CASE SCENARIO

A 34-year-old Hispanic-American woman who is in her second pregnancy and has had
one live birth and no abortions is seen for prenatal care at 24 weeks gestation. Her weight is
220 lb, and her blood pressure is 130/80 mmHg. Uterine size is appropriate for gestational age.
The patient's past obstetric history includes the spontaneous vaginal delivery of a 9-lb, 8 oz.
male infant at 40 weeks gestation, 8 years ago in Mexico. The patient reports that the child is
doing well. Her family history reveals that her mother has type 2 diabetes mellitus. A urine
dipstick shows 3+ glycosuria and negative ketones.

The patient's capillary glucose reading, performed in the clinic, was 193 mg/dl. She was
instructed to return the next morning for a fasting venous plasma glucose, which was 143
mg/dl. Given this finding, the diagnosis of GDM was established.

The patient was begun on both dietary and insulin therapy as an outpatient. Her diet
included 25 kcal/kg actual body weight divided into three meals and a bedtime snack. The diet
emphasized complex carbohydrates with the avoidance of simple carbohydrates. In addition,
she was instructed on self-monitoring of blood glucose, performing tests while fasting and 2
hours after each meal. She was started empirically on 20 units of NPH and 10 units of regular
insulin administered subcutaneously in the morning, to be adjusted after reviewing her
glucose log sheets. The patient was seen each week. Given the significant elevation of her
fasting glucose level, a trial of diet only was not advisable.

The patient did well on this regimen, maintaining good control until 30 weeks
gestation, when her total insulin dose was increased by 20%. At 28 weeks, the patient was
instructed in daily fetal movement counting to assess fetal well-being, and at 32 weeks
gestation antepartum fetal heart rate testing with nonstress tests was begun twice weekly. An
ultrasound examination at 37 weeks revealed the fetus to be growing normally with an
estimated weight of 7 lb, 1 oz. At 39 weeks, the patient started spontaneous labor and
underwent the vaginal delivery of an 8 lb, 1 oz boy. The infant was evaluated for but did not
demonstrate hypoglycemia or other morbidities.

Postpartum, the patient breastfed her infant and, with her partner, decided on a barrier
method of contraception: foam and condoms. Six weeks after delivery, she returned to the
clinic for an evaluation of her glucose tolerance. Her fasting plasma glucose was 128 mg/dl. She
returned the next day, and a repeat fasting plasma glucose was 132 mg/dl. Given these
findings, the diagnosis of diabetes mellitus was made, and a 75-g OGGT test was not needed.