancy combined with type 1 diabetes, including higher rates of preeclampsia and preterm delivery 1
• The need for a multidisciplinary approach to manage the patient's diabetes and pregnancy, including referral to a registered dietitian to establish a food plan and insulin-to-carbohydrate ratio 1.

While she has appropriately started prenatal vitamins, her diabetes management requires immediate attention before addressing other routine prenatal care aspects. The patient's current situation and the guidelines from the standards of medical care in diabetes-2019 1 support the need for prompt optimization of her glycemic control to minimize risks and ensure the best possible outcomes for both the patient and her twins.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Patient Management

The patient is a 23-year-old woman with type 1 diabetes mellitus, gravida 1 para 0, at 7 weeks gestation with a twin intrauterine gestation. Her current management includes a daily prenatal vitamin and an insulin pump.

• The patient's blood pressure is 120/74 mm Hg, which is within the normal range, but according to 2, women with twin pregnancies and blood pressure above the 95th percentile but within normal ranges are at increased risk of hypertensive disorders of pregnancy.
• The patient's Hemoglobin A1c is 8.4%, which indicates that her diabetes is not well-controlled. According to 3, women with type 1 diabetes during twin pregnancy may require more insulin than those with singleton pregnancies.
• The patient has a twin pregnancy, which is associated with an increased incidence of preeclampsia, as stated in 4.

Next Steps

Considering the patient's type 1 diabetes mellitus and twin pregnancy, the next steps in management should include:

• Close monitoring of blood pressure and urine protein to screen for preeclampsia, as recommended by 4 and 2.
• Adjusting the patient's insulin regimen as needed to achieve better control of her diabetes, as suggested by 3.
• Providing nutritional counseling to ensure the patient is meeting her increased energy and nutrient demands, as discussed in 5.
• Referring the patient to a hospital with a high-risk pregnancy unit, as recommended by 6, to ensure she receives risk-appropriate care.