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What Is Ketoacidosis In Pregnancy

A Case Of A Woman With Late-pregnancy-onset Dka Who Had Normal Glucose Tolerance In The First Trimester

A Case Of A Woman With Late-pregnancy-onset Dka Who Had Normal Glucose Tolerance In The First Trimester

Hiromi Himuro, Takashi Sugiyama, Hidekazu Nishigori, Masatoshi Saito, Satoru Nagase, Junichi Sugawara and Nobuo Yaegashi Department of Obstetrics and Gynecology Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan Summary Diabetic ketoacidosis (DKA) during pregnancy is a serious complication in both mother and fetus. Most incidences occur during late pregnancy in women with type 1 diabetes mellitus. We report the rare case of a woman with type 1 diabetes mellitus who had normal glucose tolerance during the first trimester but developed DKA during late pregnancy. Although she had initially tested positive for screening of gestational diabetes mellitus during the first trimester, subsequent diagnostic 75-g oral glucose tolerance tests showed normal glucose tolerance. She developed DKA with severe general fatigue in late pregnancy. The patient's general condition improved after treatment for ketoacidosis, and she vaginally delivered a healthy infant at term. The presence of DKA caused by the onset of diabetes should be considered, even if the patient shows normal glucose tolerance during the first trimester. The presence of DKA caused by the onset of diabetes should be considered, even if the patient shows normal glucose tolerance during the first trimester. Symptoms including severe general fatigue, nausea, and weight loss are important signs to suspect DKA. Findings such as Kussmaul breathing with ketotic odor are also typical. Urinary test, atrial gas analysis, and anion gap are important. If pH shows normal value, calculation of anion gap is important. If the value of anion gap is more than 12, a practitioner should consider the presence of metabolic acidosis. Background Diabetic ketoacidosis (DKA) is an acute metabol Continue reading >>

Diabetic Ketoacidosis (dka)

Diabetic Ketoacidosis (dka)

Tweet Diabetic ketoacidosis (DKA) is a dangerous complication faced by people with diabetes which happens when the body starts running out of insulin. DKA is most commonly associated with type 1 diabetes, however, people with type 2 diabetes that produce very little of their own insulin may also be affected. Ketoacidosis is a serious short term complication which can result in coma or even death if it is not treated quickly. Read about Diabetes and Ketones What is diabetic ketoacidosis? DKA occurs when the body has insufficient insulin to allow enough glucose to enter cells, and so the body switches to burning fatty acids and producing acidic ketone bodies. A high level of ketone bodies in the blood can cause particularly severe illness. Symptoms of DKA Diabetic ketoacidosis may itself be the symptom of undiagnosed type 1 diabetes. Typical symptoms of diabetic ketoacidosis include: Vomiting Dehydration An unusual smell on the breath –sometimes compared to the smell of pear drops Deep laboured breathing (called kussmaul breathing) or hyperventilation Rapid heartbeat Confusion and disorientation Symptoms of diabetic ketoacidosis usually evolve over a 24 hour period if blood glucose levels become and remain too high (hyperglycemia). Causes and risk factors for diabetic ketoacidosis As noted above, DKA is caused by the body having too little insulin to allow cells to take in glucose for energy. This may happen for a number of reasons including: Having blood glucose levels consistently over 15 mmol/l Missing insulin injections If a fault has developed in your insulin pen or insulin pump As a result of illness or infections High or prolonged levels of stress Excessive alcohol consumption DKA may also occur prior to a diagnosis of type 1 diabetes. Ketoacidosis can occasional Continue reading >>

Diabetic Ketoacidosis In Pregnancy

Diabetic Ketoacidosis In Pregnancy

Abstract Diabetic ketoacidosis (DKA) is a life-threatening medical emergency and is characterized by hyperglycemia, acidosis, and ketonemia. DKA is observed in 5–10 % of all pregnancies complicated by pregestational diabetes mellitus. Laboratory findings are as follows: Ketonemia 3 mmol/L and over or significant ketonuria (more than 2+ on standard urine sticks) Blood glucose over 11 mmol/L or known diabetes mellitus Bicarbonate (HCO3 −−) below 15 mmol/L and/or venous pH less than 7.3 Common risk factors for DKA in pregnancy are new-onset diabetes, infections like UTI, influenza, poor patient compliance, insulin pump failure, treatment with β-mimetic tocolytic medications, and antenatal corticosteroids for fetal lung maturity. Patient should be counseled about the precipitating cause and early warning symptoms of DKA. DKA should be treated promptly, and HDU/level 2 facility with trained nursing staff and/or insertion of central line is required during pregnancy for its management. Continuous fetal heart rate monitoring commonly demonstrates recurrent late decelerations. Delivery is rarely indicated as FHR pattern resolves as maternal condition improves. DKA therapy can lead to frequent complication of hypoglycemia and hypokalemia, so glucose and K concentration monitoring should be done judiciously. Maternal mortality is rare now with proper management, but fetal mortality is still quite high ranging from 10 to 35 %. Continue reading >>

Diabetes Ketoacidosis In Pregnancy

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 >>

Four Case Studies Of Severe Metabolic Acidosis In Pregnancy

Four Case Studies Of Severe Metabolic Acidosis In Pregnancy

Summarized from Frise C, Mackillop L, Joash K et al. Starvation ketoacidosis in pregnancy. Eur J Obstet Gynecol 2012. Available online ahead of publication at: Arterial blood gas analysis in cases of metabolic acidosis reveals primary decrease in pH and bicarbonate, and secondary (compensatory) reduction in pCO2. The most common cause of metabolic acidosis is increased production of endogenous metabolic acids, either lactic acid, in which case the condition is called lactic acidosis, or keto-acids, in which case the condition is called ketoacidosis. Ketoacidosis most commonly occurs as an acute and life-threatening complication of type I diabetes, due to severe insulin deficiency and resulting reduced glucose availability for energy production within cells (insulin is required for glucose to enter cells). Keto-acids accumulate in blood as a result of metabolism of fats mobilized to fill the energy gap created by reduced availability of glucose within cells. Starvation is also associated with reduced availability of (dietary) glucose and potential for ketoacidosis, although compared with diabetic ketoacidosis, starvation ketoacidosis is rare, usually mild and not life-threatening. Except, that is, when it occurs during pregnancy. In a recently published paper the authors outline four cases of severe starvation ketoacidosis, all occurring in the third trimester of pregnancy, following prolonged vomiting over a period of days. All four women presented for emergency admission in a very poorly state and still vomiting with severe partially compensated metabolic acidosis (bicarbonate in the range of 8-13 mmol/L and base deficit in the range of 14-22 mmol/L). All four required transfer to intensive care and premature delivery of their babies by emergency Cesarean section. Fort Continue reading >>

Successful Management Of Diabetic Ketoacidosis In Pregnancy

Successful Management Of Diabetic Ketoacidosis In Pregnancy

(* Assistant Professor, **Registrar, *** Second Year Resident, **** Additional Professor Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.) Diabetic ketoacidosis (DKA) is a complication seen in type 1 diabetes mellitus (DM) but can also occur in pregnancies complicated by type 2 DM or gestational diabetes mellitus (GDM). DKA is a medical emergency with high maternal and fetal mortality, and requires treatment in an intensive care setting. Prompt recognition and resuscitative therapy improves medical and obstetric outcomes. This report of DKA in a case of GDM provides insight into pathophysiology and successful management. Normal pregnancy is characterized by a state of decreased insulin sensitivity, accelerated lipolysis and ketogenesis.[1, 2, 3, 4] The concentration of serum ketones is estimated to be two to four times greater than in nonpregnant state.[1, 5] Despite these changes, the incidence of DKA in pregnant diabetics is only 1 to 3%.[2, 3] Fetal mortality rates of 30 to 90% in the past have now decreased to 9% due to improvements in neonatal and diabetic management.[2, 3] A 22 year old primigravida with 34+6 weeks of gestation was referred to our tertiary care center with giddiness, polyuria, polydipsia, candidial vagina discharge and deranged blood sugars (fasting blood glucose 280 mg/dl and post-meal value 410 mg/dl a few days back). She had stable vital signs, 34 weeks’ sized relaxed gravid uterus with cephalic presentation and normal fetal heart sounds. She had been diagnosed by her primary care obstetrician as GDM one month earlier and referred to us; however she did not report nor was she on any treatment. Recent sonography revealed oligohydramnios (amniotic fluid index 7 cm) but no fetal malformations. 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

Diabetic Ketoacidosis In Pregnancy

Abstract Diabetic ketoacidosis (DKA) remains a medical emergency with high maternal and fetal mortality. Prompt recognition and resuscitative therapy markedly improves outcome. The pathophysiology and management of DKA in pregnancy is discussed in detail in this article. Language English (US) Pages 481-488 Number of pages 8 Journal Obstetrics and Gynecology Clinics of North America Volume 26 Issue number 3 DOIs 10.1016/S0889-8545(05)70092-9 State Published - 1999 Externally published Yes Continue reading >>

Starvation Ketoacidosis: A Cause Of Severe Anion Gap Metabolic Acidosis In Pregnancy

Starvation Ketoacidosis: A Cause Of Severe Anion Gap Metabolic Acidosis In Pregnancy

Copyright © 2014 Nupur Sinha et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Pregnancy is a diabetogenic state characterized by relative insulin resistance, enhanced lipolysis, elevated free fatty acids and increased ketogenesis. In this setting, short period of starvation can precipitate ketoacidosis. This sequence of events is recognized as “accelerated starvation.” Metabolic acidosis during pregnancy may have adverse impact on fetal neural development including impaired intelligence and fetal demise. Short periods of starvation during pregnancy may present as severe anion gap metabolic acidosis (AGMA). We present a 41-year-old female in her 32nd week of pregnancy, admitted with severe AGMA with pH 7.16, anion gap 31, and bicarbonate of 5 mg/dL with normal lactate levels. She was intubated and accepted to medical intensive care unit. Urine and serum acetone were positive. Evaluation for all causes of AGMA was negative. The diagnosis of starvation ketoacidosis was established in absence of other causes of AGMA. Intravenous fluids, dextrose, thiamine, and folic acid were administered with resolution of acidosis, early extubation, and subsequent normal delivery of a healthy baby at full term. Rapid reversal of acidosis and favorable outcome are achieved with early administration of dextrose containing fluids. 1. Introduction A relative insulin deficient state has been well described in pregnancy. This is due to placentally derived hormones including glucagon, cortisol, and human placental lactogen which are increased in periods of stress [1]. The insulin resistance increases with gestational age 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 >>

Starvation Ketoacidosis In Pregnancy

Starvation Ketoacidosis In Pregnancy

Introduction: Starvation ketosis outside pregnancy is a rare phenomenon and is unlikely to cause a severe acidosis. Pregnancy is an insulin resistant state due to placental production of hormones including glucagon and human placental lactogen. Insulin resistance increases with advancing gestation and this confers a susceptibility to ketosis, particularly in the third trimester. Starvation ketoacidosis in pregnancy has been reported and is usually precipitated by a period of severe vomiting. Ketoacidosis has been associated with intrauterine death. Case report: A 22-year-old woman in her third pregnancy presented at 32 weeks gestation with a 24 h history of severe vomiting. She had been treated for an asthma exacerbation with prednisolone and erythromycin the day prior to presentation. She was unwell, hypertensive (145/70 mmHg) with a sinus tachycardia and Kussmaul breathing. Urinalysis showed ++++ ketones, + protein and pH 5. Fingerprick glucose was 4 mmol/l and ketones were 4.0 mmol/l. Arterial blood gas showed pH 7.27, PaCO2 1.1 kPa, base excess −23, bicarbonate 8.6 mmol/l and lactate 0.6 mmol/l. The anion gap was 20. Serum ethanol, salicylates and paracetamol levels were undetectable. She was fluid resuscitated but her biochemical parameters did not improve. She was intubated and underwent emergency caesarean section. A healthy boy was delivered and her acidosis resolved over the subsequent 8 h. Discussion: We believe this case is explained by starvation ketoacidosis. There was no evidence of diabetes mellitus or other causes of a metabolic acidosis. In view of the hypertension, proteinuria and raised urate the differential diagnosis was an atypical presentation of pre-eclampsia. This case illustrates the metabolic stress imposed by the feto-placental unit. It als Continue reading >>

Diabetic Ketoacidosis In Pregnancy ( Ahmed Walid Anwar Morad)

Diabetic Ketoacidosis In Pregnancy ( Ahmed Walid Anwar Morad)

1. Management of diabetic ketoacidosis in pregnancy Dr/ Ahmed Walid Anwar Morad Assistant professor of OB/GYN Benha University 2017 2. This talk spotlights on • Definition • Epidemiology • Pathophysiology • Diagnosis • Differential diagnosis • Prevention • Treatment • Pitfalls in DKS 3. Epidemiology • DKA is an acute medical emergency associated with: - Fetal loss rates more than 50%. - Maternal mortality rates less than 1%. 4. Epidemiology • DKA in pregnancy most commonly occurs in women with: - Poorly controlled : *T1DM *T2DM or GDM under - Glucocorticoids - B-agonists / tocolytics - First presentation of T1DM in pregnancy 6. Glucose Homeostasis 7. DKA is common during pregnancy WHY? • Pregnancy is a stat of Relative insulin resistance especially in 2nd & 3rd trimesters. • Increased levels of HPL ,E, P & Cortisol act as insulin antagonists& impair maternal insulin sensitivity. • Pregnancy is a state of respiratory alkalosis associated with a compensatory drop in bicarbonate levels; this impairs the renal buffering capacity. 8. Precipitating factors of DKA in pregnancy • Insufficient or no insulin • Protracted vomiting • Hyperemesis gravidarum • Starvation • Infections • Medications precipitating DKP • Conditions such as diabetic gastroparesis 9. Diagnosis of DKA in pregnancy • DKP may be the first presentatio n of diabetes in pregnancy 10. Laboratory confirmation of DKA in pregnancy 11. Pitfalls in DKA • Potassium level may be falsely normal/elevated. • High – WBC count without infection. – Blood urea with prerenal azotemia due to dehydration. – Creatinine in absence of true impairment of renal function. – Serum amylase even in absence of pancreatitis. 12. What is different in pregnancy? • DKA occurs at lower blo Continue reading >>

What Is The Origin/mechanism Of Abdominal Pain In Diabetic Ketoacidosis?

What Is The Origin/mechanism Of Abdominal Pain In Diabetic Ketoacidosis?

Other than all papers I could find citing the depth of the keto-acidosis (and not the height of the blood glucose levels) correlating with abdominal pain, nothing else to explain how these two are linked. Decades ago, I was taught that because of the keto-acidosis causing a shift of intracellular potassium (having been exchanged for H+ protons of which in keto-acidosis there were too many of in the extracellular fluid) to the extracellular, so also the blood compartment, resulting in hyperkalemia, paralyzing the stomach, which could become grossly dilated - that’s why we often put in a nasogastric drainage tube to prevent vomiting and aspiration - and thus cause “stomach pain”. This stomach pain in the majority of cases indeed went away after the keto-acidosis was treated and serum electrolyte levels normalized. In one patient it didn’t, she remained very, very metabolically acidotic, while blood glucose levels normalized, later we found her to have a massive and fatal intestinal infarction as the underlying reason for her keto-acidosis….. 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 >>

Retrospective Analysis Of Diabetic Ketoacidosis In Pregnant Women Over A Period Of 3 Years

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 >>

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