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Dka In Pregnancy Algorithm

Ketoacidosis In Diabetic Pregnancy

Ketoacidosis In Diabetic Pregnancy

Diabetic ketoacidosis (DKA) is a serious medical and obstetrical emergency previously considered typical of type 1 diabetes but now reported also in type 2 and GDM patients. Although it is a fairly rare condition, DKA in pregnancy can compromise both fetus and mother. Metabolic changes occurring during pregnancy predispose to DKA in fact it can develop even in setting of normoglycemia. This article will provide the reader with information regarding the pathophysiology underlying DKA, in particular euglycemic DKA, and will provide information regarding all possible effects of ketones on the fetus. Continue reading >>

Diagnosis And Treatment Of Diabetic Ketoacidosis

Diagnosis And Treatment Of Diabetic Ketoacidosis

85 Abstract Diabetic ketoacidosis (DKA) is the most frequent hyperglycaemic acute diabetic complication. Furthermore it carries a significant risk of death, which can be prevented by early and effective management. All physicians, irrespective of the discipline they are working in and whether in primary, secondary or tertiary care institutions, should be able to recognise DKA early and initiate management immediately. 86 Introduction Diabetic ketoacidosis (DKA) is a common complication of diabetes with an annual occurrence rate of 46 to 50 per 10 000 diabetic patients. The severity of this acute diabetic complication can be appreciated from the high death-to-case ratio of 5 to 10%.1 In Africa the mortality of DKA is unacceptably high with a reported death rate of 26 to 29% in studies from Kenya, Tanzania and Ghana.2 It is a complication of both type 1 and type 2 diabetes mellitus, although more commonly seen in type 1 diabetic patients. Of known diabetic patients presenting with DKA about one-quarter will be patients with type 2 diabetes. In patients presenting with a DKA as first manifestation of diabetes about 15% will be type 2.3 This correlates well with data from South Africa suggesting that one- quarter of patients with DKA will be type 2 with adequate C-peptide levels and the absence of anti-GAD antibodies.4 This review will focus on the principles of diagnosis, monitoring and treatment of DKA, with special mention of new developments and controversial issues. Clinical features DKA evolves over hours to days in both type 1 and type 2 diabetic patients, but the symptoms of poor control of blood glucose are usually present for several days before the onset or presentation of ketoacidosis.5 The clinical features of DKA are non-specific and patients may present with 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 >>

Management Of Diabetic Ketoacidosis In Pregnancy

Management Of Diabetic Ketoacidosis In Pregnancy

Department of Obstetrics and Gynaecology, Sidra Medical and Research Center, Weill Cornell Medical College, Doha, Qatar, PO Box26999 Head of the Division of Obstetrics, Professor of Obstetrics and Gynecology Sidra Medical and Research Center, Weill College Medical College in Qatar, Doha, Qatar Department of Obstetrics and Gynaecology, Sidra Medical and Research Center, Weill Cornell Medical College, Doha, Qatar, PO Box26999 Head of the Division of Obstetrics, Professor of Obstetrics and Gynecology Sidra Medical and Research Center, Weill College Medical College in Qatar, Doha, Qatar Please review our Terms and Conditions of Use and check box below to share full-text version of article. I have read and accept the Wiley Online Library Terms and Conditions of Use. Use the link below to share a full-text version of this article with your friends and colleagues. Learn more. Diabetic ketoacidosis in pregnancy (DKP) is a serious complication that poses several challenges with respect to diagnosis, management and prevention. This article covers the precipitating factors for DKP in pregnancy as well as diagnosis, management and prevention of the complication. To reduce the perinatal morbidity and mortality associated with DKP. Despite adequate knowledge and care of patients with diabetes, is DKA a major cause for concern? To increase awareness, and reduce the perinatal morbidity and mortality associated with DKP. Diabetic ketoacidosis in pregnancy (DKP) is a serious complication that poses several challenges with respect to diagnosis, management and prevention. It develops because of relative or absolute insulin deficiency and the simultaneous increase in counterregulatory hormones (cortisol, catecholamines, glucagon and growth hormone). This causes significant changes in metab Continue reading >>

Diabetic Ketoacidosis In Pregnancy.

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 >>

Managing Severe Preeclampsia And Diabetic Ketoacidosis In Pregnancy

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 >>

Diabetes In Pregnancy (nice Clinical Guideline 3)

Diabetes In Pregnancy (nice Clinical Guideline 3)

This guideline was produced by the National Collaborating Centre for Women’s and Children’s Health (NCC-WCH) on behalf of the National Institute of Health and Care Excellence (NICE). The guideline focuses on areas where additional or different care should be offered to women with diabetes and their newborn babies. Where the evidence supports it, the guideline makes separate recommendations for women with pre‑existing diabetes and women with gestational diabetes. Continue reading >>

Diabetic Ketoacidosis In Pregnancy

Diabetic Ketoacidosis In Pregnancy

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 >>

Diabetes In Pregnancy: Management From Preconception To The Postnatal Period

Diabetes In Pregnancy: Management From Preconception To The Postnatal Period

If you have type 1 diabetes, you should be given ketone testing strips and a monitor. Your care team should advise you to test the ketone levels in your blood if your blood glucose is too high (known as hyperglycaemia) or if you are unwell. This is because you are at risk of a serious condition called diabetic ketoacidosis (DKA). People with type 1 diabetes are at higher risk of DKA (although anyone with diabetes can get it). If you have any form of diabetes, your care team should advise you to get urgent medical advice if you have hyperglycaemia or you are feeling unwell, to make sure you don't have DKA. Your ketone levels should be checked as soon as possible. If you are thought to have DKA you should be admitted straight away to a unit where you can get specialist care. Continue reading >>

Diabetic Ketoacidosis

Diabetic Ketoacidosis

Authors Runa Acharya, MD, University of Iowa-Des Moines Internal Medicine Residency Program at UnityPoint Health, Des Moines, IA Udaya M. Kabadi, MD, FACP, FRCP(C), FACE, Veteran Affairs Medical Center and Broadlawns Medical Center, Des Moines, IA; Des Moines University of Osteopathic Medicine, Iowa City; and University of Iowa Carver College of Medicine, Iowa City; Adjunct Professor of Medicine and Endocrinology, University of Iowa, Iowa City, and Des Moines University, Des Moines Peer Reviewer Jay Shubrook, DO, FAAFP, FACOFP, Professor, Primary Care Department, Touro University, College of Osteopathic Medicine, Vallejo, CA Statement of Financial Disclosure To reveal any potential bias in this publication, and in accordance with Accreditation Council for Continuing Medical Education guidelines, Dr. Kabadi (author) reports he is a consultant and on the speakers bureau for Sanofi. Dr. Shubrook (peer reviewer) reports he receives grant/research support from Sanofi and is a consultant for Eil Lilly, Novo Nordisk, and Astra Zeneca. Dr. Acharya (author) reports no financial relationships relevant to this field of study. Continue reading >>

(pdf) Management Of Diabetic Ketoacidosis In Pregnancy

(pdf) Management Of Diabetic Ketoacidosis In Pregnancy

All content in this area was uploaded by Manoj Mohan on Jun 01, 2018 Management of diabetic ketoacidosis in pregnancy * Khaled Ahmed Mohamed Baagar MB BCh CABM MRCP, Attending Physician, Department of Obstetrics and Gynaecology, Sidra Medical and Research Center, Doha, Qatar, PO Box 26999, and Assistant Professor of Clinical Obstetrics and Gynaecology, Weill Cornell Medical College, Doha, Qatar Specialist Diabetologist, Diabetic Obstetric Service, Hamad General Hospital, Doha, Qatar Head of the Division of Obstetrics, Sidra Medical and Research Center, Doha, Qatar Professor of Obstetrics and Gynecology, Weill College Medical *Correspondence: Manoj Mohan. Email: [email protected] Diabetic ketoacidosis in pregnancy (DKP) is a serious complication that poses several challenges with respect to This article covers the precipitating factors for DKP in pregnancy as well as diagnosis, management and prevention of To reduce the perinatal morbidity and mortality associated Despite adequate knowledge and care of patients with diabetes, is To increase awareness, and reduce the perinatal morbidity and Keywords: diabetes / diagnosis / management / pregnancy / Linked resource: Single best answer questions are available for this article at Please cite this paper as: Mohan M, Baagar KAM, Lindow S. Management of diabetic ketoacidosis in pregnancy. The Obstetrician & Gynaecologist 2017;19: Diabetic ketoacidosis in pregnancy (DKP) is a serious complication that poses several challenges with respect to diagnosis, management and prevention. It develops because of relative or absolute insulin deciency and the simultaneous increase in counter-regulatory hormones (cortisol, catecholamines, glucagon and growth hormone). This causes signicant changes in metabolism, lipolysis and proteolysis, whic Continue reading >>

My Site - Chapter 15: Hyperglycemic Emergencies In Adults

My Site - Chapter 15: Hyperglycemic Emergencies In Adults

Literature Review Flow Diagram for Chapter 15: Hyperglycemic Emergencies in Adults *Excluded based on: population, intervention/exposure, comparator/control or study design. From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097 (82) . For more information, visit www.prisma-statement.org . Dr. Gilbert reports personal fees from Amgen, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Janssen, Merck, Novo Nordisk, and Sanofi, outside the submitted work. Dr. Goguen does not have anything to disclose. Kitabchi AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diabetes Care 2001;24:13153. Hamblin PS, Topliss DJ, Chosich N, et al. Deaths associated with diabetic ketoacidosis and hyperosmolar coma. 19731988. Med J Aust 1989;151:412, 44. Holman RC, Herron CA, Sinnock P. Epidemiologic characteristics of mortality from diabetes with acidosis or coma, United States, 197078. Am J Public Health 1983;73:116973. Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: A historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care 2014;37:312431. Wachtel TJ, Tetu-Mouradjian LM, Goldman DL, et al. Hyperosmolarity and acidosis in diabetes mellitus: A three-year experience in Rhode Island. J Gen Intern Med 1991;6:495502. Malone ML, Gennis V, Goodwin JS. Characteristics of diabetic ketoacidosis in older versus younger adults. J Am Geriatr Soc 1992;40:11004. Wang ZH, Kihl-Selstam E, Eriksson JW. Ketoacidosis occurs in both type 1 and type 2 diabetesa population-based study from Northern Sweden. Diabet Med 2008;25:86770. Kitabchi AE, Umpierrez GE, Murphy Continue reading >>

Managing Diabetic Ketoacidosis In Pregnancy

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 In Pregnancy

Diabetic Ketoacidosis In Pregnancy

Diagnosis of DKA: � Initial STAT labs include • CBC with diff • Serum electrolytes • BUN • Creatinine • Glucose • Arterial blood gases • Bicarbonate • Urinalysis • Lactate • Serum ketones • Calculation of the Anion Gap � serum anion gap = serum sodium – (serum chloride + bicarbonate) • Electrocardiogram Treatment Protocol for Diabetic Ketoacidosis Reviewed 5/2/2017 2 Updated 05/02/17 DKA Diagnostic Criteria: � Blood glucose >250 mg/dl � Arterial pH <7.3 � Bicarbonate ≤18 mEq/l � Anion Gap Acidosis � Moderate ketonuria or ketonemia 1. Start IV fluids (1 L of 0.9% NaCl per hr initially) 2. If serum K+ is <3.3 mEq/L hold insulin � Give 40 mEq/h until K ≥ 3.3 mEq/L 3. Initiate DKA Order Set Phase I (*In PREGNANCY utilize OB DKA order set) 4. Start insulin 0.14 units/kg/hr IV infusion (calculate dose) RN will titrate per DKA protocol Insulin Potassium Bicarbonate IVF Look for the Cause - Infection/Inflammation (PNA, UTI, pancreatitis, cholecystitis) - Ischemia/Infarction (myocardial, cerebral, gut) - Intoxication (EtOH, drugs) - Iatrogenic (drugs, lack of insulin) - Insulin deficiency - Pregnancy DKA/HHS Pathway Phase 1 (Adult) Approved by Diabetes Steering Committee, MMC, 2015, Revised DKA Workgroup 1_2016 Initiate and continue insulin gtt until serum glucose reaches 250 mg/dl. RN will titrate per protocol to achieve target. When sugar < 250 mg/dl proceed to DKA Phase II *In PREGNANCY when sugar <200 proceed to OB DKA Phase II *PREGNANCY � Utilize OB DKA order set Phase 1 � When glucose reaches 200mg/dL, Initiate OB DKA Phase 2 � Glucose goals 100-150mg/dL OB DKA Phase 2 Determine hydration status Hypovolemic shock Mild hypotensio Continue reading >>

Pregestational And Gestational Diabetes: Resource Overview

Pregestational And Gestational Diabetes: Resource Overview

Pregestational and Gestational Diabetes: Resource Overview Pregestational and Gestational Diabetes: Resource Overview Pregestational and Gestational Diabetes: Resource Overview The American College of Obstetricians and Gynecologists has identified additional resources on topics related to pregestational and gestational diabetes that may be helpful for ob-gyns, other health care providers, and patients. These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists' endorsement of the organization, the organization's website, or the content of the resource. These resources may change without notice. Resources for Ob-Gyns and Womens Health Care Providers Practice Bulletin: Pregestational Diabetes Mellitus (members only) " Pregestational Diabetes Mellitus ," issued by ACOG in December 2018,provides an overview of the current understanding of pregestational diabetes mellitus and suggests management guidelines during pregnancy. Read the Practice Bulletin: Pregestational Diabetes Mellitus Practice Bulletin: Gestational Diabetes Mellitus (members only) Gestational Diabetes Mellitus ,issued by ACOG in February 2018, provides evidence-based guidelines for the screening, diagnosis, treatment, and management of gestational diabetes. Drug therapies, such as insulin, and alternative treatments, such as nutrition therapy, are addressed. Read the Practice Bulletin: Gestational Diabetes Mellitus Practice Bulletin: Fetal Macrosomia (members only) Macrosomia, issued by ACOG in December 2019, provides evidence-based guidelines for the management of fetal macrosomia, a type of excessive fetal growth that is a common complication of maternal diabetes. The document reviews the Continue reading >>

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