Critical Care in

Obstetrics:

An Innovative and Integrated Model for

Learning the Essentials

Diabetic Ketoacidosis in

Pregnancy-

Case Presentations Jeffrey C. Faig, M.D., FACOG, FACP

Clinical Professor, Department of Obstetrics & Gynecology

Stanford University

I have no conflicts of interest to disclose

Disclosure

DKA in Pregnancy- Case Presentation 1

29 yo G2P0101 with DM1 for 24 years had PPROM at 29

wks. She was hospitalized, managed expectantly with

antibiotics, and had good glycemic control on split/mixed

insulin. At 34 wks induced with Pitocin.

At 0810 glucose was 67 mg/dl. Plan was to start IV insulin

and glucose when blood glucose > 100 mg/dl.

Over the next 24 hrs her glucose ranged from 45-93 mg/dl

without insulin. At this time she was still in labor without

nausea or vomiting. Na 144/K 4.0/Cl 112/HCO3 12 with

A/G 20, creat 0.7

Review of glucoses to follow:

(Journal of Perinatology, 2008 (28) 310)

Normoglycemic

DKA in pregnancy

Discussion

Insulin infusion begun with D5 ½ NS at 125 cc/hr,

insulin infusion at 1-2 units/hr. After 8 hrs a/g

normalized, pt underwent C/S for FTP, 3273 gm

infant, 5/9.

Points to remember:

Low insulin – increased hormone sensitive lipase in

adipose – increased FFA release

Low insulin /high glucagon – FFA converted to ketone

bodies in liver

Discussion On L&D, decreased po intake, increased metabolic activity,

facilitated diffusion of glucose across placenta, may yield

normoglycemia:

for prolonged labor or induction, be aware of time

since last po intake and hang D5 as indicated

monitor urine ketones at least q shift - notification re:

ketonuria will help avoid iatrogenic acidemia on busy

labor deck

DKA in Pregnancy- Case Presentation 2

32 yo G3P2002 Japanese woman with prepregnancy

BMI 19.9 and 11 wk 75 gm GTT of 77/137/134

presents at 28 wk ega with fatigue, RBS 348 mg/dl.

BP 110/84, pulse 106/min, temp 36.5 with Kussmaul

respirations and ketotic odor. Lung and cardiac exams

unremarkable. FH 28 cm with no significant abdominal

tenderness. FHT unremarkable.

Lab findings include Na+ 132/K+ 3.8/Cl 98 A/G: 22.

Anti-GAD Ab positive.

Dx’d with DKA, adult onset type 1 DM, treated with

saline, IV insulin and clinical course as noted.

Endo. Diab. Metab. Case Reports 2014

Laboratory Findings on Admission

Discussion

Initial insulin dose 58 units/24 hrs,

decreasing to approx. 10 units/24 hrs

Discharged from hospital at 34 wks,

delivered at 38 wks of healthy infant 3.1

gm, 9/9

Continued insulin postpartum

Discussion Unusual presentation with normal first trimester GTT

Differential diagnosis:

Adult onset type 1 DM

Phenotypic type 2 DM, Ab+

LADA (Latent Autoimmune Diabetes in Adults)

Small fraction of pts with DM2

> age 30

+ for at least 1 Ab (anti-islet cell, anti GAD, anti-insulin)

No insulin Rx for first 6 months of diagnosis

Usually slow progression without DKA or weight loss

Heterogeneous, variable titers of antibodies, BMI and

frequency of progression to insulin dependence

Discussion Screening adult pts with presumed DM2 for DM1 with

Ab:

Age of onset < 50 yrs

Acute symptoms

BMI < 25 kg/m2

Personal or fm hx autoimmune disease

If one or more Ab + (GAD, insulin, tyrosine

phosphatases (IA-2 and IA-2beta), islet cell) –

presumptive DM1, Rx with insulin, avoid oral

hypoglycemic agents

Discussion

DM2 Genetic Defects

MODY mutations

most common form of monogenic DM

2-5% of cases, many misclassified

clinically heterogeneous, defects of insulin secretion

DM2 dx’d at <25 years of age

autosomal dominant

lack of autoantibodies

Discussion

MODY1 – Hepatocyte Nuclear Factor 4A, 10%, Rx

OHA

MODY2 – Glucokinase, 25%, no complications, Rx

diet

MODY3 - Hepatocyte Nuclear Factor 1A,60%, Rx

OHA

Indications for genetic testing:

1) familial DM with autosomal dominant inheritance

2) onset < 25 y.o.

3) non-obese

4) negative islet cell Ab

Points to Remember

DM1 may occur even in setting of normal first trimester glucose

tolerance

Ddx of DM1

LADA – consider Ab testing, review BMI, insulin-dependence

Ddx of DM2

MODY – consider genetic testing

Diseases of exocrine pancreas

Pancreatitis, CF, Hemochromatosis

Endocrinopathies

Cushing’s, Acromegaly Glucagonoma, Pheochromocytoma,

Hyperthyroidism, Somatostatinoma

Drugs

Dilantin, Glucocorticoids, Beta-adrenergic agonists

Genetic syndromes

Turner’s, T21

DKA in Pregnancy- Case Presentation 3

37 yo G4P3003 Saudi woman presents at 33 wks with nausea,

vomiting and diffuse abdominal pain of 48 hrs duration. She

had developed GDM in her 3rd pregnancy and transitioned to

DM2 requiring insulin subsequently

Since unable to take p.o., she omitted her insulin doses. No

fever, UTI or respiratory symptoms.

Bp 120/63, temp 36.8, non-orthostatic. Mild diffuse

abdominal tenderness. FHT category 1

Lab: glucose 75 mg/dl, nl BUN, creat., nl WBC, no left shift.

LFT’s nl; HCO3 10.4/pH 7.32. UA 4+ ketones. A/G 17

Rx: Hydrated with NS

Repeat ABG demonstrated worsening of metabolic acidosis

with pH 7.21, HCO3 7.5

Saudi J. Kidney Dis Transplant 2007 (4) 590

Differential Diagnosis Anion-Gap Acidosis

Ketones

DKA

Alcoholic ketoacidosis A/G=(Na + K)-(Cl + HCO3)

Severe starvation

Metabolic (methylmalonic acidemia)

Lactate

Sepsis/hypoperfusion

Ischemic bowel

Metformin

Exogenous Acids

Methanol

ASA

Ethylene glycol

Reduced renal acid excretion

Chronic renal disease

Discussion

Workup: creat, amylase, lactate nl; salicylate level nl; abd

u/s nl; glucose repeatedly below 200 mg/dl

Pt started on D5 + insulin, dx’d with viral illness, discharged

from hospital 4 days later

Points to remember:

- Ddx anion-gap acidosis

15% of DKA pts present with glucose < 300 mg/dl; more

common in pregnancy

Eating disorders 2x as common in adolescent females with

DM1 compared with nondiabetic peers