Management of diabetic ketoacidosis in pregnancy TOG 2017 Flashcards
Precipitating factors in DKA in pregnancy?
Protracted vomiting
Hyperemesis gravidarum
Infections
Insulin non-compliance
Medications precipitating diabetic ketoacidosis in pregnancy
Insulin pump failure
Conditions such as gastroparesis
Diagnostic criteria for DKA?
Ketone: Blood >3, urine 2+
Glucose >11 or known DM
Bicarb <15 +/- venous pH <7.3
What normally happens to K levels in DKA?
Initially high or normal due to extracellular shit. During treatment drop rapidly.
What happens to bicarb and anion gap in DKA
Low bicarb
Increased anion gap
What cut offs are used for mild/moderate/severe DKA?
MildL 7.25-7.3, bicarb 15-18, anion gap >10
Molderate 7.0-7.25, bicab 10-15
Severe DKA ph <7, bicarb <10, anion gap >12
In management of DKA how much fluid should be given
0.9% 10-15ml/kg for 1st hour, then adjust to fluid status
1l/hour - 1 hour
500ml/hour - 4 hours
250ml/hour - 8 hours
then 150ml/hr
When should dextrose 10% be considered
If BM < 14 mmol/l
How to monitor K replacement, and adjustments to K and insulin
<3.3 0 Give K (40mmol) stop insulin, ensure good urine output. Once corrected restart insulin.
3.3-5.5 Give insulin and K
Insulin fixed rate 0.1unit/kg/hr.
> 5.5 Give insulin, no K
When can stop IV insulin?
When DKA resolution:
Blood ketone <0.6
pH >7.3
Bicarb >15
Anion Gap < 12
30-60 mins after 1st submit dose of rapid acting insulin, administered with meal
How to identify cause DKA
Detailed Hx
Physical bloods
FBC
urine analysis
cultures
How often should patient be monitored?
Hourly BM/ketones
2 hourly: serum electrolytes, BUN, creatinine, venous pH
Metablic targets when using IV insulin
Decrease blood ketone <0.5 per hour
Increase bicarb by 3mmol per hour
Decrease CBG <3mmol per hour
How long will normalalisation of fetal heart trace take after correction of DKP
4-8 hours
