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Dka And Fetal Demise

A Case Of Ketoacidosis In Pregnancy

A Case Of Ketoacidosis In Pregnancy

Abstract: Background: Pregnant women are predisposed to accelerated starvation due to continuous nutrient demands by the fetus, and they have increased susceptibility to ketogenesis during periods of caloric deprivation [1, 2]. We report a case of starvation ketoacidosis in a patient with gestational diabetes on a carbohydrate-restricted diet. Clinical case: A 30 year-old woman, gravida 5, para 2, with a history of spina bifida and hydrocephalus status post ventriculoperitoneal shunt, presented at 37 weeks of gestation with dyspnea. Her pregnancy had been complicated by gestational diabetes mellitus treated with a carbohydrate-restricted diet of 30 g a day. Due to a previous pregnancy complicated by late intrauterine fetal demise, a caesarean section was planned at 37 weeks of gestation after administration of steroids to induce fetal lung maturity. On admission, the patient’s blood pressure was 116/69 mm Hg, heart rate 106 beats per minute, oral temperature 36 °C, pulse ox 97%, and respiratory rate 20 breaths per minute. Laboratory tests showed a mixed metabolic acidosis and respiratory alkalosis with pH 7.3 (7.33 - 7.43), HCO3 7.3 meq/l (20 - 27 meq/l), positive urinary ketones, and glucose of 75 mg/dl (65 – 139 mg/dl). Her glycosylated hemoglobin was 5.8% (4.0 - 6.0 %), C-peptide level 14.3 ng/ml (0.6 - 12.0 ng/ml), total insulin level 4.1 uU/ml (5 to 25 uU/ml), and lactate 1.8 mmol/l (0.5 - 2.2 mmol/l). Her dyspnea progressed, requiring intubation followed by emergent caesarean section. Afterwards, she was transferred to the surgical intensive care unit. She was treated with intravenous fluids containing dextrose and bicarbonate; she never received insulin and her blood glucose ranged from 65 to 139 mg/dl. By hospital day 3, the metabolic acidosis resolved, and Continue reading >>

Legally Speaking: Uterine Rupture: Page 3 Of 3

Legally Speaking: Uterine Rupture: Page 3 Of 3

Legally Speaking: Uterine rupture: Page 3 of 3 Malpractice , Diabetes Complications , Hypertension , Labor and Delivery , Pregnancy and Birth A Mississippi woman was 22 years old when she became pregnant for the third time in 2012. She was managed by her obstetrician, who ordered a glucose test to screen for gestational diabetes. The woman failed the test and returned a few days later for a 3-hour glucose tolerance test. She passed 3 of the 4 glucose levels and was told this was consistent with her not having gestational diabetes. The pregnancy progressed normally until her prenatal visit at 33 weeks gestation, at which point she had lost 8 lb in 2 weeks and urine testing revealed both glycosuria and ketonuria. A week later, the patient went to the emergency room, was diagnosed with diabetic ketoacidosis (DKA) and was transferred to a womens hospital. By the time she arrived at the hospital, her fetus had died. The woman sued the obstetrician and alleged the diabetic testing at 28 weeks was substandard and she should have been diagnosed with gestational diabetes at that time. Her expert witness opined that the combined findings at her last prenatal visit at 33 weeks demanded immediate intervention to salvage the pregnancy. The obstetrician denied all allegations and any liability. His expert witness opined that the patients DKA developed after the last prenatal visit. A second expert alleged the patient most likely had a viral illness at the time of her last prenatal visit and that illness caused pancreatic damage, which in turn led to a transient diabetic condition that further progressed to DKA. The verdict: The jury returned a defense verdict after a 4-day trial. Continue reading >>

Chapter 11: Diabetic Ketoacidosis In Pregnancy

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 >>

Diabetic Ketoacidosis In Pregnancy | Obstetric Intensive Care Manual, 4e | Accessobgyn | Mcgraw-hill Medical

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 >>

Fetal Effects Of Diabetic Ketoacidosis

Fetal Effects Of Diabetic Ketoacidosis

The greatest hazard facing the pregnant diabetic patient with DKA is fetal loss. The exact fetal loss rate is difficult to assess because of the small reported series in the literature. Historically, the reported fetal mortality ranged between 30 and 90%7 but remarkable progress has been made both in fetal assessment techniques and in the treatment of DKA, and mortality rates in more recent reviews are 10%.20 Needless to say, fetal loss is primarily related to the severity of the maternal illness and the degree of metabolic decompensation. Most fetal losses occur prior to diagnosis and therefore to the onset of efficient treatment. As ketone bodies freely cross the placenta, maternal acidosis is assumed to cause fetal acidosis; however, the exact mechanism by which maternal DKA affects the fetus remains unclear. Suggestions include a decrease in uterine blood flow and fetal hypoxemia, maternal hyperke-tonemia inducing fetal hypoxemia, and fetal hyperglycemia causing an increased fetal oxidative mechanism and a decreased fetal myocardial contractility. Indeed, fetal potassium deficit has been found to lead to fetal cardiac arrest.7 Fetal hypoxia may also be attributed to a DKA-associated phosphate deficit which leads to depletion of red cell 2,3-diphosphoglycerate and consequent impairment of oxygen delivery. The risk of fetal distress, and even death, during the maternal DKA state makes it mandatory to continuously monitor the fetal heart and to assess the biophysical score, and to evaluate the fetal acid-base balance by cordocentesis if necessary. In the few case reports of fetal monitoring during maternal DKA, a nonreassuring pattern with tachycardia, reduced variability and late decelerations was reported.21,22 LoBue and Goodlin23 found that the administration of jus Continue reading >>

Diabetes And Pregnancy

Diabetes And Pregnancy

Pregestational and Gestational Diabetes throughout the pregnancy Pregestational vs Gestational Diabetes Pregestational diabetes is diabetes that pre exists the pregnancy Gestational diabetes develops or is first discovered during the pregnancy. Changes in glucose metabolism during pregnancy Early in pregnancy there is an increased insulin secretion At the end of the first trimester most women have an increased glucose utilization and increased insulin secretion In the second and third trimesters there is a progressive increase in insulin resistance due to pregnancy hormones from the placenta. How do these changes effect preexisting diabetes? Insulin needs may be decreased in the first trimester due to these changes as well as the nausea and vomiting pregnant women experience. There will be an progressive increased need for insulin during the second and third trimester. Post partum needs will be decreased dramatically Preconception health and diabetes This is a concept in which a mother receives care before she becomes pregnant in order to achieve optimal results for her and her baby. Primary goal in diabetes is a HbA1c of less than 7% at pre conception. To continue on birth control until it is at that level. However, remember that it is recommended that ALL women receive preconception care. Additional preconception testing Pap CBC Serum creatinine Thyroid 24 hour urine Lipid panel Retinal exam Neurological exam Medication usage Insulin regimen Referral to diabetes educator Referral to dietician Maternal Consequences of preexisting diabetes Preeclampsia Bacterial infections Polyhydraminos Birth trauma from macrosomic infants Preterm labor Cesarean delivery Postpartum hemorrhage DKA A word about DKA and pregnancies DKA is seen in 5-10% of pregnancies complicated by diabet Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes that is characterized by uncontrolled hyperglycemia, anion gap metabolic acidosis, and ketosis. Strategies for medical management that is safe for both mother and fetus will be presented. The anesthetic management of labor and delivery as well as operative deliveries will be discussed. AnesthesiaObstetricalDiabetic ketoacidosisHyperglycemiaFetal loss This is a preview of subscription content, log in to check access. Montoro MN, Myers VP, Mestman J, Xu Y, Anderson BG, Golde SH. Outcome of pregnancy in diabetic ketoacidosis. Am J Perinatol. 1993;10(1):1720. CrossRef Google Scholar Ramin KD. Diabetic ketoacidosis in pregnancy. Obstet Gynecol Clin N Am. 1999;26(3):4818. CrossRef Google Scholar Kamalakannan D, Baskar V, Barton DM, Abdu TA. Diabetic ketoacidosis in pregnancy. Postgrad Med J. 2003;79(934):4547. CrossRef Google Scholar Sibai BM, Viteri OA. Diabetic ketoacidosis in pregnancy. Obstet Gynecol. 2014;123(1):16778. CrossRef Google Scholar Cullen MT, Reece EA, Homko CJ, Sivan E. The changing presentations of diabetic ketoacidosis during pregnancy. Am J Perinatol. 1996;13(7):44951. CrossRef Google Scholar Laffel L. Ketone bodies: a review of physiology, pathophysiology and application of monitoring to diabetes. Diabetes Metab Res Rev. 1999;15(6):41226. CrossRef Google Scholar Cascio M, Pygon B, Ramanathan S. Labor analgesia with intrathecal fentanyl decreases maternal stress. Can J Anesth. 1997;44(6):6059. CrossRef Google Scholar Crites J, Ramanathan J. Acute hypoglycemia following combine spinal-epidural (CSE) in a parturient with diabetes mellitus. J Am Soc Anesthesiol. 2000;93(2):5912. CrossRef Google Scholar Hogan K, Rusy D, Springman SR. Difficult laryngoscopy and diabetes mell Continue reading >>

Diabetic Ketoacidosis Mimicking Hyperemesis Gravidarum: Case Report

Diabetic Ketoacidosis Mimicking Hyperemesis Gravidarum: Case Report

Diabetic ketoacidosis (DKA) characterized by hyperglycemia, ketosis and acidosis is a serious metabolic decompensation of diabetes mellitus (DM). It is a medical emergency that can occur in type 1, type 2 and gestational diabetes. Polyuria, polydipsia, nausea, vomiting, weakness, weight loss are the symptoms of DKA. Acidemia, hyperglycemia, increased anion gap, ketonemia, ketonuria are the laboratory findings. DKA can cause fetal and maternal mortality during pregnancy and usually occurs in the second and third trimester due to increased insulin resistance (1). Infections, emesis, non-compliance, insulin pump failure, drugs such as corticosteroids and β- sympathetomimetic agents, undiagnosed pregnancy are the precipitating factors. Maternal acidosis, hyperglycemia, volume depletion, electrolyte imbalance may effect the fetus. Aggressive fluid replacement, insulin infusion, as well as searching, correcting and treating the precipitating factors and electrolyte imbalance are the treatment modalities (1,2). Nausea and vomiting accompany 50-90% of all pregnancies (3). It is mostly self-limiting and peaks at 9 weeks of gestation. The most severe degree of vomiting during pregnancy is hyperemesis gravidarum (HG). It is characterized by persistent vomiting, weight loss, ketonuria, electrolyte abnormalities, and dehydration (4). Metabolic acidosis and ketonaemia may occur both in HG and DKA. Metabolic disorders such as DKA, gastrointestinal conditions, pyelonephritis, neurological causes and vestibular disorders should be considered in the differential diagnosis of HG (3,4). In this report, we describe a case of type 1 DM with fulminant course which occurred in the second trimester of pregnancy mimicking HG and resulted in fetal loss. Case Report A 30-year-old woman, nullipara Continue reading >>

Diabetic Ketoacidosis In Pregnancy

Diabetic Ketoacidosis In Pregnancy

Diabetic ketoacidosis is a serious metabolic complication of diabetes with high mortality if undetected. Its occurrence in pregnancy compromises both the fetus and the mother profoundly. Although predictably more common in patients with type 1 diabetes, it has been recognised in those with type 2 diabetes as well as gestational diabetes, especially with the use of corticosteroids for fetal lung maturity and β2-agonists for tocolysis.1–3 Diabetic ketoacidosis usually occurs in the second and third trimesters because of increased insulin resistance, and is also seen in newly presenting type 1 diabetes patients. With increasing practice of antepartum diabetes screening and the availability of early and frequent prenatal care/surveillance, the incidence and outcomes of diabetic ketoacidosis in pregnancy have vastly improved. However, it still remains a major clinical problem in pregnancy since it tends to occur at lower blood glucose levels and more rapidly than in non-pregnant patients often causing delay in the diagnosis. The purpose of this article is to illustrate a typical patient who may present with diabetic ketoacidosis in pregnancy and review the literature on this relatively uncommon condition and provide an insight into the pathophysiology and management. MAGNITUDE OF THE PROBLEM In non-pregnant patients with type 1 diabetes, the incidence of diabetic ketoacidosis is about 1–5 episodes per 100 per year with mortality averaging 5%–10%.4 The incidence rates of diabetic ketoacidosis in pregnancy and the corresponding fetal mortality rates from different retrospective studies5–8 are summarised in the table 1. As is evident from the table, both the incidence and rates of fetal loss in pregnancies have fallen in recent times compared with those before. In 1963 Continue reading >>

Diabetic Ketoacidosis In Pregnancy May Lead To Fetal Death

Diabetic Ketoacidosis In Pregnancy May Lead To Fetal Death

HealthDay News Diabetic ketoacidosis (DKA) during pregnancy poses risk for the fetus during and after the event, according to research published online in Diabetes Care. Fritha J.R. Morrison, MPH, from Tulane University in New Orleans, and colleagues conducted a retrospective cohort study involving pregnancies between 1996 and 2015 with at least one DKA event in women with type 1 diabetes. Data were included for 77 DKA events in 64 pregnancies among 62 women. The researchers found that fetal demise, preterm birth, and neonatal intensive care unit (NICU) admissions occurred in 15.6%, 46.3%, and 59% of pregnancies, respectively. In 60% and 40% of the cases, fetal demise occurred at the time of or within one week of DKA and between one and 11 weeks after DKA, respectively. The risk of fetal demise was significantly increased with maternal ICU admission and higher serum osmolality during the DKA event. Maternal smoking and higher pre-DKA hemoglobin A1c levels correlated with increased risk of preterm birth. Higher risk of NICU admission was seen with maternal smoking, preeclampsia during pregnancy, higher anion gap during DKA event, and preterm birth. Further research is needed to identify effective methods for prevention, early recognition, and timely treatment of DKA in pregnancy to mitigate risk of fetal demise and other adverse fetal outcomes, the researchers wrote. Continue reading >>

Fetal Outcomes After Diabetic Ketoacidosis During Pregnancy

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, ude.dravrah.hwb@nihcruta . 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 >>

Adverse Fetal Outcomes Tied To Maternal Dka, Study Finds

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 >>

Diabetes And Pregnancy

Diabetes And Pregnancy

What is diabetes? Diabetes is a condition in which the body can't produce enough insulin, or it can't use it properly. Insulin is the hormone that allows glucose (sugar) to enter the cells to be used as fuel. When glucose cannot enter the cells, it builds up in the blood. This is called hyperglycemia or high blood sugar. Damage from diabetes comes from the effects of hyperglycemia on other organ systems including the eyes, kidneys, heart, blood vessels, and nerves. In early pregnancy, hyperglycemia can result in birth defects. What are the different types of diabetes? There are three basic types of diabetes including: Type 1 diabetes. Also called insulin-dependent diabetes mellitus (IDDM), type 1 diabetes is an autoimmune disorder in which the body's immune system destroys, or attempts to destroy, the cells in the pancreas that produce insulin. Type 1 diabetes usually develops in children or young adults, but can start at any age. Type 2 diabetes. A metabolic disorder resulting from the body's inability to make enough, or properly use, insulin. It used to be called noninsulin-dependent diabetes mellitus (NIDDM). Gestational diabetes. A condition in which the blood glucose level is elevated and other diabetic symptoms appear during pregnancy in a woman who has not previously been diagnosed with diabetes. Diabetes is a serious disease, which, if not controlled, can be life-threatening. It is often associated with long-term complications that can affect every system and part of the body. Diabetes can contribute to eye disorders and blindness, heart disease, stroke, kidney failure, amputation, and nerve damage. What happens with diabetes and pregnancy? During pregnancy, the placenta supplies a growing fetus with nutrients and water. The placenta also makes a variety of horm Continue reading >>

Normoglycemic Diabetic Ketoacidosis In Pregnancy

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 Poses Fetal Risk During/after Event

Diabetic Ketoacidosis Poses Fetal Risk During/after Event

WEDNESDAY, June 21, 2017 (HealthDay News) -- Diabetic ketoacidosis (DKA) during pregnancy poses risk for the fetus during and after the event, according to research published online June 12 in Diabetes Care. Fritha J.R. Morrison, M.P.H., from Tulane University in New Orleans, and colleagues conducted a retrospective cohort study involving pregnancies between 1996 and 2015 with at least one DKA event in women with type 1 diabetes. Data were included for 77 DKA events in 64 pregnancies among 62 women. The researchers found that fetal demise, preterm birth, and neonatal intensive care unit (NICU) admissions occurred in 15.6, 46.3, and 59 percent of pregnancies, respectively. In 60 and 40 percent of the cases, fetal demise occurred at the time of or within one week of DKA and between one and 11 weeks after DKA, respectively. The risk of fetal demise was significantly increased with maternal ICU admission and higher serum osmolality during the DKA event. Maternal smoking and higher pre-DKA hemoglobin A1c levels correlated with increased risk of preterm birth. Higher risk of NICU admission was seen with maternal smoking, preeclampsia during pregnancy, higher anion gap during DKA event, and preterm birth. "Further research is needed to identify effective methods for prevention, early recognition, and timely treatment of DKA in pregnancy to mitigate risk of fetal demise and other adverse fetal outcomes," the authors write. Abstract/Full Text (subscription or payment may be required) This article: Copyright © 2017 HealthDay. All rights reserved. Continue reading >>

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