shakespeare
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please help with this one:
A 22-year-old woman, gravida 2, para 1, at 12 weeks' gestation comes to the physician for her 3rd prenatal check-up. She feels fine. Her pregnancy has been uncomplicated. She has no history of serious illness. Her previous pregnancy was uncomplicated and was delivered vaginally. She does not use tobacco, alcohol, or drugs. She has no family history of diabetes. Her blood pressure is 135/80 mm of Hg. Physical examination shows fundal height, as well as weight gain, appropriate for her gestational age. Urine dipstick shows glycosuria, without proteinuria. Which of the following is the next most appropriate step in management?
A. Reassurance and repeat follow-ups
B. Obtain fasting urine sample
C. Obtain 1 hr 50 gm oral glucose tolerance test
D. Obtain 3hr 100 gm glucose tolerance test
E. Start diabetic diet and insulin
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| arlete
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A
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| HILFIGER
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B
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| Miradautas Vras
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B FBS. 1st trimester glycosurea
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| shakespeare
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thank you!
hey say also B: but I am reluctant: shouldn't it be fasting __serum__ glucose?
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| arlete
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Who are "they"? I am sure there was a question like that in Kaplan or UW that answered A... 
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| nyimalay
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That question is from UW. The answer is B. I was wrong cause i chose A. I have no idea whether this is done in real practice. I read Kaplan notes only and I didn't find such a protocol.
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| Ivonne
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B of better make sure that the glucose level is under control 
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| arlete
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OK. Maybe my memory is playing tricks on me.
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| shakespeare
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Thank you very very much - this q is indeed from UW (forgive me to reply so late)
My problem is that I did not find anywhere a recomandation for gestational diabetes screening with an URINE sample: checked 5mmc, ferri, CMDT - nothing. And I cannot understand their answer and expl: how can you check for urine glucose again?
CMDT actually says:
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Screening and diagnostic criteria for gestational diabetes mellitus.
Screening for gestational diabetes mellitus
1. 50-g oral glucose load, administered between the 24th and 28th weeks, without regard to time of day or time of last meal. Universal blood glucose screening is indicated for patients who are of Hispanic, African, Native American, South or East Asian, Pacific Island, or Indigenous Australian ancestry. Other patients who have no known diabetes in first-degree relatives, are under 25 years of age, have normal weight before pregnancy, and have no history of abnormal glucose metabolism or poor obstetric outcome do not require routine screening.
2. Venous plasma glucose measure 1 hour later.
3. Value of 130 mg/dL (7.2 mmol/L) or above in venous plasma indicates the need for a full diagnostic glucose tolerance test.
Diagnosis of gestational diabetes mellitus
1. 100-g oral glucose load, administered in the morning after overnight fast lasting at least 8 hours but not more than 14 hours, and following at least 3 days of unrestricted diet (> 150 g carbohydrate) and physical activity.
2. Venous plasma glucose is measured fasting and at 1, 2, and 3 hours. Subject should remain seated and should not smoke throughout the test.
3. Two or more of the following venous plasma concentrations must be equaled or exceeded for a diagnosis of gestational diabetes: fasting, 95 mg/dL (5.3 mmol/L); 1 hour, 180 mg/dL (10 mmol/L); 2 hours, 155 mg/dL (8.6 mmol/L); 3 hours, 140 mg/dL (7.8 mmol/L).
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Their expl (uw) is as follows:
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Benign glycosuria is a very common finding in pregnant women because of decreased renal threshold. However, causes of glycosuria besides decreased renal threshold have to be ruled out first, which is best done with fasting urine glucose measurement. A positive result may be an early sign of gestational diabetes, and therefore, a 1-hour glucose tolerance test has to be carried out. This test is performed by giving the patient a load of 50 grams of glucose orally, then measuring glucose plasma levels 1 hour later. If the glycemia is greater than 135 mg/dLthe patient should undergo a 3-hour glucose tolerance test (confirmatory test), in which a 100gm glucose load is given orally after an 8hour overnight fast. Glycemia is measured immediately before the load, then 1,2, and 3 hours after the load. If at least two values, including the fasting glucose, are elevated, the diagnosis of gestational diabetes is made.
Diabetes screening is also mandated in all pregnant women between 24 and 28 weeks gestation. At this stage of pregnancy, the pregnant woman is at higher risk of developing gestational diabetes because of the presence of sufficient amounts of human Placental Lactogen (hPL) hormone. hPL is produced by the placenta and its production is parallel to placental growth. It has an anti-insulin action and is therefore responsible for the glucose intolerance typical of the second half of pregnancy, which may evolve into gestational diabetes. However, women with one or more risk factors for diabetes should be screened in the first trimester. These risk factors are: age greater than 25, obesity, family history of diabetes mellitus, previous infant weighing more than 4000 gm, previous stillborn infant, previous congenitally deformed infant, previous polyhydramnios, and history of recurrent abortions.
(Choice A) The presence of glycosuria could be an early sign of gestational diabetes, and therefore, this condition has to be ruled out.
(Choice C) 1-hour glucose tolerance test is used to screen for gestational diabetes in all women between 24 and 28 weeks' gestation. This woman will probably have it if the urine fasting test is positive, or at 24-28 weeks.
(Choice D) A 3-hour glucose tolerance test is the confirmatory test, and is performed if the 1-hour test is positive.
(Choice E) Treatment can be instituted after the diagnosis confirmed.
Educational Objective:
Know how to identify benign glycosuria of pregnancy and the screening recommendations of gestational diabetes.
10% of people answered this question correctly;
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| shakespeare
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please help me, what do you understand: the q asks whether you check for GDM (and if so, why would you screen with an urine sample), or if you confirm the glucose dipstick test result?
thank you all again!
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| arlete
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I am as puzzled as you. From what I've studied, ALL pregnant patients in USA are screened for GDM at 24-28 weeks, no exception. And I've never heard about fasting urine glucose.
Sorry for not helping...
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| shakespeare
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Thank you arlete for reinforcing the essential.
I guess in the end UW wanted to emphasize some other point, like ddx for glycosuria.
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| inkspot
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agree! actually UW is contradicting it self.
in one question: the option C was for screeing in pregnancy
what puzzles me is the fact that screening is done in 24-28 weeks? so cant we just reassure?
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| ricardoricardo
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A, glycosuria is physiological in pregnancy
but in more that two occasions and with a certain volume it needs GTT
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| Markus2009
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B
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