Support Article
As you were browsing PracticeUpdate, something about your browser made us think you were a bot. There are a few reasons this might happen: You're a power user moving through this website with super-human speed. You've disabled JavaScript in your web browser. A third-party browser plugin, such as Ghostery or NoScript, is preventing JavaScript from running. Additional information is available in this . After completing the CAPTCHA below, you will immediately regain access to PracticeUpdate. You reached this page when attempting to access from 35.224.243.197 on 2017-12-28 05:54:15 UTC. Trace: 507161fa-59bd-405d-a384-9b66930726bc via 0894b646-a920-4bbe-adae-63c4b22043a0 Continue reading >>
What Is The Fetal Mortality Rate For Diabetic Ketoacidosis (dka)?
What is the fetal mortality rate for diabetic ketoacidosis (DKA)? A fetal mortality rate as high as 30% is associated with DKA. The rate is as high as 60% in diabetic ketoacidosis with coma. Fetal death typically occurs in women with overt diabetes, but it may occur with gestational diabetes . In children younger than 10 years, diabetic ketoacidosis causes 70% of diabetes-related fatalities. Glaser NS, Marcin JP, Wootton-Gorges SL, et al. Correlation of clinical and biochemical findings with diabetic ketoacidosis-related cerebral edema in children using magnetic resonance diffusion-weighted imaging. J Pediatr. 2008 Jun 25. [Medline] . Umpierrez GE, Jones S, Smiley D, et al. Insulin analogs versus human insulin in the treatment of patients with diabetic ketoacidosis: a randomized controlled trial. Diabetes Care. 2009 Jul. 32(7):1164-9. [Medline] . [Full Text] . Herrington WG, Nye HJ, Hammersley MS, Watkinson PJ. Are arterial and venous samples clinically equivalent for the estimation of pH, serum bicarbonate and potassium concentration in critically ill patients?. Diabet Med. 2012 Jan. 29(1):32-5. [Medline] . Mrozik LT, Yung M. Hyperchloraemic metabolic acidosis slows recovery in children with diabetic ketoacidosis: a retrospective audit. Aust Crit Care. 2009 Jun 26. [Medline] . Bowden SA, Duck MM, Hoffman RP. Young children (12 yr) with type 1 diabetes mellitus have low rate of partial remission: diabetic ketoacidosis is an important risk factor. Pediatr Diabetes. 2008 Jun. 9(3 Pt 1):197-201. [Medline] . Potenza M, Via MA, Yanagisawa RT. Excess thyroid hormone and carbohydrate metabolism. Endocr Pract. 2009 May-Jun. 15(3):254-62. [Medline] . Taylor SI, Blau JE, Rother KI. SGLT2 Inhibitors May Predispose to Ketoacidosis. J Clin Endocrinol Metab. 2015 Aug. 100 (8):2849-5 Continue reading >>
Normoglycemic Diabetic Ketoacidosis In Pregnancy
Normoglycemic diabetic ketoacidosis in pregnancy The clinical presentation of diabetic ketoacidosis in pregnancy is usually the same as in nonpregnant women, although the blood glucose may not be as high as in the nongravid state. We report a case of a pregnant woman who developed diabetic ketoacidosis with a normal blood glucose and review the pertinent medical literature. A 29-year-old woman with type I diabetes developed diabetic ketoacidosis during induction of labor. She had a glucose level of 87 mg per 100 ml with ketonuria, a metabolic acidosis, and an anion gap of 20 mmol l1. Normoglycemic diabetic ketoacidosis during pregnancy is truly unusual but can occur with relatively low, or even normal, blood sugars and necessitates prompt recognition and treatment. In this case, the combination of an initial episode of hypoglycemia and subsequent blood glucose levels below 95 mg per 100 ml led to a prolonged delay in the initiation of a planned insulin infusion for insulin coverage during the induction of labor. A significant ketoacidosis consequently developed, despite the absence of even a single elevated blood glucose measurement. This case illustrated the importance of not withholding insulin in a patient with type I diabetes for more than a few hours even if the blood glucose is normal. Normal pregnancy is characterized by a state of decreased insulin sensitivity, as well as accelerated lipolysis and ketogenesis. 1 , 2 , 3 , 4 The concentration of serum ketones has been estimated to be two to four times greater than in the nonpregnant state. 1 , 5 In addition, pregnant women have a respiratory alkalosis, lowering the serum bicarbonate concentration, thus reducing the capacity to buffer hydrogen ions. Despite these changes, the incidence of diabetic ketoacidosis (D Continue reading >>
Diabetic Ketoacidosis In Pregnancy | Obstetric Intensive Care Manual, 4e | Accessobgyn | Mcgraw-hill Medical
Despite recent advances in the evaluation and medical treatment of diabetes in pregnancy, diabetic ketoacidosis (DKA) remains a matter of significant concern. The fetal loss rate in most contemporary series has been estimated to range from 10% to 25%. Fortunately, since the advent and implementation of insulin therapy, the maternal mortality rate has declined to 1% or less. In order to favorably influence the outcome in these high-risk patients, it is imperative that the obstetrician/provider be familiar with the basics of the pathophysiology, diagnosis, and treatment of DKA in pregnancy. DKA is characterized by hyperglycemia and accelerated ketogenesis. Both a lack of insulin and an excess of glucagon and other counter-regulatory hormones significantly contribute to these problems and their resultant clinical manifestations. Glucose normally enters the cell secondary to the effects of insulin. The cell then may use glucose for nutrition and energy production. When insulin is lacking, glucose fails to enter the cell. The cell responds to this starvation by facilitating the release of counter-regulatory hormones, including glucagon, catecholamines, and cortisol. These counter-regulatory hormones are responsible for providing the cell with an alternative substrate for nutrition and energy production. By the process of gluconeogenesis, fatty acids from adipose tissue are broken down by hepatocytes to ketones (acetone, acetoacetate, and -hydroxybutyrate [BHB] = ketone bodies), which are then used by the body cells for nutrition and energy production ( Fig. 11-1 ). The lack of insulin also contributes to increased lipolysis and decreased reutilization of free fatty acids, thereby providing more substrate for hepatic ketogenesis. A basic review of the biochemistry involving Continue reading >>
- Bariatric Surgery versus Intensive Medical Therapy for Diabetes — 5-Year Outcomes
- Type 2 Diabetes Remission With Intensive Treatment
- Relative effectiveness of insulin pump treatment over multiple daily injections and structured education during flexible intensive insulin treatment for type 1 diabetes: cluster randomised trial (REPOSE)
Chapter 11: Diabetic Ketoacidosis In Pregnancy
Despite recent advances in the evaluation and medical treatment of diabetes in pregnancy, diabetic ketoacidosis (DKA) remains a matter of significant concern. The fetal loss rate in most contemporary series has been estimated to range from 10% to 25%. Fortunately, since the advent and implementation of insulin therapy, the maternal mortality rate has declined to 1% or less. In order to favorably influence the outcome in these high-risk patients, it is imperative that the obstetrician/provider be familiar with the basics of the pathophysiology, diagnosis, and treatment of DKA in pregnancy. DKA is characterized by hyperglycemia and accelerated ketogenesis. Both a lack of insulin and an excess of glucagon and other counter-regulatory hormones significantly contribute to these problems and their resultant clinical manifestations. Glucose normally enters the cell secondary to the effects of insulin. The cell then may use glucose for nutrition and energy production. When insulin is lacking, glucose fails to enter the cell. The cell responds to this starvation by facilitating the release of counter-regulatory hormones, including glucagon, catecholamines, and cortisol. These counter-regulatory hormones are responsible for providing the cell with an alternative substrate for nutrition and energy production. By the process of gluconeogenesis, fatty acids from adipose tissue are broken down by hepatocytes to ketones (acetone, acetoacetate, and β-hydroxybutyrate [BHB] = ketone bodies), which are then used by the body cells for nutrition and energy production (Fig. 11-1). The lack of insulin also contributes to increased lipolysis and decreased reutilization of free fatty acids, thereby providing more substrate for hepatic ketogenesis. A basic review of the biochemistry involving D Continue reading >>
Fetal Outcomes After Diabetic Ketoacidosis During Pregnancy
Fetal Outcomes After Diabetic Ketoacidosis During Pregnancy 1Department of Epidemiology, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA 2Greater Baltimore Medical Center, Baltimore, MD 3Division of Endocrinology, Diabetes and Hypertension, Brigham and Womens Hospital, Boston, MA 5Section of Endocrinology, Department of Medicine, West Virginia University School of Medicine, Morgantown, WV 6Department of Obstetrics and Gynecology, Brigham and Womens Hospital, Boston, MA 7Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA Corresponding author: Alexander Turchin, [email protected] . Received 2017 Jan 25; Accepted 2017 Mar 2. Copyright 2017 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at . This article has been cited by other articles in PMC. Historical literature reports risk of fetal demise after diabetic ketoacidosis (DKA) in pregnancy as high as 2560% ( 1 , 2 ). However, estimates have generally been based on small sample sizes, with limited investigation of other fetal outcomes or risk factors associated with poor fetal outcomes. We aimed to provide an updated assessment of the incidence and risk factors for fetal demise and other adverse outcomes in women with DKA during pregnancy. This retrospective cohort study included pregnancies between 1996 and 2015 with at least one DKA event in women with type 1 diabetes at one of three teaching hospitals in Boston. Data were collected through medical record review. Pregnancies were excluded if information on birth status (live or demise) and gestational age at birth or demise were unknown. Amon Continue reading >>
- Improved pregnancy outcomes in women with type 1 and type 2 diabetes but substantial clinic-to-clinic variations: a prospective nationwide study
- World Diabetes Day - Research uncovering link between gut health and pregnancy outcomes
- Risk of Diabetic Ketoacidosis after Initiation of an SGLT2 Inhibitor
Diabetes In Pregnancy
Patient professional reference Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use. You may find the Type 2 Diabetes article more useful, or one of our other health articles. This article deals with pregnancy in patients with pre-existing diabetes. See also separate Gestational Diabetes article. Epidemiology Diabetes is the most common pre-existing medical disorder complicating pregnancy in the UK. Up to 5% of women giving birth in England and Wales have either pre-existing diabetes or gestational diabetes[1]. The number of people with type 1 diabetes and the prevalence of type 2 diabetes amongst women of child-bearing age are increasing. Pregnancies of women with diabetes are regarded as high-risk for both the woman and the baby[2]. Of women who have diabetes during pregnancy, it is estimated that approximately 87.5% have gestational diabetes, 7.5% have type 1 diabetes and the remaining 5% have type 2 diabetes[1]. Possible complications Diabetes in pregnancy is associated with risks to the woman and to the developing fetus[1]. Miscarriage, pre-eclampsia and preterm labour are more common in women with pre-existing diabetes. Diabetic retinopathy can worsen rapidly during pregnancy. Stillbirth, congenital malformations, macrosomia, birth injury, perinatal mortality and postnatal adaptation problems (eg, hypoglycaemia) are more common in babies born to women with pre-existing diabetes. Pre-conception care and good glucose control before and during pregnancy can reduce these risks. Increased risk of complications of diabetes Ketoacidosis may occur during the pregnancy. Progression of microvascular complications including retinopathy and nephropathy: poor Continue reading >>
Management Of Pregnancy In Women With Type 1 Diabetes Mellitus: Guidelines Of The French-speaking Diabetes Society (société Francophone Du Diabète [sfd])
The clinical guidelines reported by the French-Speaking Diabetes Society (Société francophone du diabète) include updated recommendations for preconceptual planning and care in the management of pregnancy in women with type 1 diabetes mellitus (T1DM). The working group included diabetologists, as well as an obstetrician, a nurse and a dietician. A review of the literature was performed using PubMed and Cochrane databases. Guidelines published by foreign diabetes societies were also consulted. In women with T1DM, pregnancy increased the risks of hypoglycaemia, diabetic ketoacidosis, pregnancy-induced hypertension, infections and worsening of diabetic microvascular disease. Moreover, T1DM during pregnancy had an impact on the embryo and the fetus, and may have increased the risk of spontaneous miscarriages, malformations, premature births, and fetal and neonatal complications. However, intensive glycaemic control and preconceptual care have been shown to decrease the rate of fetal demise and malformations. Also, the use of insulin analogues during pregnancy is now regarded as safe. Tight glucose control and frequent follow-up are recommended throughout pregnancy in women with T1DM. Their obstetric management should take place in a maternity hospital with an appropriate perinatal environment and in close collaboration with diabetologists. Pregnancy planning and adequate management during pregnancy are mandatory for improving the outcomes of women with T1DM. The full text of this article is available in PDF format. Ce référentiel de la Société francophone du diabète a pour objet de préciser les modalités de la prise en charge préconceptionnelle et pendant la grossesse des femmes atteintes de diabète de type 1 (DT1). Le groupe de travail a été constitué de dia Continue reading >>
- Improved pregnancy outcomes in women with type 1 and type 2 diabetes but substantial clinic-to-clinic variations: a prospective nationwide study
- Women in India with Gestational Diabetes Mellitus Strategy (WINGS): Methodology and development of model of care for gestational diabetes mellitus (WINGS 4)
- Practical Approach to Using Trend Arrows on the Dexcom G5 CGM System for the Management of Adults With Diabetes | Journal of the Endocrine Society | Oxford Academic
Diabetic Ketoacidosis In Pregnancy
Diabetic ketoacidosis affects only 1% to 3% of pregnancies complicated by diabetes; nonetheless it is an acute medical emergency with a potential for dire consequences for both mother and fetus.9,19,31 The maternal mortality rate secondary to diabetes has fallen remarkably from a preinsulin era high of 50% to less than 1% today.18 The rate of maternal loss owing to diabetic ketoacidosis in pregnancy is unknown but most likely ranges from 4% to 15%.18,24,46 The majority of reports on ketoacidosis in pregnancy contain data on 20 or fewer patients, thus maternal mortality rates once ketoacidosis ensues must be extrapolated from nonpregnant data. In the series reported by Gabbe and co-workers,18 7 of 24 deaths in pregnant diabetic women resulted from metabolic complications, with 4 caused by ketoacidosis. Clements and Vourganti11 and Hollingsworth28 have suggested that many of these deaths could have been prevented by appropriate management. Diabetic ketoacidosis more commonly occurs in the second and third trimesters when increased insulin resistance is present.18,41 Fetal mortality has also decreased markedly since the introduction of insulin; however, it is still excessively high. Historically, fetal loss rates have ranged from 30% to 90%.16,32,33 Recently, Montoro and co-workers39 studied 20 type I diabetic pregnant women with ketoacidosis. On admission, seven women (35%) were diagnosed with a fetal demise. None of the remaining 13 women sustained fetal loss once therapy was begun. Kilvert and colleagues31 reported a fetal loss rate of 22% (including spontaneous abortions), with only one (14%) loss among seven cases occurring after the first trimester. Kent and co-workers30 compared fetal mortality among 21 pregnant women with brittle diabetes (those with recurrent keto Continue reading >>
Acute Starvation Ketoacidosis In Pregnancy With Severe Hypertriglyceridemia
Both mother and baby were discharged clinically well. Starvation ketoacidosis may happen in special patient who was in pregnancy and with severe hypertriglyceridemia, after just one day fasting and vomiting. Ketoacidosis occurs most often as diabetic ketoacidosis (DKA) in type 1 diabetes mellitus, and similar ketoacidosis can also occur in patients undergoing a long fast, a condition referred to as starvation ketoacidosis. [1] Emergency ketoacidosis during pregnancy not only has adverse effects for her mother but also for the fetus, such as neurological impairment and fetal demise. Compared with nonpregnant women, women who are pregnant are ketone-prone due to relative insulin deficiency. In 1970, Felig and Lynch [2] first described this exaggerated response to fasting that results in producing more ketones during the second trimester of pregnancy. Pregnant women are more prone to ketosis due to their relative insulin resistance, accelerated lipolysis and increased free fatty acids. In this case, even a short period of starvation during pregnancy can lead to severe ketoacidosis, which is called accelerated starvation. In addition, pregnant women tend to develop hyperlipidemia because of their elevated levels of estrogen. Some cases of starvation ketoacidosis occurring in pregnancy have been described previously. [38] We report there an unusual case of starvation ketoacidosis in the third trimester of pregnancy with severe hypertriglyceridemia. The patient provided written consent and authorized us to publish her case. A 37-year-old pregnant woman weighing 74 kg and 158 cm tall at 38+6 weeks of her second pregnancy was admitted with vaginal bleeding for 2 hours, Kussmaul's breathing (42/min), and history of persistent vomiting for 1 day. She had a previous history of hy Continue reading >>
Course Materials - Case Study: Diabetic Ketoacidosis In Adults - Jefferson State Community College Libraries At Jefferson State Community College
Case Study: Diabetic Ketoacidosis in Adults To provide information about diabetic ketoacidosis (DKA) in adults, including risk factors and clinical presentation, along with treatment goals for the healthcare provider. Information for patient and/or family education is included. Objectives: After reviewing this information, the reader should be able to: Describe the clinical presentation of DKA in adults List diagnostic tests and studies that can be used in the assessment of DKA in adults Discuss treatment strategies for DKA in adults Diabetic ketoacidosis (DKA) is a potentially life-threatening metabolic emergency that occurs as a complication of uncontrolled diabetes. Low serum insulin levels in DKA prevent glucose from entering the cells to perform normal metabolic functions, causing the cells to respond as if in a starvation state. DKA occurs mainly in patients with diabetes mellitus, type 1 (DM1), but it can affect patients with diabetes mellitus, type 2 (OM2) or, rarely, patients with gestational diabetes (i.e., pregnancy-induced diabetes). Most patients with DKA are seen in the emergency department and require admission to the ICU for close monitoring and management. Treatment includes insulin and glucose administration, fluid/electrolyte restoration, and resolution of the underlying cause. Diabetic ketoacidosis (DKA) is a potentially life-threatening metabolic emergency that occurs as a complication of uncontrolled diabetes. Low serum insulin levels in DKA prevent glucose from entering the cells to perform normal metabolic functions, causing the cells to respond as if in a starvation state. The production of counter-regulatory hormones (e.g., catecholamines, cortisol, glucagon, growth hormone) in response to the low insulin levels exacerbates the perceived state Continue reading >>
Diabetes Ketoacidosis In Pregnancy
Abstract Diabetic ketoacidosis (DKA) is a serious medical and obstetrical emergency usually occurring in patients with type 1 (insulin-dependent) diabetes mellitus. Although modern management of the patient with diabetes should prevent the occurrence of DKA during pregnancy, this complication still occurs and can result in significant morbidity and mortality for mother and/or fetus. Metabolic changes occurring during pregnancy can predispose a pregnant diabetic to DKA. The diagnosis of DKA can be more challenging during pregnancy as it does not always manifest with the classic presenting symptoms or laboratory findings. In fact, although uncommon, during pregnancy, DKA may develop even in the setting of relative normoglycemia. Prompt diagnosis and management is essential in order to optimize maternal and fetal outcomes. This article will provide the reader with information regarding the pathophysiology underlying DKA complicating pregnancy and will provide practical management guidelines for the diagnosis and management of this condition. Continue reading >>
Adverse Fetal Outcomes Tied To Maternal Dka, Study Finds
A study in Diabetes Care found that fetal demise occurred in 15.6% of cases among 62 women who had at least one diabetic ketoacidosis event during pregnancy. Higher pre-DKA A1C levels and smoking were associated with an increased risk of preterm birth, while higher NICU admission rates correlated with higher anion gap during DKA event, preterm birth, preeclampsia and smoking. Continue reading >>
Euglycemic Diabetic Ketoacidosis In Pregnancy: A Case Report And Review Of Current Literature
Volume 2019 |Article ID 8769714 | 5 pages | Euglycemic Diabetic Ketoacidosis in Pregnancy: A Case Report and Review of Current Literature 1Division of Internal Medicine, University of Florida College of Medicine, Gainesville, FL, USA 2Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida College of Medicine, Gainesville, FL, USA Diabetic ketoacidosis (DKA) in pregnancy is associated with high fetal mortality rates. A small percentage of DKA occurs in the absence of high glucose levels seen in traditional DKA. Prompt recognition and management is crucial. We report a case of a 30-year-old pregnant woman with type 1 diabetes mellitus admitted with euglycemic DKA (blood glucose <200 mg/dL). Initial laboratory testing revealed a severe anion gap acidosis with pH 7.11, anion gap 23, elevated -hydroxybutyric acid of 9.60 mmol/L, and a blood glucose of 183 mg/dLsurprisingly low given her severe acidosis. The ketoacidosis persisted despite high doses of glucose and insulin infusions. Due to nonresolving acidosis, her hospital course was complicated by spontaneous intrauterine fetal demise. Euglycemia and severe acidosis continued to persist until delivery of fetus and placenta occurred. It was observed that the insulin sensitivity dramatically increased after delivery of fetus and placenta leading to rapid correction of ketoacidosis. This case highlights that severe ketonemia can occur despite the absence of severely elevated glucose levels. We discuss the mechanism that leads to this pathophysiologic state and summarize previously published case reports about euglycemic DKA in pregnancy. Euglycemic diabetic ketoacidosis (EDKA) is a biochemical triad consisting of blood glucose level less than 200 mg/dL, increased anion gap metabolic acidosis, and keto Continue reading >>
Diabetic Ketoacidosis Among Pregnant And Non-pregnant Women: A Comparison Of Morbidity And Mortality
Get access/doi/full/10.1080/14767058.2018.1443071?needAccess=true Purpose: Diabetic ketoacidosis (DKA) is a critical diagnosis that can cause severe morbidity and mortality in the diabetic population. Although it is rare in pregnancy, the aim of this study is to compare DKA in pregnant women with age-matched non-pregnant women to determine if outcomes are influenced by pregnancy. Materials and methods: A population-based age-matched retrospective cohort was carried out using data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1999 to 2013. Pregnant patients with DKA were age-matched with non-pregnant controls also admitted with DKA at a ratio of 1:10. Severe morbidities and mortality were compared among the two groups. Logistic regression was used to adjust for baseline characteristics and comorbidities. Results: We identified 4661 cases of DKA in pregnancy during our study period, which were age-matched to 46,610 non-pregnant controls. Pregnant women with DKA were more likely to stay in hospital for >3 d (odds ratios (OR) 2.15, 95% CI 2.062.25) and had more associated renal failure (OR 2.86, 95% CI 1.764.55); however, they were less likely to require ventilation (OR 0.70, 95% CI 0.620.79), experience systemic inflammatory response syndrome (OR 0.53, 95% CI 0.380.73), or seizures (OR 0.49, 95% CI 0.420.57). Among pregnant women, rates of coma (0.04%) and death (0.17%, OR 0.23, 95% CI 0.140.39) were lower than previously reported and lower than non-pregnant women. Conclusion: Pregnant women with DKA are admitted to hospital for longer periods than non-pregnant controls and are at higher risk for renal failure but otherwise have better outcomes and less mortality than non-pregnant controls. Continue reading >>
