Interactive diabetes case 11: A 34-year-old pregnant patient with type 2 diabetes

CASE — A 34-year-old woman with Hispanic ethnicity returns to see you after an interval of two years for management of diabetes during pregnancy. The patient was diagnosed with diabetes at age 17 years. She was treated with oral agents for several years and switched to insulin at age 24 years. Glycemic management has been poor, with glycated hemoglobin (A1C) values repeatedly in the 12 to 14 percent range. The patient has had microalbuminuria for at least one year. She had not been following a diet for many years, although she reduced her caloric intake a few months ago in anticipation of pregnancy, and she is sedentary. She intermittently has polyuria, polydipsia, and nocturia. Her last menstrual period was 14 weeks ago. Her home pregnancy test was positive one week ago. She performs fingerstick blood glucose testing intermittently. You download the memory on her glucose meter. The printout indicates a 14-day average glucose value of 229 mg/dL (12.7 mmol/L), with average values of 119 mg/dL before breakfast, 175 mg/dL before lunch, 284 mg/dL before supper, and 244 mg/dL at bedtime. Her most recent dilated eye examination, 11 months ago, revealed moderate nonproliferative retinopathy with scattered microaneurysms and exudates. Physical examination reveals a blood pressure of 118/68 mmHg, weight of 176 lbs (80 kg, unchanged from the previous visit), and body mass index (BMI) of 31.2 kg/m². Peripheral pulses are present in both feet. Vibratory sensation is reduced at the great toes and medial malleoli, light touch is reduced to the mid-calf level, and deep tendon reflexes are absent at the ankles but present at the knees. Laboratory studies include the following: blood urea nitrogen (BUN) 19 mg/dL, creatinine 0.9 mg/dL, urine microalbumin/creatinine ratio 86.3 mg/g (normal <30), A1C 8.6 percent. The quantitative human chorionic gonadotropin (hCG) test is positive at 48,418 international units/L. The patient is on an insulin regimen of NPH 20 units and regular 5 units before breakfast, regular insulin 5 units before supper, and NPH 15 units at bedtime.

What is your assessment?

●The patient has type 2 diabetes, obesity related, with nonproliferative retinopathy, distal sensory neuropathy, and microalbuminuria. She has poor glycemic management. She needs intensive insulin therapy to decrease the risks of spontaneous abortion, fetal macrosomia, and the neonatal complications of diabetic pregnancy, including hypoglycemia, hypocalcemia, hyperbilirubinemia, and polycythemia. (See "Interactive diabetes case 11: A 34-year-old pregnant patient with type 2 diabetes – A1".)

●The patient has type 2 diabetes, obesity related, with nonproliferative retinopathy, distal sensory neuropathy, and microalbuminuria. She has poor glycemic management. She needs intensive insulin therapy to decrease the risk of congenital malformations and also the risks of spontaneous abortion, fetal macrosomia, and the neonatal complications of diabetic pregnancy, including hypoglycemia, hypocalcemia, hyperbilirubinemia, and polycythemia. (See "Interactive diabetes case 11: A 34-year-old pregnant patient with type 2 diabetes – A2".)

●The patient has type 2 diabetes, obesity related, with nonproliferative retinopathy, distal sensory neuropathy, and microalbuminuria. She has poor glycemic management. She needs urgent referral for a therapeutic abortion to prevent the maternal and fetal complications of diabetic pregnancy. (See "Interactive diabetes case 11: A 34-year-old pregnant patient with type 2 diabetes – A3".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Care during pregnancy for people with type 1 or type 2 diabetes (The Basics)")

●Beyond the Basics topics (see "Patient education: Care during pregnancy for patients with type 1 or 2 diabetes (Beyond the Basics)")