EXPERT SOLUTION: Assessment Description You are part of a surgical team and your role is postoperative management of

Assessment Description

You are part of a surgical team and your role is postoperative management of thoracic surgery. In your role, you are required to determine the course of action for the patient before you call surgeon. A right lower-lobe resection occurred due to adenocarcinoma. The nurse has called at the 12-hour interval from surgery concerned with the amount of drainage within the chest tube.

  • Describe the role of an AGACNP at each of the steps in postoperative care for a surgical patient.
  • Describe the assessment steps you would take.
  • Explain the drainage and decompression devices and how you manage these as an AGACNP.
  • Discuss potential differential diagnoses you could expect from the assessment.
  • Discuss the hemodynamic findings one might see with your provided diagnosis.
  • Propose potential treatment plans that would be appropriate.

Support your summary and recommendations plan with a minimum of two APRN approved scholarly resources.

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PART 19 Consultative Medicine

465 Approach to Medical Consultation
Jack Ende, Jeffrey Berns

Effective health care requires teams of generalists and specialists with complementary
expertise. Many clinical conditions require the input of more than one clinical provider,
either because the diagnosis and recommended treatment is uncertain or because a
patient may have multiple diseases that may be best managed by involving multiple

To consult is to seek advice from someone with expertise in a particular area, whereas
consultation refers to the meeting or comparable outcome arising from that request.
Medical consultation takes several forms. Its most traditional forms include in-hospital
consultation in which physicians provide recommendations or perform procedures for a
hospitalized patient, and out-patient consultations, in which patients are seen in the office
setting. More contemporary forms of consultation include e-consultations, telemedicine
evaluations (see “Consultation Involving Telemedicine,” below), and remote medical
second opinions. In these forms, the consultant may not actually see the patient but,
nonetheless, assumes the responsibility of evaluating the patient’s clinical condition,
assessing and analyzing pertinent clinical data, and offering a synthesis and appropriate

While forms of medical consultation evolve, basic responsibilities associated with
medical consultation endure. These responsibilities can be divided into those that fall to
the requesting physician or non-physician practitioner; the consultant, who provides the
consultation; and the health system, hospital, or organization that must support this
important medical encounter (Table 465-1).

TABLE 465-1 Stakeholder Responsibilities in the Medical Consultation Process

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Before requesting a consultation, the provider should ensure that the patient endorses the
purpose of the consultation, understands the role of the consultant, and anticipates the
likely outcomes of the encounter. Further responsibilities of the requesting practitioner
include being specific and communicating clearly the reason for the consultation. Vague
messages such as, “Please evaluate” are not as helpful as more specific inquiries such as,
“What is the cause of the declining kidney function?” or, “How should this asymptomatic
pulmonary nodule be evaluated?” To the extent possible, the requesting practitioner
should provide the relevant clinical information, summarized as succinctly as possible.
Urgency should be clearly conveyed, typically with a phone call or other direct

The requesting practitioner should be explicit regarding the intended outcome of the
consultation, i.e., is this for a single evaluation or ongoing co-management?
Communication between the requesting and the consulting providers is paramount.
Whether this communication includes direct contact is less important than that the
relevant information and desired outcome be explicit and clear, regardless of
communication medium. Consultations should be requested for clinical purposes and
always directed to qualified consultants; they should not be driven by entrepreneurial or
relationship-building purposes. Another responsibility of the referring provider is not to
“over- consult.” Medical care should be focused on value, not volume.

Just as the referring provider should attend to clear and explicit communication, so too
should the consultant follow the precepts of effective interactions between professionals,
which include courtesy, availability, and clarity. Particularly on the inpatient service, where
consultants may receive several requests each day, it is important that the incoming
consultations are triaged and dispatched as clinically appropriate. Consultants also need
to determine the requested level of involvement going forward and not assume that long-

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term co- management is being sought. While consultants can and should make use of
available clinical data, they should also assemble independently their own database,
including taking a history, performing a physical exam, and reviewing pertinent clinical
studies. Absent that, they may be unable to provide an independent and actionable
synthesis. Just as the referring provider needs to be clear and concise, so too should the
consultant be specific and focused in the recommendations provided. “Possible malignant
ascites” is less helpful than, “I will arrange for paracentesis to exclude the possibility of
malignant ascites.” For the most part, recommendations to “consider” some diagnosis or
test are less helpful than more specific and concrete advice. Some referring practitioners
wish to be called after a patient is seen; others prefer that communication be handled as
part of the medical record. How this communication is handled must also align with the
complexity and urgency of the consultation and clinical circumstances.

Health systems, hospitals, and medical organizations also have responsibilities in the
consultation process. This responsibility includes ensuring that qualified consultants are
accessible and available on the medical staff. Consultations within a single system are
aided by common shared electronic medical records, particularly when consultations
originate in the hospital, but can also involve care in the outpatient setting. Finally, health
care entities should strive to foster a culture of team-based care and collegiality.


Curbside Consults        Curbside consults are requests from one practitioner to another for
an informal and unwritten opinion about a specific patient care matter. They are typically
limited in scope, mostly regarding management or questions regarding procedures, and
developed from information provided by the consulting practitioner and perhaps the
medical record (such as labs and imaging studies), but without a comprehensive review of
the record or any direct contact with the patient. Although often viewed as convenient,
efficient, and a common aspect of clinical care, by their very nature, curbside consults
have been found to often be incomplete or even flawed. It is not uncommon for the
question being asked to be deemed too complex for a curbside consult, or for it not to be
the actual or only issue the consultant feels needs to be addressed. As a general rule,
curbside consults should be avoided. While medicolegal liability is often cited as a reason
to limit curbside consults, the risk is actually negligible as U.S. courts have ruled that
curbside consults do not establish a doctor-patient relationship necessary for creating the
basis for medical malpractice litigation. An important exception, however, is when a
curbside consult is provided by a resident or fellow in training; in this circumstance the
trainee’s supervising physician, whether aware of the curbside consult or not, is
responsible for the recommendations of the trainee.

Second Opinions    Physicians may find themselves providing consultations requested by
patients who have already been evaluated for the same problem by another physician. Not
a “consult” in the usual context of one physician referring a patient to another, the service
provided by the consultant here is, nonetheless, very much aligned with a physician-
referred consult. Second opinions, which often are encouraged by the patient’s physician,
may be sought by patients for reassurance that a diagnosis and treatment

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recommendation is correct, out of dissatisfaction with the initial physician, or with the
hope of an entirely different opinion and recommendation. The physician providing the
second opinion should strive to understand the patient’s motivations for seeking the
additional opinion. While a second opinion may have been initiated by the patient rather
than referral from another physician, it is recommended that the consulting physician
communicate with the patient’s primary physician or specialist as would be done
following a standard consultation unless the patient insists otherwise. In addition,
professional behavior in how the consulting physician refers to the recommendations or
actions of previously consulted physicians is important, even when there is disagreement.
Likewise, it is important that a transfer of care from prior consultants to the one providing
a second opinion be enacted only if specifically requested by the patient or the physician
who encouraged the second opinion.

Consults Involving Mid-Level Providers Increasingly, specialist physicians may find
themselves being consulted by nurse practitioners and physician assistants rather than
other physicians. Whether the quality of the information provided to the consultant
physician by a mid-level provider is different from physician-to-physician referrals has not
been studied. Consulting physicians should know whether they should respond back to
the mid-level provider or to the supervising physician. As with physician-to-physician
consults, it is also important for the consultant to know whether the individual calling for
the consult has an ongoing role in the care of the patient or is simply covering for a limited
period of time. Finally, the consultant, if responding back to the mid-level provider, should
make sure that the information provided meets the needs of that provider, and that
questions are answered as they would be if responding back to another physician.

Consultation Involving Telemedicine        Consultations making use of electronic health
records, patient portals, and various forms of telecommunication technology, including
video conferencing or cell phone communication, can improve access to care, reduce cost,
and improve outcomes. This is particularly true when employed in geographic areas of
health care shortage and when the clinical issues can be handled without direct contact
with the patient, e.g., radiology or dermatology. However, the absence of direct contact
between patient and consultant introduces special issues related to diagnostic accuracy
and physician-patient relationship. Regulatory issues, liability, security, and confidentiality
issues arise as well. Consultation via telemedicine holds considerable promise, but the
aforementioned concerns will need to be better understood.

DANIEL H, SULMASY LS: Policy recommendations to guide the use of telemedicine in

primary care: An American College of Physicians Position Paper. Ann Intern Med
163:787, 2015.

PEARSON SD: Principles of generalist-specialist relationships. J Gen Intern Med 14(Suppl
1):S13, 1999.

466 Medical Disorders During Pregnancy
Robert L. Barbieri, John T. Repke

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Each year, approximately 4 million births occur in the United States, and more than 130
million births occur worldwide. A significant proportion of births are complicated by
medical disorders. Advances in medical care and fertility treatment have increased the
number of women with serious medical problems who attempt to become pregnant.
Medical problems that interfere with the physiologic adaptations of pregnancy increase
the risk for poor pregnancy outcome; conversely, in some instances, pregnancy may
adversely impact an underlying medical disorder.

(See also Chap. 271) In pregnancy, cardiac output increases by 40%, with most of the
increase due to an increase in stroke volume. Heart rate increases by ~10 beats/min
during the third trimester. In the second trimester, systemic vascular resistance decreases,
and this decline is associated with a fall in blood pressure. During pregnancy, a blood
pressure of 140/90 mmHg is considered to be abnormally elevated and is associated with
an increase in perinatal morbidity and mortality. In all pregnant women, the measurement
of blood pressure should be performed in the sitting position, because the lateral
recumbent position may result in a lower blood pressure. The diagnosis of hypertension
requires the measurement of two elevated blood pressures at least 4 h apart. Hypertension
during pregnancy is usually caused by preeclampsia, chronic hypertension, gestational
hypertension, or renal disease.

Approximately 5–7% of all pregnant women develop preeclampsia, the new onset of
hypertension (blood pressure >140/90 mmHg) and proteinuria (either a 24 h urinary
protein >300 mg/24 h, or a protein- creatinine ratio =0.3) after 20 weeks of gestation.
Recent revisions to the diagnostic criteria include: proteinuria is no longer an absolute
requirement for making the diagnosis; the terms mild and severe preeclampsia have been
replaced; and the disease is now termed preeclampsia either with or without severe
features and fetal growth restriction is no longer a defining criterion for preeclampsia with
severe features. Although the precise pathophysiology of preeclampsia remains unknown,
recent studies show excessive placental production of antagonists to both vascular
endothelial growth factor (VEGF) and transforming growth factor ß (TGF-ß). These
antagonists to VEGF and TGF-ß disrupt endothelial and renal glomerular function resulting
in edema, hypertension, and proteinuria. The renal histological feature of preeclampsia is
glomerular endotheliosis. Glomerular endothelial cells are swollen and encroach on the
vascular lumen. Preeclampsia is associated with abnormalities of cerebral circulatory
autoregulation, which increase the risk of stroke at mildly and moderately elevated blood
pressures. Risk factors for the development of preeclampsia include nulliparity, diabetes
mellitus, a history of renal disease or chronic hypertension, a prior history of preeclampsia,
extremes of maternal age (>35 years or <15 years), obesity, antiphospholipid antibody
syndrome, and multiple gestation. Low-dose aspirin (81 mg daily, initiated at the end of
the first trimester) modestly reduces the risk of preeclampsia in pregnant women at high
risk of developing the disease.

Preeclampsia with severe features is the presence of new-onset hypertension and
proteinuria accompanied by end-organ damage. Features may include severe elevation of
blood pressure (>160/110 mmHg), evidence of central nervous system (CNS) dysfunction
(headaches, blurred vision, seizures, coma), renal dysfunction (oliguria or creatinine >1.5

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mg/dL), pulmonary edema, hepatocellular injury (serum alanine aminotransferase level
more than twofold the upper limit of normal), hematologic dysfunction (platelet count
<100,000/L or disseminated intravascular coagulation [DIC]). The HELLP syndrome
(hemolysis, elevated liver enzymes, low platelets) is a special subtype of severe
preeclampsia and is a major cause of morbidity and mortality in this disease. Platelet
dysfunction and coagulation disorders further increase the risk of stroke.


Preeclampsia resolves within a few weeks after delivery. For pregnant women with
preeclampsia prior to 37 weeks of gestation, delivery reduces the mother’s morbidity
but exposes the fetus to the risk of premature birth. The management of preeclampsia
is challenging because it requires the clinician to balance the health of the mother and
fetus simultaneously. In general, prior to term, women with preeclampsia without
severe features may be managed conservatively with limited physical activity, although
bed rest is not recommended, close monitoring of blood pressure and renal function,
and careful fetal surveillance. For women with preeclampsia with severe features,
delivery is recommended unless the patient is eligible for expectant management in a
tertiary hospital setting. Expectant management of preeclampsia with severe features
remote from term affords some benefits for the fetus, but significant risks for the
mother. Postponing delivery beyond 34 weeks gestation in this group of patients is not
recommended. In preeclampsia without severe features delivery at 37 weeks is

The definitive treatment of preeclampsia is delivery of the fetus and placenta. For
women with preeclampsia with severe features, aggressive management of blood
pressures >160/105 mmHg reduces the risk of cerebrovascular accidents. IV labetalol
or hydralazine is most commonly used to acutely manage severe hypertension in
preeclampsia; labetalol is associated with fewer episodes of maternal hypotension.
Elevated arterial pressure should be reduced slowly to avoid hypotension and a
decrease in blood flow to the fetus.

Magnesium sulfate is the preferred agent for the prevention and treatment of
eclamptic seizures. Large, randomized clinical trials have demonstrated the superiority
of magnesium sulfate over phenytoin and diazepam in reducing the risk of seizure and,
possibly, the risk of maternal death. Magnesium may prevent seizures by interacting
with N-methyl-D-aspartate (NMDA) receptors in the CNS. The universal use of
magnesium sulfate for seizure prophylaxis in preeclampsia without severe features is
no longer recommended by most experts. There is consensus that magnesium sulfate
should be used in all cases of preeclampsia with severe features, or in cases of
eclampsia. Women who have had preeclampsia appear to be at increased risk of
cardiovascular and renal disease later in life.

Pregnancy complicated by chronic essential hypertension is associated with intrauterine
growth restriction and increased perinatal mortality. Pregnant women with chronic

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hypertension are at increased risk for superimposed preeclampsia and abruptio placentae.
Women with chronic hypertension should have a thorough prepregnancy evaluation, both
to identify remediable causes of hypertension and to ensure that the prescribed
antihypertensive agents (e.g., angiotensin-converting enzyme [ACE] inhibitors, angiotensin-
receptor blockers) are not associated with an adverse outcome of pregnancy. Labetalol
and nifedipine are the most commonly used medications for the treatment of chronic
hypertension in pregnancy. The target blood pressure is in the range of 130–150 mmHg
systolic and 80–100 mmHg diastolic. Should hypertension worsen during pregnancy,
baseline evaluation of renal function (see below) is necessary to help differentiate the
effects of chronic hypertension from those of superimposed preeclampsia. There are no
convincing data that the treatment of mild chronic hypertension improves perinatal

The development of elevated blood pressure after 20 weeks of pregnancy or in the first 24
h post-partum in the absence of preexisting chronic hypertension or proteinuria is referred
to as gestational hypertension. Mild gestational hypertension that does not progress to
preeclampsia has not been associated with adverse pregnancy outcome or adverse long-
term prognosis.

Normal pregnancy is characterized by an increase in glomerular filtration rate and
creatinine clearance. This increase occurs secondary to a rise in renal plasma flow and
increased glomerular filtration pressures. Patients with underlying renal disease and
hypertension may expect a worsening of hypertension during pregnancy. If superimposed
preeclampsia develops, the additional endothelial injury results in a capillary leak
syndrome that may make management challenging. In general, patients with underlying
renal disease and hypertension benefit from aggressive management of blood pressure.
Preconception counseling is also essential for these patients so that accurate risk
assessment and medication changes can occur prior to pregnancy. In general, a
prepregnancy serum creatinine level <133 µmol/L (<1.5 mg/dL) is associated with a
favorable prognosis. When renal disease worsens during pregnancy, close collaboration
between the internist and the maternal-fetal medicine specialist is essential so that
decisions regarding delivery can be weighed to balance the sequelae of prematurity for the
neonate versus long-term sequelae for the mother with respect to future renal function.


(See also Chaps. 256–263) Valvular heart disease is the most common cardiac problem
complicating pregnancy.

Mitral Stenosis    This is the valvular disease most likely to cause death during pregnancy.
The pregnancy-induced increase in blood volume, cardiac output, and tachycardia can
increase the transmitral pressure gradient and cause pulmonary edema in women with
mitral stenosis. Women with moderate to severe mitral stenosis (mitral valve area =1.5
cm2) who are planning pregnancy and have either symptomatic disease or pulmonary

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hypertension should undergo valvuloplasty prior to conception, preferably with
percutaneous balloon valvotomy (PBV). Pregnancy associated with long-standing mitral
stenosis may result in pulmonary hypertension. Sudden death has been reported when
hypovolemia occurs. Careful control of heart rate, especially during labor and delivery,
minimizes the impact of tachycardia and reduced ventricular filling times on cardiac
function. Pregnant women with mitral stenosis are at increased risk for the development
of atrial fibrillation and other tachyarrhythmias. The immediate postpartum period is a
time of particular concern secondary to rapid volume shifts. Careful monitoring of cardiac
and fluid status should be observed.

Mitral Regurgitation and Aortic Regurgitation and Stenosis        The pregnancy-induced
decrease in systemic vascular resistance reduces the risk of cardiac failure with these
conditions, especially in women with chronic lesions. Acute onset of mitral or aortic
regurgitation may not be well tolerated during pregnancy. For women with severe aortic
stenosis, treatment before pregnancy should be considered for a peak-to-peak valve
gradient >50 mmHg. In women with aortic stenosis and a mean valve gradient <25 mmHg,
pregnancy is likely to be well tolerated. For women with mitral or aortic regurgitation and
left ventricular dysfunction (LVEF <30%) pregnancy should be avoided.

(See also Chap. 264) Reparative surgery has markedly increased the number of adult
women with surgically repaired congenital heart disease. Maternal morbidity and mortality
are greater among these women than among those without surgical cardiac repair. When
pregnant, these patients should be jointly managed by a cardiologist and an obstetrician
familiar with these problems. The presence of a congenital cardiac lesion in the mother
increases the risk of congenital cardiac disease in the newborn. Prenatal screening of the
fetus for congenital cardiac disease with ultrasound is recommended.

Supraventricular tachycardia (Chap. 241) is a common cardiac complication of
pregnancy. Treatment is the same as in the nonpregnant patient, and fetal tolerance of
medications such as adenosine and calcium channel blockers is acceptable. When
necessary, pharmacologic or electric cardioversion may be performed to improve cardiac
performance and reduce symptoms. This intervention is generally well tolerated by mother
and fetus.

Peripartum cardiomyopathy (Chap. 254) is an uncommon disorder of pregnancy and
its etiology remains unknown. Approximately 10% of women with peripartum
cardiomyopathy carry a truncating mutation in the gene encoding the titin sarcomere
protein. Treatment is directed toward symptomatic relief and improvement of cardiac
function. Many patients recover completely; others are left with progressive dilated
cardiomyopathy. Recurrence in a subsequent pregnancy has been reported, and women
who do not have normal baseline left-ventricular function after an episode of peripartum
cardiomyopathy should be counseled to avoid pregnancy.


Marfan Syndrome (See also Chap. 406)        This autosomal dominant disease is
associated with an increased risk of aortic dissection and rupture. An aortic root diameter

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<40 mm is associated with a favorable outcome of pregnancy; conversely, an aortic root
diameter >40 mm is associated with an increased risk of aortic dissection. Prophylactic
therapy with beta blockers has been advocated to reduce aortic dilation and the risk of
dissection. A “cardiac delivery” with reduced pushing and early intervention with operative
delivery is often recommended to reduce increases in aortic wall stress caused by the
Valsalva maneuver.

Ehlers-Danlos syndrome (EDS) may be associated with premature labor, and in type IV
EDS there is increased risk of organ or vascular rupture that may cause death. For women
with vascular EDS, pregnancy is relatively contraindicated because of the high risk of
vascular and uterine rupture.

Pulmonary Hypertension (See also Chap. 277)        Maternal mortality in the setting of
severe pulmonary hypertension is high, and primary pulmonary hypertension is a
contraindication to pregnancy. Termination of pregnancy may be advisable in these
circumstances to preserve the life of the mother. In the Eisenmenger syndrome, i.e., the
combination of pulmonary hypertension with right-to-left shunting due to congenital
abnormalities (Chap. 264), maternal and fetal deaths occur frequently. Systemic
hypotension may occur after blood loss, prolonged Valsalva maneuver, or regional
anesthesia; sudden death secondary to hypotension is a dreaded complication.
Management of these patients is challenging, and invasive hemodynamic monitoring
during labor and delivery is recommended in severe cases.

In patients with pulmonary hypertension, vaginal delivery is less stressful
hemodynamically than cesarean section, which should be reserved for accepted obstetric

(See also Chap. 273) Pregnancy is associated with venous stasis, endothelial injury and a
hypercoagulable state. Inherited thrombophilias and the presence of antiphospholipid
antibodies increase the risk of venous thromboembolism (VTE) in pregnancy. Deep
venous thrombosis (DVT) or pulmonary embolism (PE) occurs in about 1 in 500
pregnancies, with DVT being three times more common than PE. VTE occurs more
commonly in the 6 weeks post-partum than antepartum. In pregnant women, most
unilateral DVTs occur in the left leg because the left iliac vein is compressed by the right
iliac artery and the uterus compresses the inferior vena cava.


Deep Venous Thrombosis
Aggressive diagnosis and management of DVT and suspected pulmonary embolism
optimize the outcome for mother and fetus. In general, all diagnostic and therapeutic
modalities afforded that the nonpregnant patient should be utilized in pregnancy
except for D-dimer measurement, in which values are elevated in normal pregnancy.
Anticoagulant therapy with low-molecular-weight heparin (LMWH) or unfractionated
heparin is indicated in pregnant women with DVT. LMWH may be associated with an
increased risk of epidural hematoma in women receiving an epidural anesthetic in
labor and must be discontinued at least 24 h before placement of an epidural catheter.

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Warfarin therapy is contraindicated in the first trimester due to its association with fetal
chondrodysplasia punctata. In the second and third trimesters, warfarin may cause
fetal optic atrophy and mental retardation. In pregnancy the use of warfarin is
restricted to women with mechanical heart valves. Warfarin is not contraindicated in
breast-feeding women. For women at moderate or high risk of DVT who have a
cesarean delivery, mechanical and/or pharmacologic prophylaxis is warranted.


(See also Chaps. 396–398) In pregnancy, the fetoplacental unit induces major metabolic
changes, the purpose of which is to shunt glucose and amino acids to the fetus while the
mother uses ketones and triglycerides to fuel her metabolic needs. These metabolic
changes are accompanied by maternal insulin resistance caused in part by placental
production of steroids, a growth hormone variant, and placental lactogen. Although
pregnancy has been referred to as a state of “accelerated starvation,” it is better
characterized as “accelerated ketosis.” In pregnancy, after an overnight fast, plasma
glucose is lower by 0.8–1.1 mmol/L (15–20 mg/dL) than in the nonpregnant state. This
difference is due to the use of glucose by the fetus. In early pregnancy, fasting may result
in circulating glucose concentrations in the range of 2.2 mmol/L (40 mg/dL) and may be
associated with symptoms of hypoglycemia. In contrast to the decrease in maternal
glucose concentration, plasma hydroxybutyrate and acetoacetate levels rise to two to four
times normal after a fast.


Diabetes Mellitus in Pregnancy
Pregnancy complicated by diabetes mellitus is associated with higher maternal and
perinatal morbidity and mortality rates. Preconception counseling and treatment are
important for the diabetic patient contemplating pregnancy and can reduce the risk of
congenital malformations and improve pregnancy outcome. Folate supplementation
reduces the incidence of fetal neural tube defects, which occur with greater frequency
in fetuses of diabetic mothers. In addition, optimizing glucose control during key
periods of organogenesis reduces other congenital anomalies, including sacral
agenesis, caudal dysplasia, renal agenesis, and ventricular septal defect.

Once pregnancy is established, glucose control should be managed more
aggressively than in the nonpregnant state. In addition to dietary changes, this
enhanced management requires more frequent blood glucose monitoring and often
involves additional injections of insulin or conversion to an insulin pump. Fasting
blood glucose levels should be maintained at <5.8 mmol/L (<105 mg/dL), with
avoidance of values >7.8 mmol/L (140 mg/

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