Management of diabetic ketoacidosis in pregnancy

Dr/ Ahmed Walid Anwar MoradAssistant professor of OB/GYN

Benha University2017

This talk spotlights on• Definition • Epidemiology• Pathophysiology • Diagnosis • Differential diagnosis• Prevention • Treatment • Pitfalls in DKS

Epidemiology

• DKA is an acute medical emergency associated with:

- Fetal loss rates more than 50%.

- Maternal mortality rates less than 1%.

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

PATHOPHYSIOLOGY

Glucose Homeostasis

DKA is common during pregnancyWHY?

• 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.

Precipitating factors of DKA in pregnancy

• Insufficient or no insulin• Protracted vomiting• Hyperemesis gravidarum• Starvation• Infections• Medications precipitating DKP• Conditions such as diabetic gastroparesis

Diagnosis of DKA in pregnancy

• DKP may be

the first

presentati

on of

diabetes in

pregnancy

Laboratory confirmation of DKA in pregnancy

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.

What is different in pregnancy?

• DKA occurs at lower blood

glucose level (Euglycaemic DKA)

• DKA can develop more rapidly

than in non-pregnant women

• Nausea and vomiting are common.

Differential diagnosis of DKA

Complications

Fetal• Distress• Perinatal death• Brain injury• Long term

developmental impacts.

Management of DKA in pregnancy

Multidisciplinary approach

Patient monitoring in HDU Consider

1. IV line

2. Arterial line

3. Urinary catheter (if not

producing urine after 3

hours).

4. 4. Nasogastric tube (if

drowsy / vomiting).

ICU admission • pH < 7.0• Altered consciousness• Poor response to acute

resuscitation• More intensive

monitoring anticipated (e.g. K+, intercurrent illness)

Management of DKA in pregnancy

Goals1. Re-hydration (IV fluid therapy)2. Normalization of serum glucose (IV insulin

therapy)3. Electrolyte correction4. Correction of acidemia (need for bicarbonate

administration)5. Elimination of the underlying cause 6. Monitoring of maternal and fetal responses

-Hourly intake and output. Foley catheter ??- Goal is correction of total fluid deficit over 12-24 hours.- After BP and urine output stabilize may change fluids to 0.45 NS at 250-500 cc/hr and then may decrease infusion rate- Avoid lactate-containing solution as this will aggravate acidosis.

-

Aim

Volume deficit

Time

Monitor

Type

Rate

Hypercholermic

acidosis

Insulin & K+ therapy are complementary

Phosphate

• Not usually indicated.

• Considered if severe hypophosphataemia

(<0.35mmol/L) +/- cardiorespiratory

depression

Correction of acidosis • The use of bicarbonate is

not recommended why?1. Bicarbonate inhibits the

compensatory hyperventilation → ↑ CO2 partial pressure → ↓ fetal oxygen delivery

2. Paradoxical fall in CSF PH. 3. Delays the wash out of

ketones4. Worsen hypokalaemia

• Consider Bicarbonate:

1. PH < 6.9

2. PH < 7 with homodynamic instability

3. Hyperkalemia with EG changes

• Limited studies

DKA resolution criteria

• Blood ketone level < 6mmol/ l

• pH > 7.3

• Bicarbonate > 15mmol/l

• Anion gap ≤ 12

Broad spectrum antibiotics

Fetal considerations

The frequency of fetal monitoring is unknown and nodefinite recommendations are currently available.

Fetal considerations

b. Fetuses exposed to maternal acidosis, dehydration and electrolyte disturbance (K+) may have:

Decreased variability and late decelerations or even fetal death.

The ominous patterns will typically correctable with correction of maternal

metabolic disturbance (4–8 hours) .

Maternal oxygen therapy is always useful in nonreassuring

fetal heart rate.

Fetal biophysical profile and Doppler studies may also reflect

the fetal acidotic status.

Fetal considerations c. Delivery decision should be individualized according to:

– Maternal clinical status

– Gestational age

– The results of fetal investigations such as fetal heart

tracing.

d. Delivery of a compromised fetus should be undertaken ONLY after the mother is metabolically stable.

Fetal considerations

• Continue the pregnancy with complete resolution of DKP.

• After complete resolution of DKP, further fetal monitoring especially in preterm fetus is not recommended.

Mode of delivery is guided by fetal ,maternal and obstetrical indications.

Fetal considerationsAvoid use of Betamimetics and corticosteroids while

DKA is being controlled.

The best practice, however, is aimed at educating the

patient to avoid further recurrence of DKP, and an

increased surveillance to ensure adequate diabetic

control and compliance with treatment.

Take home message

1. DKA during pregnancy is a life-threatening condition.

2. DKA may be the first presentation of DM during pregnancy.

3. Rapid diagnosis with rapid initiation of a multidisciplinary team management could help to reduce maternal and fetal mortality, and morbidity.

4. Decreased variability and late decelerations or even fetal death are common findings.

Take home message

5.The ominous patterns will typically correctable with correction of maternal metabolic disturbance.

6.Avoid use of Betamimetics and corticosteroids while DKA is being controlled.

7.Delivery decision should be individualized.8.Delivery should be undertaken ONLY after the

mother is metabolically stable.

Take home message

9. Continue the pregnancy with complete resolution of DKA.

10. Mode of delivery is guided by fetal, maternal and obstetrical indications.

11. Patient education will form the main framework to reduce the risks associated with DKA.

Thank You

Any Questions or Comments?