Diabetic emergencies and pregnancy in diabetes

Question 1

What should you do if the adult is experiencing hypoglycaemic symptoms

Answer 1

• 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

Question 2

what features differentiate HHS from other hyperglycaemic states

Answer 2

• hypovolaemic
• marked hyperglycaemia without significant hyperketonaemia or acidosis
• osmolality usually 320mosmol/kg or more

Question 3

How many pregnant women get diabetes

Answer 3

5% of pregnant women

Question 4

what type of diabetes do pregnant women get

Answer 4

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.

Question 5

How does diabetes affect pregnancy

Answer 5

• increased risk of miscarriage
• pre-eclampsia
• preterm labour
• fetal congenital anomaly,
• large for gestational age babies,
• stillbirth, among other problems

Question 6

which women get a 75g OGTT in pregnancy

Answer 6

• 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.

Question 7

How do you diagnose gestational diabetes

Answer 7

• 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

Question 8

if you have a HbA1c of…. or more should you get pregnant

Answer 8

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

Question 9

women with evidence of micro or macrovascular complications of diabetes should…

Answer 9

avoid hormone based methods of contraception if possible

Question 10

What insulin is the preferred in pregnancy

Answer 10

• insulator insulin is the preferred long acting preparation in pregnancy

Question 11

in pregnancy there is an increased risk of

Answer 11

Blood glucose targets are more stringent in pregnancy, and so there is a significantly increased risk of hypoglycaemia

Question 12

how often do women who are pregnant with diabetes need to test there blood glucose

Answer 12

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).

Question 13

what happens to insulin requirements during pregnancy

Answer 13

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.

Question 14

what happens to HbA1c during pregnancy

Answer 14

• 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.

Question 15

what do women with type 1 diabetes also need to assess in pregnancy

Answer 15

• 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.

Question 16

why should women with diabetes breastfeed their babies

Answer 16

Apart from the known benefits for the infant, it will also help with weight loss and glycaemic control

Question 17

What should women with type 1 diabetes do to their insulin intake after pregnancy

Answer 17

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.

Question 18

What glucose test do you use to test glucose levels after pregnancy

Answer 18

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.

Question 19

in an acutely unwell patient …

Answer 19

it is advisable that the largest possible cannula is inserted

Question 20

What cannula would you use in a DKA patient

Answer 20

• green 18G cannnula
• 5040 ml/hr
  84 ml/min

Question 21

What are the diagnosis requirements for a DKA

Answer 21

1. Blood glucose greater than 11 mmol/L or known diabetes mellitus
2. Venous bicarbonate less than 15 mmol/L or pH less than 7.3
3. Ketonaemia (greater than or equal to 3 mmol/L or ketnouria 2+ on urine dipstick)

Question 22

What can precipitate a DKA

Answer 22

• Infection
• Poor compliance with insulin therapy
• Acute illness (myocardial infarction, stroke etc…)
• Medications (e.g. clozapine)
• Alcohol / Substance misuse
• Fasting
• Pregnancy

Question 23

How does the body compensate with a DKA

Answer 23

• 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

Question 24

describe why DKA happens in type 1 diabetic patients and HHS happens in type 2 diabetic patients

Answer 24

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.

Question 25

What is prandial insulin

Answer 25

this refers to the insulin that is injected by a patient immediately before a meal to counter the immediate rise in plasma glucose after eating.

Question 26

What is basal insulin

Answer 26

this is ‘background insulin’ used to counter fasting hyperglycaemia. Often insulin is in the form of intermediate or long acting preparations.