Diabetes Ketoacidosis/ Tog

Question 1

What are the pregnancy associated physiological changes that can predispose a pregnant woman with diabetes to diabetic ketoacidosis?

Answer 1

1* respiratory alkalosis associated with pregnancy 👉 ⬇️bicarbonate
2* insulin resistance in pregnancy
3* enhanced lipolysis in pregnancy
4* elevated free fatty acids in pregnancy which form the base for DKP.
5- ⬆️ HPL + ⬆️progesterone + ⬆️cortisol 👉impaire maternal insulin sensitivity.

Question 2

What is the diagnostic criteria for DKP?

Answer 2

1* blood ketone level more than 3 mmol/L or urine ketone level more than +2
2* blood glucose > 11 mmol/L or known DM
3* bicarbonate < 15 mmol/L or venous ph < 7.3

Question 3

What are the precipitating factors for DKP?

Answer 3

1- protracted vomiting
2- hyperemesis gravidarum
3- infections
4- insulin noncompliance
5- medication ( diabetic drugs - dapa / empa…)
6- insulin pump failure
7- gastroparesis

Question 4

What are the signs and symptoms of DKP?

Answer 4

1- Nausea or vomiting
2- abdominal pain
3- polyuria or polydipsia
4- blurred vision
5- muscle weakness
6- drowsiness/ lethargy
7- tachycardia/tachypnoea
8- hypotension
9- shock/ coma
10- hyperventilation / kussmaul breathing
11 change in mental status
12 - abnormal fetal heart tracing

Question 5

What are the investigations for DKP ?

Answer 5

1- positive serum/urine ketones
2- glucose > 11 mmol/L ( DKP may occur at lower glucose level)
3- bicarbonate < 15 mmol/L
4- arterial ph =< 7.3
5- anion gap > 12
6- k+ may be falsely normal or elevated
7- base deficit > 4 mEq/ L

Question 6

Where to manage DKP?

Answer 6

At least level 2 critical care

Question 7

What are the main aspects of management DKP?

Answer 7

Multidisciplinary approach
1- IV fluid therapy
2- IV insulin therapy
3- Electrolyte correction
4- evaluation of the need for bicarbonate administration
5- treatment of any precipitating factors
6- Monitoring of maternal and fetal responses

Question 8

What is the protocol of IV fluid therapy in DKP?

Answer 8

• 0.9 % normal saline ( 10- 15 ml/ kg / h) = 1 L / first hour.
• when the B glucose < 14 ( 250)
  :add dextrose 10% .

Question 9

Insulin and K+ replacement in the management of DKP?

Answer 9

• K+ < 3.3 👉 give K+ / don’t give insulin
• K+ 3.3 - 5.5 👉 give K+ and IV insulin
• K+ > 5.5 👉 don’t give K+ / give IV insulin
  🔴 IV insulin: 0.1 unit/kg/hr.
  🔴 stop IV insulin after 30- 60 min from the first dose of subcutaneous rapid acting insulin, administered with meal

Question 10

What tests should be done to monitor in DKP ?

Answer 10

1- blood glucose hourly
2- blood ketones hourly then q 2 hours
3- serum electrolytes + cr+ Venous ph : a 2 hours

Question 11

How to monitor the fetus in DKP?

Answer 11

1- confirm viability
2- CTG 3- ultrasound if indicated
4- delivery if indicated.

Question 12

What is the fetal complication of maternal hypokalemia?

Answer 12

Fetal cardiac arrhythmias

Question 13

Is bicarbonate replacement indicated in DKP?

Answer 13

No : delays the wash out of ketones and can worsen hypokalemia

Question 14

What are the maternal complications of DKP?

Answer 14

Acute renal failure
ARDS
Cerebral oedema
Coma / death

Question 15

What are the fetal complications of DKP?

Answer 15

Hypoxia/ preterm delivery

Question 16

What is the fetal mortality rate in DKP?

Answer 16

9- 36 %

Question 17

How much time may require the normalization of fetal heart tracing after correction of DKP?

Answer 17

May require 4-8 hours