MKSAP quiz: History of gestational diabetes
This month's quiz asks readers to evaluate a 26-year-old woman who had gestational diabetes during a pregnancy 4 years ago, but her 12-week postpartum oral glucose tolerance test was normal.
A 26-year-old woman is evaluated during a routine examination. She had gestational diabetes during a pregnancy 4 years ago, but her 12-week postpartum oral glucose tolerance test was normal. A copper intrauterine device (IUD) for contraception was placed at that time. A Pap smear obtained 1 year ago was normal. She received the human papillomavirus (HPV) vaccine as a child. She is sexually active with her husband and has no sexual or vaginal concerns. Medical history is otherwise unremarkable, and she takes no medications.
On physical examination, vital signs are normal. BMI is 20. The remainder of the examination is unremarkable.
Which of the following is the most appropriate management?
A. Cervical cytology and HPV testing
B. Hemoglobin A1c test
C. Nucleic acid amplification test for chlamydia
D. Replace copper IUD
MKSAP Answer and Critique
The correct answer is B. Hemoglobin A1c test. This item is available to MKSAP 19 subscribers as item 109 in the General Internal Medicine 2 section. More information about MKSAP is online.
The most appropriate management is a hemoglobin A1c test (Option B). Women with a history of gestational diabetes, such as this patient, are at high risk for developing diabetes in the future. These patients should be screened with either a fasting blood glucose level or 2-hour, 75-g oral glucose tolerance test between 6 and 12 weeks postpartum and then screened every 1 to 3 years with a hemoglobin A1c measurement. These patients should also be counseled on the importance of achieving a healthy weight and dietary and exercise interventions to prevent diabetes.
Cervical cytology and human papillomavirus (HPV) testing (Option A) are not indicated. This patient had a normal Pap smear 1 year ago; she does not need additional screening at this time. According to the U.S. Preventive Services Task Force, women younger than 30 years require a Pap smear every 3 years but do not require co-testing for HPV. Women aged 30 years or older should be screened every 5 years with a Pap smear and HPV co-testing. If HPV co-testing is unavailable, patients can be screened every 3 years with Pap testing only. The American Cancer Society recommends that individuals with a cervix initiate cervical cancer screening at age 25 years and undergo HPV testing every 5 years through age 65 years; if primary HPV testing is not available, then individuals aged 25 to 65 years should be screened with co-testing (HPV testing in combination with cytology) every 5 years or cytology alone every 3 years.
Because this patient has no vaginal concerns, a nucleic acid amplification test for chlamydia (Option C) is not indicated. The CDC recommends annual screening for chlamydia in women aged 25 years or younger or those with risk factors, such as having multiple sexual partners. Any woman reporting symptoms or requesting screening for sexually transmitted infections should be offered testing.
The copper intrauterine device (IUD) (Option D) is approved for 10 years of use, and thus the patient does not need her IUD replaced at this time. Levonorgestrel-releasing IUDs are FDA approved for 3 to 5 years of use, depending on the brand.
Key Points
- Women with a history of gestational diabetes are at high risk for developing diabetes in the future.
- Women with a history of gestational diabetes require screening with either a fasting blood glucose level or 2-hour, 75-g oral glucose tolerance test between 6 to 12 weeks postpartum, followed by screening every 1 to 3 years with hemoglobin A1c measurement.