Diabetic emergencies and pregnancy in diabetes Flashcards
What should you do if the adult is experiencing hypoglycaemic symptoms
- measure the adults capillary blood glucose
- if they have a blood glucose above 4 mmol/L you should treat them with a small carbohydrate snack
if less than 4 mmol/L then treat them as followed:
if the adult is conscious, oriented and able to swallow- - give 15-20g of quick acting carbohydrate e.g. 4-5 glucose tablets, 90ml to 120ml of original lucozade, 120-200ml of pure fruit juice or 3-4 heaped teapots f sugar dissolved
- repeat capillary blood glucose 10-15 minutes later
- if blood glucose is till less than 4 after 30-45 minutes or three cycles give IM glucagon or admit to hospital for IV glucose
- once their blood glucose is above 4 mmol/L and the patient has recovered give them a long acting carbohydrate, two biscuits, one slice of toast
if conscious and able to swallow but confused, disoriented, unable to cooperate or aggressive
- give carbohydrate gel in the mouth, teeth, gums
- recheck their blood glucose after 10 to 15 minutes - if still less than 4mmol/L then repeat step 1 but no more than three treatments in total
- if patients blood glucose is less than 4mmol/L after 30-45 minutes or three cycles you should consider admission to hospital for IV glucose
If unconscious
- check ABCDE
- give IM glucagon or IV glucose
what features differentiate HHS from other hyperglycaemic states
- hypovolaemic
- marked hyperglycaemia without significant hyperketonaemia or acidosis
- osmolality usually 320mosmol/kg or more
How many pregnant women get diabetes
5% of pregnant women
what type of diabetes do pregnant women get
The vast majority (over 80%, depending upon background risk) of pregnant women with diabetes have gestational diabetes (GDM), which is defined as glucose intolerance diagnosed in pregnancy.
How does diabetes affect pregnancy
- increased risk of miscarriage
- pre-eclampsia
- preterm labour
- fetal congenital anomaly,
- large for gestational age babies,
- stillbirth, among other problems
which women get a 75g OGTT in pregnancy
- Body mass index (BMI) above 30 kg/m2
- Previous macrosomic baby weighing 4.5 kg or above
- Previous gestational diabetes
- Family history of diabetes (first degree relative with diabetes)
- Minority ethnic family origin with a high prevalence of diabetes.
How do you diagnose gestational diabetes
- NICE recommends a diagnosis of gestational diabetes if the women has either a fasting plasma glucose level of 5.6 mmol/L or a two hour post 75 oral glucose load level of 7.8 mmol/L or above
if you have a HbA1c of…. or more should you get pregnant
Women with diabetes whose HbA1c is above 86 mmol/mol (>10%) should be advised not to get pregnant because of the high risk of congenital anomaly
women with evidence of micro or macrovascular complications of diabetes should…
avoid hormone based methods of contraception if possible
What insulin is the preferred in pregnancy
- insulator insulin is the preferred long acting preparation in pregnancy
in pregnancy there is an increased risk of
Blood glucose targets are more stringent in pregnancy, and so there is a significantly increased risk of hypoglycaemia
how often do women who are pregnant with diabetes need to test there blood glucose
All women on hypoglycaemic therapies in pregnancy will need to test their blood glucose seven or more times each day,
- You should also advise them to maintain their blood glucose above 4 mmol/L
- You should ensure that all pregnant women with type 1 diabetes have been prescribed glucagon 1 mg (subcutaneous, intramuscular, or intravenous).
what happens to insulin requirements during pregnancy
Insulin requirements can more than double in pregnancy due to pregnancy related hormones which increase insulin resistance, such as human placental lactogen and progesterone, so women often need more frequent repeat prescriptions of insulin. This increase usually starts from week 20 and may plateau from week 36.
what happens to HbA1c during pregnancy
- Due to changes in red blood cell turnover in pregnancy, HbA1c becomes less precise as an estimate of average blood glucose
- However, it can be useful as a means of assessing the risk of complications, such as large for gestational age babies and pre-eclampsia.
- It should be checked at least once in each trimester.
what do women with type 1 diabetes also need to assess in pregnancy
- women with type 1 diabetes need to be able to test for capillary blood ketones because of the risk that ketoacidosis poses for the foetus
- Pregnancy can be considered to be an accelerated fasting state because of the nutritional needs of the baby. This predisposes pregnant women with diabetes to ketosis.
why should women with diabetes breastfeed their babies
Apart from the known benefits for the infant, it will also help with weight loss and glycaemic control
What should women with type 1 diabetes do to their insulin intake after pregnancy
Women with type 1 diabetes prior to pregnancy will need to reduce their insulin to at least pre-pregnancy levels following birth; if they are breastfeeding, they will need an even smaller amount.
What glucose test do you use to test glucose levels after pregnancy
HbA1c as a test for diabetes is only useful once red cell turnover has returned to normal approximately three months after birth, and a formal oral glucose tolerance testing was not found to be useful by NICE. Therefore, a fasting plasma glucose test is recommended six to 13 weeks after the birth, and an HbA1c test is recommended annually for women who had a negative postnatal test for diabetes.
in an acutely unwell patient …
it is advisable that the largest possible cannula is inserted
What cannula would you use in a DKA patient
- green 18G cannnula
- 5040 ml/hr
84 ml/min
What are the diagnosis requirements for a DKA
- Blood glucose greater than 11 mmol/L or known diabetes mellitus
- Venous bicarbonate less than 15 mmol/L or pH less than 7.3
- Ketonaemia (greater than or equal to 3 mmol/L or ketnouria 2+ on urine dipstick)
What can precipitate a DKA
- Infection
- Poor compliance with insulin therapy
- Acute illness (myocardial infarction, stroke etc…)
- Medications (e.g. clozapine)
- Alcohol / Substance misuse
- Fasting
- Pregnancy
How does the body compensate with a DKA
- Increase the respiratory rate to excrete carbon dioxide (Kussmaul’s breathing)
- Increase the renal excretion of ketones (ketonuria)
- Buffering via bicarbonate and other intravascular substances
describe why DKA happens in type 1 diabetic patients and HHS happens in type 2 diabetic patients
DKA is more likely to occur in type 1 diabetes mellitus as there is an absolute deficiency of insulin. In people with type 2 diabetes, there may be a relative insulin insufficiency which can still result in hyperglycaemia, however, there is enough insulin to prevent ketogenesis. It should be noted that the varying degrees of insulin insufficiency may occur in type 2 diabetes, leading to hyperglycaemia associated with a mild acidosis and ketosis (so called ketosis prone type 2 diabetes), but this is not common.
