Diabetic ketoacidosis in pregnancy

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.

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.

A 10-Year Audit of Pregnancies Affected by Diabetic Ketoacidosis at the Pretoria Academic Complex

BACKGROUND

Diabetic ketoacidosis (DKA) during pregnancy is associated with increased rates of maternal and perinatal mortality and morbidity. DKA management guidelines are designed to ensure optimal management and minimise adverse outcomes.

OBJECTIVES

To determine the level of adherence to DKA management guidelines at a tertiary centre in Pretoria, South Africa and report on maternal and perinatal outcomes of the pregnancies complicated by DKA.

METHODS

This was a retrospective clinical record audit using the SEMDSA guidelines against documented management. Adherence to three cornerstones of therapy: intravenous fluids, insulin therapy and management of electrolytes was measured.

RESULTS

Fifty-six records of pregnancies that were complicated with DKA over a 10-year period were reviewed. Mean age was 29.6 years (range 20-43). Thirty-six (64.3%) women had Type 1 diabetes mellitus. DKA was categorised into mild (n=26, 46.4%), moderate (n=22, 39.3%) and severe (n=8, 14.3%). The study demonstrated lack of adherence to the three cornerstones of therapy. Of the 49 (85.7%) women with recorded perinatal outcomes, 30.6% had stillbirths. Severe maternal DKA (pH < 7.0) demonstrated adverse perinatal outcomes (p=0.005).

CONCLUSION

Despite the availability of guidelines, DKA is sub-optimally manged in pregnancy which may contribute to adverse maternal and perinatal outcomes.

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.

Endocrine Emergencies in Obstetrics

Endocrine emergencies in pregnancy can be life threatening and are associated with increased morbidity for both the mother and fetus. Thyroid storm, diabetic ketoacidosis, and hypercalcemic crisis require a high clinical suspicion, rapid treatment, and multidisciplinary care to ensure best outcomes. Critical care consultation and intensive care unit admission are often warranted. Fetal testing may initially be concerning; however often improves with correction of the underlying metabolic derangement(s) and delivery is generally avoided until maternal status improves.

Case Studies in Thyroid Dysfunction and Pregnancy

This chapter represents a selection of 8 clinical scenarios that may commonly be encountered. They help summarize some of the literature and teaching points of the previous chapters. They are not meant to represent every possible presentation of thyroid disease, but rather to present common symptoms and findings that may aid a clinician in making a diagnosis or in selecting initial treatment.

Euglycemic Diabetic Ketoacidosis in the ICU: 3 Case Reports and Review of Literature

Diabetic ketoacidosis (DKA) is an acute complication of diabetes mellitus, both type I and type II, as well as other types with diabetes such gestacional diabetes mellitus. It is characterized by blood glucose levels greater than 250 mg/dL and metabolic acidosis (pH < 7.3 and serum bicarbonate < 15 mEq/dL) with an increased anion gap and the presence of ketone bodies in the blood or urine. Within this pathology, there is a subgroup of pathologies which are characterized by being present with no signs of hyperglycemia, posing a diagnostic challenge due to the absence of the main sign of the pathology and the diversity of their pathophysiology. In this article, we will present 3 clinical cases with 3 different forms of clinical presentation: a case of DKA in pregnancy, a case of DKA associated with the use of sodium-glucose cotransporter 2 (SGLT-2) inhibitors, and a third case related to sepsis, together with a narrative review of the literature on the topic.

Diabetic Nephropathy and Pregnancy

Women with diabetic nephropathy have challenging pregnancies, with pregnancy outcomes far worse than expected for the stage of chronic kidney disease. The underlying mechanisms that cause the adverse events remain poorly understood, but it is a widely held belief that substantial endothelial injury in these women likely contributes. Maternal hypertension, preeclampsia, and cesarean section rates are high, and offspring are often preterm and of low birth weight, with additional neonatal complications associated with glycemic control. This review will present the current evidence for maternal and fetal outcomes of women with diabetic nephropathy and describe prepregnancy, antenatal, and peripartum optimization strategies.

Acute starvation ketoacidosis in pregnancy with severe hypertriglyceridemia: A case report

RATIONALE

Pregnant women are more prone to ketosis due to the relative insulin resistance, accelerated lipolysis and increased free fatty acids.

PATIENT CONCERNS

We report a pregnant woman with hyperlipidemia, who experienced severe metabolic acidosis after a short period of starvation.

DIAGNOSES

Based on her clinical symptoms, exclusion diagnosis and therapeutic diagnosis, her condition was diagnosed as starvation ketoacidosis.

INTERVENTIONS

An emergency caesarean section under general anesthesia was implemented 2 hours after her admission. The metabolic acidosis was treated with fluid resuscitation using compound sodium lactate, bicarbonate, and 5% dextrose together with insulin 6U.

OUTCOMES

Both mother and baby were discharged clinically well.

LESSONS

Starvation ketoacidosis may happen in special patient who was in pregnancy and with severe hypertriglyceridemia, after just one day fasting and vomiting.

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.

Nondiabetic ketoacidosis in a pregnant woman due to acute starvation with concomitant influenza A (H1N1) and respiratory failure

Threatening refractory metabolic acidosis due to short-term starvation nondiabetic ketoacidosis is rarely reported. Severe ketoacidosis due to starvation itself is a rare occurrence, and more so in pregnancy with a concomitant stressful clinical situation. This case report presents a nondiabetic woman admitted in intensive care for respiratory failure type 1 during the third trimester of pregnancy with a severe metabolic acidosis refractory to medical treatment. We diagnosed the patient with acute starvation ketoacidosis based on her history and the absence of other causes of high anion gap metabolic acidosis after doing a rigorous analysis of her acid-base disorder.

Diabetic ketoacidosis complicating pregnancy

BACKGROUND

Although diabetic ketoacidosis (DKA) in pregnancy can result in significant adverse consequences for both mother and fetus, the response to treatment, time course of recovery, and perinatal outcomes have not been well studied in pregnancy.

OBJECTIVE

We examined the precipitating factors, laboratory abnormalities, treatment strategies, and clinical recovery in pregnancies complicated by DKA.

STUDY DESIGN

This is a retrospective cohort study of pregnancies complicated by DKA between October 1999 and June 2015. The diagnosis was verified by hyperglycemia; anion gap >12 mEq/L, pH <7.3, HCO3 <15 mEq/L; and the presence of ketones. Each episode of DKA was reviewed and subsequent perinatal outcomes analyzed.

RESULTS

During this period, we identified 33 women with 40 admissions (incidence: 0.2%). The majority of women had type 1 diabetes (67%), and almost all presented with nausea and vomiting (97%). Over half had poor compliance with prescribed insulin. The initial mean blood glucose was 380 mg/dL, within 6 hours, it was <200 mg/dL. By 12 hours, the acidosis had resolved in 90% of patients.

CONCLUSION

Nausea and vomiting is a prominent presenting feature of DKA in pregnancy. With aggressive insulin and resuscitation, hyperglycemia and acidosis improve rapidly. With current treatment, good perinatal outcomes can be expected.

Sepsis in Pregnancy: Identification and Management

Sepsis accounts for up to 28% of all maternal deaths. Prompt, appropriate treatment improves maternal and fetal morbidity and mortality. To date, there are no validated tools for identification of sepsis in pregnant women, and tools used in the general population tend to overestimate mortality. Once identified, management of pregnancy-associated sepsis is goal-directed, but because of the lack of studies of sepsis management in pregnancy, it must be assumed that modifications need to be made on the basis of the physiologic changes of pregnancy. Key to management is early fluid resuscitation and early initiation of appropriate antimicrobial therapy directed toward the likely source of infection or, if the source is unknown, empiric broad-spectrum therapy. Efforts directed at identifying the source of infection and appropriate source control measures are critical. Development of an illness severity scoring system and treatment algorithms validated in pregnant women needs to be a research priority.

Critical Illness in Pregnancy: Part II: Common Medical Conditions Complicating Pregnancy and Puerperium

The first of this two-part series on critical illness in pregnancy dealt with obstetric disorders. In Part II, medical conditions that commonly affect pregnant women or worsen during pregnancy are discussed. ARDS occurs more frequently in pregnancy. Strategies commonly used in nonpregnant patients, including permissive hypercapnia, limits for plateau pressure, and prone positioning, may not be acceptable, especially in late pregnancy. Genital tract infections unique to pregnancy include chorioamnionitis, group A streptococcal infection causing toxic shock syndrome, and polymicrobial infection with streptococci, staphylococci, and Clostridium perfringens causing necrotizing vulvitis or fasciitis. Pregnancy predisposes to VTE; D-dimer levels have low specificity in pregnancy. A ventilation-perfusion scan is preferred over CT pulmonary angiography in some situations to reduce radiation to the mother's breasts. Low-molecular-weight or unfractionated heparins form the mainstay of treatment; vitamin K antagonists, oral factor Xa inhibitors, and direct thrombin inhibitors are not recommended in pregnancy. The physiologic hyperdynamic circulation in pregnancy worsens many cardiovascular disorders. It increases risk of pulmonary edema or arrhythmias in mitral stenosis, heart failure in pulmonary hypertension or aortic stenosis, aortic dissection in Marfan syndrome, or valve thrombosis in mechanical heart valves. Common neurologic problems in pregnancy include seizures, altered mental status, visual symptoms, and strokes. Other common conditions discussed are aspiration of gastric contents, OSA, thyroid disorders, diabetic ketoacidosis, and cardiopulmonary arrest in pregnancy. Studies confined to pregnant women are available for only a few of these conditions. We have, therefore, reviewed pregnancy-specific adjustments in the management of these disorders.

Dietary Patterns and Their Associations with the Diet Quality Index-International (DQI-I) in Korean Women with Gestational Diabetes Mellitus

The aim of this study was to examine dietary pattern, nutritional intake, and diet quality of Korean pregnant women with gestational diabetes mellitus (GDM). Between October 2008 and May 2012, 166 pregnant women diagnosed with GDM completed a questionnaire and dietary intake was assessed using a 3-day food record. Blood pressure, fasting plasma glucose, and glycated hemoglobin (HbA1c) concentrations were measured and oral glucose tolerance test (OGTT) was performed. Two major dietary patterns ("carbohydrate and vegetable" and "western" patterns) were identified through factor analysis. Dietary pattern scores for each dietary pattern were categorized into tertiles. The dietary quality index-international (DQI-I) was used to measure overall diet quality. Subjects with higher carbohydrate and vegetable pattern scores reported less physical activity (p < 0.05) and have higher diastolic blood pressure levels (p = 0.05). After adjusting for age and energy intake, higher carbohydrate and vegetable pattern scores were associated with higher sodium intakes (p = 0.02), but lower intakes of fat (p = 0.002) and other micronutrients. On the other hand, higher western pattern scores were associated with higher fat intake (p = 0.0001), but lower intakes of sodium (p = 0.01) and other micronutrients. Higher scores for both dietary patterns were associated with lower scores in the moderation category of the DQI-I (p < 0.0001). HbA1c and fasting plasma glucose levels were significantly lower among participants with high DQI-I than those with low DQI-I (p < 0.05). The study findings suggest that many Korean women with GDM do not consume nutritionally adequate or balanced diets, regardless of dietary pattern.

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.

Inpatient management of women with gestational and pregestational diabetes in pregnancy

For women with type 1 diabetes (T1DM), type 2 diabetes (T2DM), and gestational diabetes (GDM), poor maternal glycemic control can significantly increase maternal and fetal risk for adverse outcomes. Outpatient medical and nutrition therapy is recommended for all women with diabetes in order to facilitate euglycemia during the antepartum period. Despite intensive outpatient therapy, women with diabetes often require inpatient diabetes management prior to delivery as maternal hyperglycemia can significantly increase neonatal risk of hypoglycemia. Consensus guidelines recommend maternal glucose range of 80-110 mg/dL in labor. The most optimal inpatient strategies for the prevention of hyperglycemia and hypoglycemia proximate to delivery remain unclear and will depend upon factors such as maternal diabetes diagnosis, her baseline insulin resistance, duration and route of delivery etc. Low dose intravenous insulin and dextrose protocols are necessary to achieve optimal predelivery glycemic control for women with T1DM and T2DM. For most with GDM however, euglycemia can be maintained without intravenous insulin. Women treated with a subcutaneous insulin pump during the antepartum period represent a unique challenge to labor and delivery staff. Strategies for self-managed subcutaneous insulin infusion (CSII) use prior to delivery require intensive education and coordination of care with the labor team in order to maintain patient safety. Hospitalization is recommended for most women with diabetes prior to delivery and in the postpartum period despite appropriate outpatient glycemic control. Women with poorly controlled diabetes in any trimester have an increased baseline maternal and fetal risk for adverse outcomes. Common indications for antepartum hospitalization of these women include failed outpatient therapy and/or diabetic ketoacidosis (DKA). Inpatient management of DKA is a significant cause of maternal and fetal morbidity and remains a common indication for hospitalization of the pregnant woman with diabetes. Changes in maternal physiology increase insulin resistance and the risk for DKA. A systematic approach to its management will be reviewed.

Endocrine emergencies

Several potentially fatal endocrine emergencies in relation to obstetrics and gynecology are discussed in the article. Rates of case fatality vary in different series, but range from 10% to 30%. Rapid recognition, prompt supportive care, and intervention likely maximize maternal and fetal outcomes.

Endocrine emergencies in pregnancy

Endocrine emergencies in pregnancy are rare and are more likely to occur in the absence of good obstetric care. Serious thyroid and diabetes related events in pregnancy are more common because of their higher prevalence in the normal population. Pituitary complications in pregnancy are now relatively rare. A high index of suspicion is needed for early diagnosis, and medical treatment is directed primarily at maintaining maternal hemodynamic stability. A close liaison between an endocrinologist, maternal-fetal specialist and intensivist is critical in optimising both maternal and fetal outcomes.

Nutritional intake of pregnant women with gestational diabetes or type 2 diabetes mellitus

Adequate intake of nutrients by pregnant women diagnosed with gestational diabetes mellitus (GDM) or type 2 diabetes (T2DM) is very important for appropriate weight gain and maintenance of normoglycemia without ketonuria. The aim of this study was to investigate the nutritional intake of pregnant women with GDM or T2DM who had not been provided with nutritional education regarding blood glucose management. Between June 2008 and May 2010, 125 pregnant women who had been diagnosed with GDM or T2DM and had not received any nutrition education regarding glycemic control and proper diet during pregnancy were interviewed to collect data regarding background characteristics, health-related behaviors, and course of pregnancy and instructed to record their dietary intake using a 24-hour recall method for one day. Using the collected data, the index of nutritional quality, nutrient adequacy ratio, and mean adequacy ratio values of the subjects were calculated. Analysis of the values indicated that the majority of the subjects did not meet recommended intake levels for most micronutrients and consumed an undesirable ratio of macronutrients, specifically a higher percentage of total carbohydrates than the current recommendation level. The GDM and T2DM groups obtained 56.6% and 63.6%, respectively (p = 0.012), of their calories by carbohydrate intake, which exceeded the recommended levels (125.8% in GDM groups, 141.3% in T2DM groups).

Hyperglycemic crisis

BACKGROUND

Hyperglycemic crisis is a metabolic emergency associated with uncontrolled diabetes mellitus that may result in significant morbidity or death. Acute interventions are required to manage hypovolemia, acidemia, hyperglycemia, electrolyte abnormalities, and precipitating causes. Despite advances in the prevention and management of diabetes, its prevalence and associated health care costs continue to increase worldwide. Hyperglycemic crisis typically requires critical care management and hospitalization and contributes to global health expenditures.

OBJECTIVE

Diagnostic and resolution criteria and management strategies for diabetic ketoacidosis and hyperosmolar hyperglycemic crisis are provided. A discussion of prevalence, mortality, pathophysiology, risk factors, clinical presentation, differential diagnosis, evaluation, and management considerations for hyperglycemic crisis are included.

DISCUSSION

Emergency physicians confront the most severe sequelae of uncontrolled diabetes and provide crucial, life-saving management. With ongoing efforts from diabetes societies to incorporate the latest clinical research to refine treatment guidelines, management and outcomes of hyperglycemic crisis in the emergency department continue to improve.

CONCLUSION

We provide an overview of the evaluation and treatment of hyperglycemic crisis and offer a concise, targeted management algorithm to aid the practicing emergency physician.

A case of nondiabetic ketoacidosis in third term twin pregnancy

CONTEXT

We report on a case of nondiabetic ketoacidosis due to mild starvation in a third term twin pregnancy.

OBJECTIVE

The aim was to present a case report and review of the literature in nondiabetic ketoacidosis in pregnancy, including precipitating factors and underlying pathophysiology.

DESIGN

The case report includes collation of earlier data and literature review.

SETTING

The patient was admitted to the obstetrics ward of a large general hospital and, after cesarean section, was transferred to the intensive care unit.

PATIENT

We present the case of a 26-yr-old obese patient with a 35-wk twin pregnancy.

INTERVENTION

We provided appropriate management with fluid infusion after cesarean delivery.

RESULTS

The patient and her two daughters survived, and no disabilities were foreseen. Alcohol, methanol, and lactic acid levels were normal. No signs of renal disease or diabetes were present. Pathological examination revealed no abnormalities of the placentae. Toxicological tests revealed a salicylate level of less than 5 mg/liter, an acetaminophen level of less than 1 mg/liter, and an acetone level of 300 mg/liter (reference, 5-20 mg/liter).

CONCLUSIONS

We present a case of third term twin pregnancy with high anion gap metabolic acidosis due to (mild) starvation. Starvation, obesity, third term twin pregnancy, and perhaps a gastroenteritis were the ultimate provoking factors. In the light of the erroneous suspicion of sepsis and initial fluid therapy lacking glucose, one wonders whether, under a different fluid regime, cesarean section could have been avoided. Severe ketoacidosis in the pregnant woman is associated with impaired neurodevelopment. It therefore demands early recognition and immediate intervention.

Management of diabetes in pregnancy

The link between diabetes and poor pregnancy outcomes is well established. As in the non-pregnant population, pregnant women with diabetes can experience profound effects on multiple maternal organ systems. In the fetus, morbidities arising from exposure to diabetes in utero include not only increased congenital anomalies, fetal overgrowth, and stillbirth, but metabolic abnormalities that appear to carry on into early life, adolescence, and beyond. This article emphasizes the newest guidelines for diabetes screening in pregnancy while reviewing their potential impact on maternal and neonatal complications that arise in the setting of hyperglycemia in pregnancy.

Diabetic ketoacidosis during gestational diabetes. A case report

Diabetic ketoacidosis is an infrequent complication of gestational diabetes but results in fetal loss. It usually occurs in the later stages of pregnancy. We report two young pregnant women who were admitted because of newly diagnosed diabetes with ketoacidosis. One patient presented with intrauterine fetal demise.

Gestational Diabetes Mellitus with Diabetic Ketoacidosis in a Yorkshire Terrier Bitch

A 6 yr old pregnant Yorkshire terrier bitch presented 62 days after mating with an acute history of vomiting and coughing. The owners also reported that the dog was polyuric and polydypsic for the last 2 weeks. Complete blood count, serum biochemistry, and urinalysis revealed hyperglycemia, ketonemia, ketonuria, and metabolic acidosis. Diabetic ketoacidosis was diagnosed and after emergency treatment, including fluid therapy, prophylactic antibiotics, and regular insulin, the bitch whelped six healthy normal puppies. Two weeks after treatment, the bitch was clinically normal with normal fructosamine levels. To the authors' knowledge, this is the first reported case of gestational diabetes mellitus in a small breed dog.

Pregestational diabetes

The prevalence of preexisting diabetes in pregnancy is increasing largely because of an increase in type 2 diabetes. Outcomes of diabetic pregnancies for mother and newborn have improved greatly in recent decades from advances in understanding the disease process, improved education, and new treatment modalities delivered in a team approach. Nausea and vomiting from pregnancy and pregnancy-associated insulin resistance can make glycemic control a challenge. Care of women with preexisting diabetes demands careful monitoring in the preconception, prenatal, and peripartum periods.

Spontaneous pneumomediastinum: a rare presentation of diabetic ketoacidosis in a pregnant woman

Pneumomediastinum (PM) or mediastinal emphysema is defined as the presence of free air around mediastinal structures. Spontaneous (or atraumatic) pneumomediastinum (SPM) is a rare complication during pregnancy. Primary or spontaneous PM can arise due to increased intra-alveolar pressure. Secondary PM is due to direct trauma, intrathoracic infections or violation of the aerodigestive track. This case report describes a pregnant woman newly diagnosed with diabetes presenting with an SPM due to vigorously vomiting and Kussmaul's breathing caused by diabetic ketoacidosis. Appropriate management of SPM and its underlying cause is required to reduce the risks for both mother and child.

Gestational diabetes: risk factors and recent advances in its genetics and treatment

The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study of over 23000 diabetes-free pregnancies has shown that at a population level an unequivocal linear relationship exists between maternal glucose concentrations around the beginning of the third trimester of pregnancy and the risk of their baby being born above the ninetieth centile for weight. With the rising incidence of gestational diabetes (GDM) across the developed world, largely paralleling the increased prevalence of obesity, there has been a sharp increase in the risk of pregnancy complications developing related to the birth of macrosomic babies. The associated additional long-term complications of GDM pregnancies means that in the future there is likely to be a large increase in the incidence of type 2 diabetes and associated conditions in both the mothers and their affected offspring. The present review seeks to highlight recent advances and remaining gaps in knowledge about GDM in terms of its genetics (where some of the recently discovered polymorphic risk factors for type 2 diabetes have also proved to be risk factors for GDM) and its treatment by diet, exercise and drugs.

Diabetic ketoacidosis in pregnancy tends to occur at lower blood glucose levels: case-control study and a case report of euglycemic diabetic ketoacidosis in pregnancy

BACKGROUND AND OBJECTIVE

The occurrence of diabetic ketoacidosis (DKA) during pregnancy is considered a medical emergency. The aims of the present study were to evaluate the incidence of DKA in pregnant and non-pregnant women with diabetes; to compare the blood glucose levels at the diagnosis of DKA in pregnant and non-pregnant women; and to show a case of euglycemic DKA in pregnancy.

METHODS

The subjects consisted of 90 cases of DKA in pregnant women with diabetes and 286 cases of non-pregnant female inpatients receiving treatment for diabetes during 2001 to 2005 in our hospital. The incidence of DKA in pregnant and non-pregnant women with diabetes and the blood glucose levels at the diagnosis of DKA in pregnant and non-pregnant women were compared.

RESULTS

DKA had a higher incidence in pregnant women with diabetes (8/90, 8.9%) than in non-pregnant women with diabetes (9/286, 3.1%) (P < 0.05). The blood glucose levels (mmol/L) in pregnant women with DKA were significantly lower than those in non-pregnant women with DKA (16.3 +/- 4.6 vs 27.5 +/- 4.8, P < 0.001). A case of euglycemic DKA in pregnancy was described whose serum glucose level was only 6.9 mmol/L.

CONCLUSIONS

DKA in pregnant women with diabetes may occur more frequently, and at lower blood glucose levels than DKA in non-pregnant women with diabetes.

Normoglycemic diabetic ketoacidosis in pregnancy

The clinical presentation of diabetic ketoacidosis in pregnancy is usually the same as in nonpregnant women, although the blood glucose may not be as high as in the nongravid state. We report a case of a pregnant woman who developed diabetic ketoacidosis with a normal blood glucose and review the pertinent medical literature. A 29-year-old woman with type I diabetes developed diabetic ketoacidosis during induction of labor. She had a glucose level of 87 mg per 100 ml with ketonuria, a metabolic acidosis, and an anion gap of 20 mmol l(-1). Normoglycemic diabetic ketoacidosis during pregnancy is truly unusual but can occur with relatively low, or even normal, blood sugars and necessitates prompt recognition and treatment. In this case, the combination of an initial episode of hypoglycemia and subsequent blood glucose levels below 95 mg per 100 ml led to a prolonged delay in the initiation of a planned insulin infusion for insulin coverage during the induction of labor. A significant ketoacidosis consequently developed, despite the absence of even a single elevated blood glucose measurement. This case illustrated the importance of not withholding insulin in a patient with type I diabetes for more than a few hours even if the blood glucose is normal.