Learning Objectives
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Identify risk factors for diabetic ketoacidosis in pregnancy.
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Recognize presentation of diabetic ketoacidosis in pregnancy.
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Describe management algorithm for diabetic ketoacidosis in pregnancy.
Diabetic ketoacidosis (DKA) is a relatively rare but life-threatening condition. Pregnant women are prone to develop more severe and more rapidly progressive episodes of DKA at lower glucose levels than nonpregnant women. In pregnancy, there is a particularly increased susceptibility to starvation, infection, and ketogenic factors .
Risk Factors
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Vomiting
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Starvation
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Infections (urinary tract, respiratory tract, chorioamniotic infections, skin infections, dental infections, ENT infections, etc.)
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Poorly controlled glycemia (including noncompliance, insulin pump failure)
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Beta agonist use
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Steroid use
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Diabetic gastroparesis
Diagnosis
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The signs and symptoms of diabetic ketoacidosis during pregnancy tend to develop faster than in the nonpregnant state. Signs and symptoms include the following (Fig. 22.1) :
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Hyperventilation/tachypnea or “Kussmaul respirations”
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Tachycardia
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Hypotension
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Dehydration
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Mental status changes with disorientation or coma
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Abnormal fetal heart tracing
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Polyuria or polydipsia
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Nausea or vomiting
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Abdominal pain or contractions
Diabetic Ketoacidosis Simulation
Materials Needed
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Volunteer to act as standardized patient
Key Personnel
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Attending obstetrician
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Nurse
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Resident physician (if available in your institution)
Sample Scenario
A 22-year-old G1P0 at 26 weeks gestation presents to labor and delivery. The patient has a known history of Type I diabetes mellitus since age 11. She states she has not taken her insulin for the last 2 days because she has had nausea and vomiting and has not been eating much. She now complains of worsening vomiting and abdominal pain. Her fingerstick BGT is 324. What other history and physical would you perform? What is your first priority in treating this patient? What lab work would you like to test?
Bloodwork is remarkable for the following:
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Serum glucose 336 mg/dL
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Sodium 136 mEq/L
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Potassium 3.6 mEq/L
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Bicarbonate 12 mEq/L
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Anion gap 16 mEq/L
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pH 7.22
Explain your strategies for the following:
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IV fluid replacement
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Potassium replacement
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Blood glucose control
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pH management
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Fetal monitoring
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Repeating bloodwork
Debriefing and Documentation
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Suspected precipitating factor for DKA
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Total fluid, electrolyte, insulin replacement received
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Plan for transitioning to subcutaneous insulin
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