From the Guidelines
For a 33-year-old Hispanic female in her first trimester with an HbA1c of 10.9%, I strongly recommend prioritizing tight blood glucose control to minimize risks to both mother and fetus, as emphasized by the American Diabetes Association guidelines 1. Given the significantly elevated HbA1c, close monitoring for potential pregnancy complications is essential.
Key Recommendations:
- Schedule an appointment with a maternal-fetal medicine specialist and a registered dietitian specializing in pregnancy and diabetes within the next two weeks.
- Check blood sugar more frequently - before meals and 1-2 hours after meals, not just once daily upon waking, to provide better data for adjusting insulin dosing, as recommended by the standards of care in diabetes-2023 1.
- Consider adding a rapid-acting insulin like insulin aspart (NovoLog) or insulin lispro (Humalog) before meals to control post-meal glucose spikes, starting at 2-4 units per meal and adjusting based on glucose readings.
- Take a prenatal vitamin with folic acid daily if not already doing so, as this is essential for fetal development.
- Increase water intake to at least 8-10 glasses daily to maintain hydration.
- Monitor for hypoglycemia symptoms (shakiness, sweating, confusion) and always carry fast-acting glucose tablets.
- Incorporate 30 minutes of pregnancy-safe exercise daily, such as walking or swimming, to help improve insulin sensitivity, as suggested by evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications 1.
Dietary Considerations:
- Focus on balanced macronutrients, as endorsed by nutrition counseling 1.
- Limit carbohydrate intake to 30 grams for breakfast, 45-60 grams for lunch and supper, and no more than 175 grams total per day.
- Choose whole, unprocessed foods like lean proteins, non-starchy vegetables, and whole fruits in moderation.
- Avoid regular pop, fruit juice, ice cream, cake, and other sweets for the rest of the pregnancy.
- Drink water and limit milk intake to one cup (8 oz.) at a time.
Importance of Continuous Monitoring:
- Use continuous glucose monitoring (CGM) as directed to help achieve the A1C target in diabetes and pregnancy, as recommended by the standards of care in diabetes-2023 1.
- Bring your blood glucose meter and CGM receiver (or smartphone with the app) to every office visit with Endocrinology or Diabetes Educators.
Follow-Up:
- Follow up with Dr. Alfonso as scheduled on 5/14/2025.
- Be prepared to discuss your blood glucose readings, insulin adjustments, and any concerns or questions you may have.
From the Research
Medication Management
- The patient is currently taking two 500 mg tablets of metformin extended release once a day, which will be continued for now 2.
- Ozempic will not be taken for the rest of the pregnancy.
- The dose of Tresiba will be increased to 20 units subcutaneously once daily for now.
- The patient will check their finger-stick blood sugar once daily upon waking up, fasting.
- The dose of Tresiba will be increased by 2 units every 3 days if the average fasting blood sugar remains 95 mg/dL or greater.
Blood Sugar Monitoring
- The patient will wear a DEXCOM G7 CGM as directed, with the sensor changed every 10 days 3, 4, 5.
- The goal fasting blood sugar throughout pregnancy is ~ 63 to less than 95 mg/dL.
- The goal postprandial (after meals) blood sugars during pregnancy is less than 140 mg/dL 1-hour after eating and less than 120 mg/dL 2 hours after eating.
- The goal HbA1c during pregnancy is less than 6.0%.
Dietary Recommendations
- The patient should avoid regular pop, fruit juice, ice cream, and cake for the rest of the pregnancy.
- The patient should drink water and eat moderate amounts of pasta, rice, and bread, with whole wheat being preferred.
- The patient should eat more lean proteins and lots of non-starchy vegetables.
- Whole fruit should be eaten in moderation.
- The patient should monitor portion sizes, with 30 grams of carbohydrates for breakfast, 45-60 grams for lunch and supper, and no more than 175 gm carbohydrates total per day.
Follow-up
- The patient will follow up with Dr. Alfonso on 5/14/2025 as scheduled.
- The patient should bring their blood glucose meter and continuous glucose monitor receiver (if used) or smartphone to every office visit with Endocrinology or Diabetes Educators.
- Medication adherence is crucial for effective management, and the patient should be aware of the factors that affect adherence, such as intentional or non-intentional non-adherence 6.