Diabetic ketoacidosis (DKA)

Diabetic ketoacidosis (DKA)

Department of Obstetrics and Gynaecology

Diabetic ketoacidosis is an acute metabolic and obstetric emergency that can jeopardize both mother and fetus. Normally treated in ICU.

Fetal mortality as high as 50%.

The clinical features of DKA are due to:

Marked dehydration
Acidosis
Electrolyte disturbance

Presenting signs and symptoms of DKA:

Vomiting
Polydipsia
Polyuria
Weakness
Abdominal pain
Weight loss
Hyperventilation
Dry mucus membranes
Tachycardia
Hypotension
Disorientation
Coma
Underlying infection

Laboratory Findings:
Pregnant patient can develop DKA with glucose level less than 20 mg/dl.

Diabetic	Plasma glucose	>16 mmol/l
Keto	Serum Acetone	1,2 or more
Acidosis	Arterial pH S-HCO3 Anion Gap	less than 7,4 <15,1 [Na+ - (Cl- +HCO-3)] > 12

Diagnostic criteria for diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS)

	DKA	DKA	DKA	HHS
	Mild	Moderate	Servere	.
Plasma glucose (mg/dL)	>250	>250	>250	>600
Arterial pH	7.25-7.30	7.00-7.24	<7,00	>7,30
Serum bicarbonate (mEq/L)	15-18	10-15	<10	>15
Urine ketones*	Positive	Positive	Positive	Small
Serum ketones*	Positive	Positive	Positive	Small
Effective serum osmolality (mOsm/kg)	Variable	Variable	Variable	>320
Anion gap	>10	>12	>12	<12
Alteration in sensoria or mental obtundation	Alert	Variable/drowsy	Stupor/coma	Stupor/coma

* Nitroprusside reaction method.
Calculation: 2[measured Na (mEq/L)] + glucose (mg/dL)/18.
Calculation: (Na+) - (Cl- + HCO3-) (mEq/L). See text for details.
Copyright © 2006 American Diabetes Association From Diabetes Care Vol 29, Issue 12, 2006. Reprinted with permission from the American Diabetes Association.

Additional Laboratory Findings
Glucosuria
Leukocytosis
Ketonuria
Elevated CPK
Metabolic acidosis
Elevated amylase
Hyperosmolarity
Elevated transaminase
Hypokalemia
Elevated BUN
Hypomagnesemia
Elevated Creatinine
Hypophosphatemia

Monitoring
Serum glucose, serum ketones, arterial blood gas, creatinine, HCO2, serum electrolytes, anion gap, BUN, pulse oximetry, Urinary output

Repeat blood and urine test frequently
Place patient in left lateral position
Monitor fetal heart rate
Check for evidence of infection
If in coma/stupor O2 nasal cather.

Specific Treatments

Tabel II

Protocol for the management of adult patients with HHS

HHS diagnostic criteria: serum glucose >600 mg/dl, arterial pH >7.3, serum bicarbonate >15 mEq/l, and minimal ketonuria and ketonemia. Normal atory laboratory values vary; check local lab normal ranges for all electrolytes.
IV: intravenous; SC: subcutaneous.
* After history and physical exam, obtain capillary glucose and serum or urine ketones (nitroprusside method). Begin one liter of 0.9 percent NaCl over one hour and draw arterial blood gases, complete blood count with differential, urinalysis, serum glucose, BUN, electrolytes, chemistry profile and creatinine levels STAT. Obtain electrocardiogram, chest X-ray, and specimens for bacterial cultures, as needed.
Serum Na+ should be corrected for hyperglycemia (for each 100 mg/dl glucose >100 mg/dl, add 1.6 mEq to sodium value for corrected serum sodium value).
Copyright © 2006 American Diabetes Association From Diabetes Care Vol 29, Issue 12, 2006. Reprinted with permission from the American Diabetes Association.

Protocol for the management of adult patients with DKA

DKA diagnostic criteria: serum glucose >250 mg/dl, arterial pH <7.3, serum bicarbonate <18 mEq/l, and moderate ketonuria or ketonemia. Normal laboratory values vary; check local lab normal ranges for all electrolytes.
IV: intravenous; SC: subcutaneous.
* After history and physical exam, obtain capillary glucose and serum or urine ketones (nitroprusside method). Begin one liter of 0.9 percent NaCl over one hour and draw arterial blood gases, complete blood count with differential, urinalysis, serum glucose, BUN, electrolytes, chemistry profile, and creatinine levels STAT. Obtain electrocardiogram, chest X-ray, and specimens for bacterial cultures, as needed.
* Serum Na+ should be corrected for hyperglycemia (for each 100 mg/dl glucose >100 mg/dl, add 1.6 mEq to sodium value for corrected serum sodium value).
American Diabetes Association From Diabetes Care Vol 29, Issue 12, 2006

Management of diabetes
(1) Full diet
(2) Calculate the total number of insulin units administered over 24 hours following stabilization.

Total units/day

Before breakfast	Distribution
1/3 of total units / day	2/3 NPH 1/3 Regular
.	.
Before dinner	½ NPH
1/3 og total units/day	½ Regular

(NPH may be given at bedtime instead of at dinner of hypoglycemia occurs at 3 AM)

Hypoglycemia

The increased risk of hypoglycemia during pregnancy occurs in:: Early pregnancy; first trimester

During sleep

Patient with previous history of hypoglycemia

Symptoms: Tachycardia

Tremor

Hunger

Pallor

Dizziness

Irritability

Nausea

Headache

Paraesthesia

Concentration & memory loss

Confusion

Somnolence

Stupor, convulsions and coma

Treatment

Timing of Delivery
Induction of labor before 40 week should be limited to those maternal or fetal complications that necessitate delivery before 40 weeks.
Estimated fetal weight of 4500 or more cesarean delivery should be considered.

Indication for IOL before 40 weeks: Poor metabolic control

Diabetic patient with vascular disease

Poor compliance

Premature stillbirth

Progresing retinopathy

Fetal reson as macrosome

If preterm labor occurs in pregnant diabetic, tocolytic therapy with parenteral B-sympathomimetic agents is best avoided and Indomethacin and/or Oxytocin antagonist should be used (steroids and insulin).