Scenario in a Nutshell
Diabetic ketoacidosis (DKA) in pregnancy.
Stage 1: Initial assessment of acutely unwell pregnant woman and diagnosis of DKA.
Stage 2: Emergency management of DKA and consideration of abnormal CTG.
Stage 3: Ongoing management and monitoring of DKA 1 hour after initiation of treatment.
Target Learner Groups
Obstetricians, anaesthetists and midwives.
| Specific learning opportunities |
|---|
| Assessment and resuscitation of the acutely unwell pregnant patient |
| Recognition of diabetic ketoacidosis (DKA) in pregnancy |
| Demonstrate the emergency management of the acutely unwell pregnant woman with DKA |
| Demonstrate appropriate senior multidisciplinary involvement |
| Suggested learners (to represent their normal roles) | In the room from the start | Available when requested |
|---|---|---|
| Midwife in room | √ | |
| Midwife Coordinator | √ | |
| Obstetric ST3+ | √ | |
| Anaesthetic ST3+ | √ | |
| Suggested facilitators | ||
| Faculty to play role of obstetric ST2 | √ |
Details for Facilitators
Patient Demographics
Name: Emma Age: 25 Gestation: 34+4 Booking weight: 65 kg Parity: P0 |
Scenario Summary for Facilitators
A 25-year-old primigravida presents at 34 weeks gestation to the obstetric triage department with a 3-day history of feeling generally unwell. This lady is a known type 1 diabetic. She has been compliant with antenatal care and has had negative screening for both microvascular and macrovascular complications.
Apart from diabetes, she is otherwise fit and well and has been well in the antenatal period.
She presents with suprapubic abdominal pain and vomiting. Although usually compliant with her insulin regime she does say that she has not been taking her insulin properly over the last 24 hours due to persistent vomiting and anorexia.
On examination: she appears pale and clammy and unwell. She is tachypnoeic and her breath has a ketotic odour.
Her urine shows significant ketonuria (4+), nitrites and protein and her initial capillary blood glucose is 17.0 mmol/l.
This woman has diabetic ketoacidosis, probably triggered by a urinary tract infection.
She is unwell on triage. Emergency treatment of DKA is initiated and she is moved to obstetric HDU.
CTG is abnormal. Mother stabilised prior to consideration of delivery.
Trigger for DKA sought. Investigations and treatment for sepsis.
After 1 hour of treatment with insulin and fluids, review biochemistry to check for adequate improvement.
Set-up Overview for Facilitators
| Clinical setting | In a triage room on a trolley |
| Patient position | Semi-recumbent |
| Initial monitoring in place | ECG, NIBP, SpO2 |
| Other equipment | None |
Medical Equipment
For core equipment checklist, see Chapter 9.
| Additional equipment specific to scenario | ||
|---|---|---|
| Vomit bowl | Urinalysis multistix | Blood ketone monitor and testing strips |
| Human soluble insulin (e.g. Actrapid) – syringe, giving set, drug labels | Normal saline (0.9% sodium chloride) and giving set | 10% glucose |
| IV broad-spectrum antibiotics | Arterial line | IV paracetamol |
Information Given to the Learners
Handover from ST2 Obstetrics (faculty) on for triage to ST3+ Obstetrics |
The SBAR handover is as follows: |
Situation: This is Emma, who has come into triage with a 3-day history of abdominal pain, vomiting and feeling generally unwell. |
Background: She is a 25-year-old, primiparous woman who is 34+4 weeks pregnant. She is a known type 1 diabetic on insulin. She only took a small dose of her insulin yesterday as she hardly ate anything all day and hasn’t had any insulin today as she has been vomiting and unable to keep any food or fluids down. She has no allergies. |
Assessment: We are just doing a first set of observations now. |
Recommendation: Could you help me? |
