Reversal of fetal distress following intensive treatment of maternal diabetic ketoacidosis

Diabetic acidosis with severe fetal hypoxia in pregnancy: Narrative review and case study

Diabetic ketoacidosis (DKA) in pregnancy could be a disastrous event with increased maternal and perinatal morbidity and mortality. DKA can occur with a normal blood glucose level, known as euglycemic DKA. It particularly affects pregnant women with type I diabetes. Here, we report the case of a 28 year-old primigravid patient, with a diagnosis of type 1 diabetes for 8 years. This patient consulted our department at 29 weeks of gestation with a previous history of headaches, vomiting and diarrhea for 9 h. Blood glucose level was 8.8 mmol/L with a ketone test positive (>15 mg/dL). Blood test showed high anion gap (17.9 mmol/L) with low serum bicarbonate rate (21 mmol/L). Systemic examination and fetal heart rate (FHR) was reassuring. The patient was subsequently discharged. She returned to the clinic 19 h later with further symptoms of nausea, polyuria-polydipsia, asthenia and a weight loss of 4 kg since the day before. Blood sugar was 14.3 mmol/L and a ketone test was strongly positive. Cardiotocography showed fetal tachycardia and repeated late decelerations. A diagnosis of DKA was made and emergency cesarean was performed for fetal distress. At delivery, pH was acidosis (pH: 7.02, lactates: 6.2). The patient was successfully treated with intravenous hydration and insulin. Neonatal evolution was favorable. Pregnant women with type I diabetes can develop euglycemic DKA. Early recognition and prompt treatment could help prevent severe maternal and fetal adverse outcomes. DKA in pregnant women can induce fetal acidosis with abnormal FHR. In this situation, a cesarean can be performed to improve neonatal outcome even inducing a premature delivery. Prolonged pregnancy can lead to irreversible neonatal brain abnormalities.

Fulminant type 1 diabetes linked with fetal death in utero

Fulminant type 1 diabetes is a relatively new subtype of type 1 diabetes characterised by a sudden onset of severe diabetic ketoacidosis (DKA) in patients with no history of diabetes and can cause imminent death if untreated. We discuss a rare case of a Pacific Islander woman who was 36 weeks pregnant and presented to the emergency department with DKA and fetal death in utero having had a normal glucose tolerance test 4 weeks earlier. She was diagnosed with fulminant type 1 diabetes and was treated with an intravenous insulin-dextrose infusion. She delivered a stillborn female infant and was discharged on regular subcuticular insulin. This case is helpful in understanding a rare, lethal disease that is not well reported globally and especially in Australia, as it requires prompt recognition and treatment to prevent detrimental outcomes.

Management of Diabetic Ketoacidosis in Pregnancy

Diabetic ketoacidosis (DKA) is a rare, but potentially life-threatening complication of diabetes. Certain physiological changes during pregnancy predispose pregnant individuals to developing DKA. Early recognition and aggressive treatment are essential to avoid maternal and fetal morbidity and mortality. Although laboratory values can help to support, pregnant patients with DKA may not meet the usual criteria and the diagnosis can be made clinically. The key components to treatment include volume replacement, insulin infusion, correction of serum potassium, and fetal monitoring. With appropriate treatment, maternal mortality is low. After recovery, steps should be taken to avoid recurrence.

Diabetic ketoacidosis in pregnancy

The clinical presentation of diabetic ketoacidosis (DKA) includes nausea, vomiting, thirst, polyuria, polydipsia, abdominal pain, tachypnoea, and change in mental status in cases of severe DKA. DKA is similar in pregnant and non-pregnant women, but in pregnant women it can be seen at lower serum glucose levels and symptoms may develop more rapidly. Most, but not all, cases occur in the second or third trimester.DKA results in reduction in uteroplacental blood flow due to osmotic diuresis, and also in metabolic abnormalities (maternal acidosis, hyperglycaemia, electrolyte imbalance), resulting in fetal hypoxaemia and acidosis. In fetuses with mature cardiac activity, the fetal heart rate may show minimal or absent variability, repetitive deceleration and absence of acceleration. These abnormalities in heart rate usually resolve with resolution of the DKA, which may last for several hours before normalisation.For the patient reported on here, immediate delivery based on pathological fetal heart rate would have resulted in preterm delivery and jeopardised the maternal clinical condition. However, a holistic clinical approach by the multidisciplinary team to management of the patient led to normal term delivery 5 weeks after presentation with DKA; fetal and maternal outcome were good.

Endocrine Emergencies During Pregnancy: Diabetic Ketoacidosis and Thyroid Storm

The physiologic changes and common signs and symptoms of pregnancy can make the early recognition of endocrine emergencies more challenging. Diabetic ketoacidosis (DKA) can occur at only modestly elevated glucose levels (euglycemic DKA), often accompanied by starvation ketosis due to substantial fetal-placental glucose demands and is associated with a high stillbirth rate. Thyroid storm is life threatening with a higher rate of heart failure and both require prompt and aggressive treatment to avoid maternal and fetal morbidity and mortality. Treatment of these disorders and the special considerations for recognition and management in the context of pregnancy are reviewed.

Euglycemic diabetic ketoacidosis in pregnancy with COVID-19: A case report and literature review

Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes and is considered a medical emergency. Euglycemic DKA (EKDA) is a variant of DKA with a normal or minimally elevated glucose level <200 mg/dl. The condition can be difficult to diagnose due to the relatively normal glucose levels. Pregnancy, infection, and a low-calorie intake are some of the contributing common etiologies of EDKA. Despite a rapid increase in scientific publications on COVID-19, there are still knowledge gaps regarding the course of COVID-19 in some patient subset. This is especially the case for pregnant women. In this case report, we discuss the course of COVID-19 infection in a pregnant woman with gestational diabetes who developed severe euglycemic diabetic ketoacidosis triggered by various precipitating factors, including starvation, caused by COVID-19 infection and its gastrointestinal effects.

Ethical challenges in management of critically ill pregnant patients with coronavirus disease 2019 (COVID-19)

Despite the overwhelming number of coronavirus disease 2019 (COVID-19) cases worldwide, data regarding the optimal clinical guidance in pregnant patients is not uniform or well established. As a result, clinical decisions to optimize maternal and fetal benefit, particularly in patients with critical COVID-19 in the early preterm period, continue to be a challenge for obstetricians. There is often uncertainty in clinical judgment about fetal monitoring, timing of delivery, and mode of delivery because of the challenge in balancing maternal and fetal interests in reducing morbidity and mortality. The obstetrician and critical care team should empower pregnant patients or their surrogate decision maker to make informed decisions in response to the team's clinical evaluation. A clinically grounded ethical framework, based on the concepts of the moral management of medical uncertainty, beneficence-based obligations, and preventive ethics, should guide the decision-making process.

Severe metabolic ketoacidosis as a primary manifestation of SARS-CoV-2 infection in non-diabetic pregnancy

We present a case of a metabolic acidosis in a term-pregnant woman with SARS-CoV-2 infection.

Our patient presented with dyspnoea, tachypnoea, thoracic pain and a 2-day history of vomiting, initially attributed to COVID-19 pneumonia. Differential diagnosis was expanded when arterial blood gas showed a high anion gap metabolic non-lactate acidosis without hypoxaemia. Most likely, the hypermetabolic state of pregnancy, in combination with maternal starvation and increased metabolic demand due to infection, had resulted in metabolic ketoacidosis. Despite supportive treatment and rapid induction of labour, maternal deterioration and fetal distress during labour necessitated an emergency caesarean section. The patient delivered a healthy neonate. Postpartum, after initial improvement in metabolic acidosis, viral and bacterial pneumonia with subsequent significant respiratory compromise were successfully managed with oxygen supplementation and corticosteroids. This case illustrates how the metabolic demands of pregnancy can result in an uncommon presentation of COVID-19.

Resolution of severe fetal distress following treatment of maternal diabetic ketoacidosis

Diabetic ketoacidosis (DKA) during pregnancy is a serious metabolic complication of diabetes with high mortality and morbidity if not detected and treated immediately. We report a case of a woman with type 1 diabetes mellitus who had poorly controlled diabetes in the first half of pregnancy and developed DKA at 29 weeks gestation. At presentation, she had a pathological fetal heart tracing but delivery was delayed for maternal stabilisation and reversal of acidosis. Once hyperglycaemia, acidosis and maternal stabilisation were achieved, fetal compromise resolved and delivery was no longer indicated. The patient was subsequently discharged home. She delivered vaginally a 2400 g baby at 34 weeks gestation after presenting with spontaneous rupture of membranes.

Safe delivery of two parturient women in severe metabolic acidosis

Care of an acutely ill parturient is particularly difficult when we have to balance the needs of both mother and the fetus to survive. The literature suggests there should be emphasis on stabilising the mother's condition. In dealing with metabolic acidosis, however, we believe delivering the baby early might not only relieve the threat of the acidosis on the mother, it may be the only way to deliver a live baby. We report two parturient women with severe metabolic acidosis which was considerably reduced very soon after the delivery and how our timely delivery resulted in the birth of two neurologically intact babies.

Diabetic ketoacidosis in pregnancy

Pregnancies complicated by diabetic ketoacidosis are associated with increased rates of perinatal morbidity and mortality. A high index of suspicion is required, because diabetic ketoacidosis onset in pregnancy can be insidious, usually at lower glucose levels, and often progresses more rapidly as compared with nonpregnancy. Morbidity and mortality can be reduced with early detection of precipitating factors (ie, infection, intractable vomiting, inadequate insulin management or inappropriate insulin cessation, β-sympathomimetic use, steroid administration for fetal lung maturation), prompt hospitalization, and targeted therapy with intensive monitoring. A multidisciplinary approach including a maternal-fetal medicine physician, medical endocrinology specialists familiar with the physiologic changes in pregnancy, an obstetric anesthesiologist, and skilled nursing is paramount. Management principles include aggressive volume replacement, initiation of intravenous insulin therapy, correction of acidosis, correction of electrolyte abnormalities and management of precipitating factors, as well as monitoring of maternal-fetal response to treatment. When diabetic ketoacidosis occurs after 24 weeks of gestation, fetal status should be continuously monitored given associated fetal hypoxemia and acidosis. The decision for delivery can be challenging and must be based on gestational age as well as maternal-fetal responses to therapy. The natural inclination is to proceed with emergent delivery for nonreassuring fetal status that is frequently present during the acute episode, but it is imperative to correct the maternal metabolic abnormalities first, because both maternal and fetal conditions will likewise improve. Prevention strategies should include education of diabetic pregnant women about the risks of diabetic ketoacidosis, precipitating factors, and the importance of reporting signs and symptoms in a timely fashion.

Diabetic ketoacidosis in pregnancy

OBJECTIVE

The development of diabetic ketoacidosis in pregnancy is a medical emergency, requiring treatment in an intensive care setting. Both the mother and the fetus are at risk for significant morbidity and mortality. Physiologic changes unique to pregnancy provide a background for the development of diabetic ketoacidosis. An understanding of these physiologic changes assists in the management of the two patients being treated. Treatment of the patient with diabetic ketoacidosis includes insulin therapy and careful fluid management; recommendations for management are presented.

PATIENTS

Pregnant women, either with preexisting diabetes or with diabetes diagnosed during pregnancy.

CONCLUSIONS

Prompt recognition of the clinical manifestations of diabetic ketoacidosis, followed by appropriate, timely treatment will optimize outcome for the pregnant woman and her fetus.

Asthma, diabetic ketoacidosis and fetal distress

A known insulin-dependent diabetic parturient at 32 weeks' gestation was treated with oral steroids for presumed exacerbation of asthma. This resulted in maternal ketoacidosis and a non-reassuring fetal heart rate trace for which caesarean section was considered. Cessation of steroids and aggressive management of ketoacidosis resulted in improved maternal and fetal condition without the need for emergency caesarean section.

The impact of maternal ketonuria on fetal test results in the setting of postterm pregnancy

OBJECTIVE

The aim of this study was to determine whether ketonuria, a commonly assessed urinary marker of maternal starvation and dehydration, is associated with abnormal fetal test results in the setting of postterm pregnancy.

STUDY DESIGN

During a 4-year period (January 1993-December 1996), a total of 3655 visits for antepartum maternal-fetal testing of postterm pregnancies (> or =41 weeks' gestation) occurred at our institution. Maternal assessment included vital signs and urinalysis. The presence and degree of maternal ketonuria was correlated against abnormal results of fetal heart rate tests, nonstress tests, amniotic fluid index measurements, and biophysical profile scores performed on the same day.

RESULTS

There were 3601 encounters suitable for inclusion in the study. Clinically detectable ketonuria occurred in 10.9% of the patients studied. Patients with clinically detectable ketonuria were at increased risk relative to patients without ketonuria for abnormal outcomes during postterm testing, including the presence of oligohydramnios (24% vs. 9.3%; P<.0001 ), nonreactive nonstress tests (6.2% vs. 2.15%; P<.0001), and fetal heart rate decelerations (14% vs 9.2%; P =.0039 ).

CONCLUSION

Maternal ketonuria among patients with postterm pregnancy was associated with a >2-fold increase in the occurrence of oligohydramnios, a 3-fold increase in nonreactive nonstress tests, and a significant increase in fetal heart rate decelerations. Further studies are required to evaluate the potential benefits of treating ketonuria before fetal testing.

Diabetic ketoacidosis in pregnancy

Diabetic ketoacidosis (DKA) remains a medical emergency with high maternal and fetal mortality. Prompt recognition and resuscitative therapy markedly improves outcome. The pathophysiology and management of DKA in pregnancy is discussed in detail in this article.