A 38-year-old returns to see you after an interval of two years for management of diabetes during pregnancy

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A 38-year-old returns to see you after an interval of two years for management of diabetes during pregnancy. The patient was diagnosed with diabetes at age 20 years . She was treated with oral agents for several years and switched to insulin at age 24 years . 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 . 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 exam , 11 months ago , revealed moderate non proliferative retinopathy with scattered microaneurysms and exudates . Physical examination reveals a blood pressure of 118 /68 mmHg , weight of 176 1bs (80 kg , unchanged from the previous visit ), and body mass index (BMI ) of 31.2 kg/m2 . Peripheral pulses are present in both feet . 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 Neutral