Diabetic Ketoacidosis During Pregnancy: A Case Report And Review Of The Literature
Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes1,2. DKA is characterized by the triad of hyperglycemia, metabolic acidosis and increased total ketone body concentration (ketonuria or ketonemia)2. Although DKA is rarely seen in pregnant women with diabetes mellitus (DM), it carries a risk for both mother and fetus and fetal loss may occur despite treatment3. The incidence of DKA is approximately 1-2% in pregnant woman with DM4. DKA most often emerges during the second or third trimester when insulin resistance increases. It is also more common in pregnancies with Type 1 DM compared with pregnancies with Type 2 DM and gestational DM5,6, especially with the use of corticosteroids for fetal lung maturity and β2-agonists for tocolysis7. DKA during pregnancy with DM despite intensive insulin therapy and strict metabolic control may ocur3,4. On the other hand, normoglycemic DKA during pregnancy is truly unusual but can occur with relatively low, or even normal blood glucose levels8,9. A variety of hormonal and physical changes during pregnancy increases the tendency for DKA1,3. The maternal mortality rate in pregnancies with DKA is %5-15 whereas the fetal mortality rate is approximately % 30-901,4,5. Diabetic ketoacidosis in pregnancy is an emergency that demands prompt and vigorous treatment and modalities of treatment do not differ from the modalities of treatment for non-pregnant women. Continue reading >>
Retrospective Analysis Of Diabetic Ketoacidosis In Pregnant Women Over A Period Of 3 Years
1Department of Diabetes and Endocrine, Hamad Medical Corporation, Doha, Qatar 2Department of Obstetrics and Gynecology, Hamad Medical Corporation, Doha, Qatar 3Department of Obstetrics, Sidra Medical and Research Center, Doha, Qatar Corresponding Author: Khaled Ahmed Baagar Department of Diabetes and Endocrine Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar Tel: +974-66049423 E-mail: [email protected] Citation: Baagar KA, Aboudi AK, Khaldi HM, Alowinati BI, Abou-Samra AB, et al. (2017) Retrospective Analysis of Diabetic Ketoacidosis in Pregnant Women over a Period of 3 Years . Endocrinol Metab Syndr 6:265. doi:10.4172/2161-1017.1000265 Copyright: © 2017 Baagar KA, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Visit for more related articles at Endocrinology & Metabolic Syndrome Abstract Objective: The incidence of diabetic ketoacidosis in pregnancy (DKP) varies from 0.5%, the lowest reported rate in western countries, to 8.9% in a study conducted in China. The associated fetal mortality is 9-36%. This study aimed to assess the current incidence, causes, and outcomes of diabetic ketoacidosis in pregnancy and identify factors associated with favorable outcomes. Methods: A retrospective chart review of 20 diabetic ketoacidosis hospital admissions of 19 pregnant women from 3,679 diabetic pregnancies delivered between June 2012 and May 2015 was conducted. Those with successful DKP management (group A) or with intrauterine fetal death or urgent delivery during diabetic ketoacidosis management (group B) were compared. Results: Thirteen cases had type 1 diabetes, and 6 cases had Continue reading >>
Diabetes Crisis In Pregnancy: A Case Report
McCaffrey, Mary P. MSN, RNC-OB Keith, Tracy L. BSN, RNC-OB, C-EFM Lazear, Janice L. MN, FNP, CRNP, CDE Abstract Optimal maternal, fetal, and neonatal outcomes are the goal of care for pregnant women with preexisting diabetes. Women with a long history of poorly managed diabetes begin pregnancy with a deficit that poses additional challenges for the patient and the healthcare team. The following case study presents a woman who had a history of type 1 diabetes that was poorly controlled and experienced an incidence of severe hypoglycemia with serious sequelae. Article Content Pregnant women with preexisting diabetes, particularly type 1 diabetes, face significant challenges. Optimal maternal, fetal, and neonatal outcomes are the goal of care for pregnant women with preexisting diabetes. In addition to the stresses and demands of any pregnant woman, one who has a pregnancy that is complicated by diabetes may need lifestyle changes, frequent appointments, intensive fetal surveillance, and rigorous management of diabetes to achieve tight glycemic control. However, women with diabetes often experience barriers to optimal care. These may include financial limitations, a poor support system, lack of knowledge about diabetes, and psychiatric comorbidities, as well as lack of access to the comprehensive care needed.1 The following case study illustrates a woman with a history of poor glycemic control. Optimal pregnancy outcomes are achieved when the maternal glucose level is maintained within the reference range, avoiding levels that are below the reference range as well as those above.2 Glycemic control over time can be determined using the A1c test, also known as glycosylated hemoglobin test. Plasma glucose attaches to the hemoglobin in red blood cells (RBCs). The A1c test give Continue reading >>
Pregnancy Complicated By Diabetic Ketoacidosis
Maternal and fetal outcomes Despite intensified insulin treatment and strict surveillance of metabolic control in diabetic women during pregnancy, diabetic ketoacidosis (DKA) complicates 2–9% of diabetic pregnancies (1) and represents the leading cause of fetal loss, with a fetal mortality rate of 30–90% (1–3). From August 1991 to December 2001, 2,025 pregnant women with diabetes were admitted to the University of Tennessee Women’s Hospital. Of these, 888 women (44%) received insulin therapy, and 11 women (1.2%) presented with DKA (blood glucose: 377 ± 27 mg/dl, pH: 7.22 ± 0.01, bicarbonate 7.9 ± 3 mEq/l, and positive serum ketones). White’s diabetic classification included class A2, four patients (27%); class B, five patients (45%); class C, one patient (9%); and class D, one patient (9%). The four women with gestational diabetes mellitus (GDM) were African-American, had a mean age of 25 ± 1 year, a BMI of 34 ± 3 kg/m2, and an estimated gestational age of 29 ± 1 weeks. Patients with a previous history of diabetes had a mean duration of diabetes of 6 ± 1 year, a mean age of 27 ± 1 year, a BMI of 30 ± 2 kg/m2, and a gestational age of 28 ± 1 weeks. Infection (27%) and a history of the omission of insulin therapy (18%) were the most common precipitating causes. There were no maternal deaths, and the mean maternal length of hospital stay was 7 ± 2 days. Two patients presented with intrauterine fetal demise, and there was one additional fetal death giving an overall fetal death rate of 27%. During labor, four patients had nonreassuring fetal heart rate tracings in the form of late decelerations that resolved with correction of DKA. At birth, the mean (5 min) Apgar was 8.7 ± 0.4, and fetal weight was 1,278 ± 202 g. Four obese women with DKA had newly d Continue reading >>
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 >>
357: Diabetic Ketoacidosis Complicating Pregnancy
Jump to Section Objective Diabetic ketoacidosis (DKA) in pregnancy can result in significant consequences for both the mother and the fetus, however, the time course of recovery with treatment has not been well characterized. Our aim was to examine the precipitating factors, laboratory abnormalities, treatment strategies, and clinical recovery in pregnancies complicated by DKA. Jump to Section Results A total of 20 episodes of DKA in pregnancy were reviewed and analyzed. Clinical features of these women are shown in Table 1. Two thirds of these women had Type 1 diabetes. All women presented with nausea and vomiting (90%), poor compliance (50%), and/or concomitant infection (30%) between 6 and 34 weeks gestation. No cases were precipitated by insulin pump failure. Figure 1 displays the laboratory values at admission and during treatment. The initial blood glucose averaged 386 mg/dL(range 158-776 mg/dL). These women received 3.1 L of intravenous crystalloid within the first 4 hours of treatment, and an average of 90 units of insulin by 24 hours. The glucose was <200 mg/dL in most women by 6 hours of treatment. The anion gap acidosis resolved by 16 hours in 90% of patients, however urine ketones remained positive at 24 hours in 90%. There were no fetal deaths in this limited cohort. Jump to Section Conclusion Nausea and vomiting is the most prominent presenting feature of DKA in pregnancy, and should prompt thorough evaluation in women with diabetes, regardless of gestational age. With early, aggressive insulin therapy and fluid resuscitation, hyperglycemia and acidosis improve rapidly with subsequent resolution of DKA. Continue reading >>
Diabetic Ketoacidosis In Pregnancy.
Abstract Pregnancies complicated by diabetic ketoacidosis are associated with increased rates of perinatal morbidity and mortality. A high index of suspicion is required, because diabetic ketoacidosis onset in pregnancy can be insidious, usually at lower glucose levels, and often progresses more rapidly as compared with nonpregnancy. Morbidity and mortality can be reduced with early detection of precipitating factors (ie, infection, intractable vomiting, inadequate insulin management or inappropriate insulin cessation, β-sympathomimetic use, steroid administration for fetal lung maturation), prompt hospitalization, and targeted therapy with intensive monitoring. A multidisciplinary approach including a maternal-fetal medicine physician, medical endocrinology specialists familiar with the physiologic changes in pregnancy, an obstetric anesthesiologist, and skilled nursing is paramount. Management principles include aggressive volume replacement, initiation of intravenous insulin therapy, correction of acidosis, correction of electrolyte abnormalities and management of precipitating factors, as well as monitoring of maternal-fetal response to treatment. When diabetic ketoacidosis occurs after 24 weeks of gestation, fetal status should be continuously monitored given associated fetal hypoxemia and acidosis. The decision for delivery can be challenging and must be based on gestational age as well as maternal-fetal responses to therapy. The natural inclination is to proceed with emergent delivery for nonreassuring fetal status that is frequently present during the acute episode, but it is imperative to correct the maternal metabolic abnormalities first, because both maternal and fetal conditions will likewise improve. Prevention strategies should include education of diabet Continue reading >>
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 >>
Diabetic Ketoacidosis In Pregnancy.
Abstract Episodes of diabetic ketoacidosis (DKA) can represent a life-threatening emergency for mother and fetus. The cornerstones of treatment of DKA are aggressive fluid replacement and insulin administration while ascertaining which precipitating factors brought about the current episode of DKA, and then treating accordingly to mitigate those factors. The incidence of DKA and factors unique to pregnancy are discussed in this article, along with the effects of the disease process on pregnancy. Clinical presentation, diagnosis, and treatment modalities are covered in detail to offer ideas to improve maternal and fetal outcome. Continue reading >>
Case Of Nondiabetic Ketoacidosis In Third Term Twin Pregnancy | The Journal Of Clinical Endocrinology & Metabolism | Oxford Academic
We provided appropriate management with fluid infusion after cesarean delivery. The patient and her two daughters survived, and no disabilities were foreseen. Alcohol, methanol, and lactic acid levels were normal. No signs of renal disease or diabetes were present. Pathological examination revealed no abnormalities of the placentae. Toxicological tests revealed a salicylate level of less than 5 mg/liter, an acetaminophen level of less than 1 mg/liter, and an acetone level of 300 mg/liter (reference, 520 mg/liter). We present a case of third term twin pregnancy with high anion gap metabolic acidosis due to (mild) starvation. Starvation, obesity, third term twin pregnancy, and perhaps a gastroenteritis were the ultimate provoking factors. In the light of the erroneous suspicion of sepsis and initial fluid therapy lacking glucose, one wonders whether, under a different fluid regime, cesarean section could have been avoided. Severe ketoacidosis in the pregnant woman is associated with impaired neurodevelopment. It therefore demands early recognition and immediate intervention. A 26-yr-old patient was admitted to our hospital complaining of rapid progressive dyspnea and abdominal discomfort. She was pregnant with dichorial, diamniotic twins for 35 wk and 4 d. Medical history showed that she was heterozygous for hemochromatosis. Two years before, she had given birth to a healthy girl of 3925 g by cesarean section, and 1 yr before, she had had a spontaneous abortion. Her preadmission outpatient surveillance revealed slightly elevated blood pressure varying from 132158 mm Hg systolic and 7995 mm Hg diastolic. Glucose and glycosylated hemoglobin were tested at 24 wk and were normal at 4.6 mmol/liter and 5.4% (36 mmol/mol), respectively. Urine analysis at the outpatient obstetri Continue reading >>
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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 >>
Managing Severe Preeclampsia And Diabetic Ketoacidosis In Pregnancy
US Pharm. 2010;35(9):HS-2-HS-8. Pregnancy is associated with increased levels of emotional and physical stress. Women with preexisting conditions such as hypertension and diabetes require intense prenatal monitoring by health care professionals. Pharmacists in direct contact with patients can play an integral role in identifying signs and symptoms that require immediate care. Two conditions that require emergent treatment in pregnant women are severe preeclampsia and diabetic ketoacidosis. SEVERE PREECLAMPSIA Hypertensive disorders can affect 6% to 8% of women and increase the risk of morbidity and mortality in both the expectant mother and the unborn child.1,2 Hypertension in pregnancy is divided into four categories: chronic hypertension, gestational hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension. The focus in this article is on severe preeclampsia, but a brief discussion of preeclampsia is warranted. Preeclampsia, a pregnancy-specific syndrome of unknown etiology, is a multiorgan disease process characterized by the development of hypertension and proteinuria after 20 weeks' gestation.1,2 See TABLE 1 for diagnostic criteria.1,2 History of antiphospholipid antibody syndrome, chronic hypertension, chronic renal disease, elevated body-mass index, age 40 years or older, multiple gestation, nulliparity, preeclampsia in a previous pregnancy, and pregestational diabetes mellitus increase a woman's risk of preeclampsia.1 Preeclampsia is classified as mild or severe based on the degree of hypertension, the level of proteinuria, and the presence of symptoms resulting from the involvement of the kidneys, brain, liver, and cardiovascular system. The incidence of severe preeclampsia is 0.9% in the United States.3 Severe preeclampsia is associate Continue reading >>
Diabetic Ketoacidosis In Pregnancy
Abstract Episodes of diabetic ketoacidosis (DKA) can represent a life-threatening emergency for mother and fetus. The cornerstones of treatment of DKA are aggressive fluid replacement and insulin administration while ascertaining which precipitating factors brought about the current episode of DKA, and then treating accordingly to mitigate those factors. The incidence of DKA and factors unique to pregnancy are discussed in this article, along with the effects of the disease process on pregnancy. Clinical presentation, diagnosis, and treatment modalities are covered in detail to offer ideas to improve maternal and fetal outcome. Continue reading >>
Managing Diabetic Ketoacidosis In Pregnancy
Sir, Diabetic ketoacidosis (DKA) is a potentially life-threatening condition in pregnancy,[1] affecting 0.5-3% of diabetic pregnancies.[2] We describe a woman who developed DKA due to insulin pump malfunction. A 35-year-old nulliparous diabetic, usually well-managed with a subcutaneous insulin pump, presented at 33 weeks gestation with malaise, vomiting, Kussmaul breathing and uterine contractions. Vital signs were, blood pressure 140/70 mmHg, heart rate 110 beats/min, respiratory rate 25 breaths/min and temperature 37°C. Laboratory tests were abnormal [Table 1]. The fetal heart trace showed poor variability, with late decelerations. In the intensive care unit, she received intravenous 0.9% normal saline (2 L over 3 h), then plasmalyte solution at 250 ml/h); insulin 10 u/h; and intravenous potassium. Her clinical and metabolic condition improved over 24 h [Table 1] and both contractions and late decelerations resolved. She was later discharged with a new subcutaneous insulin pump and was delivered uneventfully by elective cesarean section at 37 weeks. Pregnancy constitutes a state of insulin resistance, accelerated starvation and respiratory alkalosis with compensatory renal bicarbonate excretion, predisposing to DKA.[2] Increased insulin resistance and/or inadequate insulin[3] may lead to hormonal-induced release of alternative energy substrates,[1] with uncontrolled hyperglycemia, dehydration, loss of electrolytes (osmotic diuresis), ketosis and metabolic acidosis.[2] The physiological response is a self-perpetuating chain of events, involving increased respiratory rate and depth (Kussmaul respiration) and compensatory low serum bicarbonate, producing an abnormal high anion gap[1] [Figures 1 and 2]. Fetal distress follows compromised uteroplacental perfusion (materna Continue reading >>
Diabetic Ketoacidosis Poses Fetal Risk During / After Event
(HealthDay)—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. More information: Abstract/Full Text (subscription or payment may be required) Continue reading >>
