Insulin sensitivity has been demonstrated to fall by as much
Diabetic ketoacidosis in pregnancy
The occurrence of diabetic ketoacidosis in pregnancy compromises both the fetus and the mother. It usually occurs in the later stages of pregnancy and is also seen in newly presenting type 1 diabetes patients. Despite improvement in its incidence rates canada goose store and outcomes over the years, it still remains a major clinical problem since it tends to occur at lower blood glucose levels and more rapidly than in non pregnant patients often causing delay in the diagnosis. This article illustrates a typical case of diabetic ketoacidosis in pregnancy and reviews the literature to provide an insight into its pathophysiology and management.diabetesketoacidosispregnancyDiabetic ketoacidosis is a serious metabolic complication of diabetes with high mortality if undetected. Its occurrence in pregnancy compromises both the fetus and the mother profoundly. Although predictably more common in patients with type 1 diabetes, it has been recognised in those with type 2 Canada Goose online diabetes as well Canada Goose Parka as gestational diabetes, especially with the use of corticosteroids for fetal lung maturity and 2 agonists for tocolysis.1 3 Diabetic ketoacidosis usually occurs in the second and third trimesters because of increased insulin resistance, and is also seen in newly presenting type 1 diabetes patients.With increasing practice of antepartum diabetes screening and the availability of early and frequent prenatal care/surveillance, the incidence and outcomes of diabetic ketoacidosis in pregnancy have vastly improved. However, it still remains a major clinical problem in pregnancy since it tends to occur at lower blood glucose levels and more rapidly than in non pregnant patients often causing delay canada goose black friday sale in the diagnosis. The purpose of this article is to illustrate a typical patient who may present with diabetic ketoacidosis in pregnancy and review the literature on this relatively uncommon condition and provide an insight into the pathophysiology and management.MAGNITUDE OF THE PROBLEMIn non pregnant patients with type 1 diabetes, the incidence of diabetic ketoacidosis is about 1 5 episodes per 100 per year with mortality averaging 5% 10%.4 The incidence rates of diabetic ketoacidosis in pregnancy and the corresponding fetal mortality rates from different retrospective studies5 8 are summarised in the table 1. As is evident from the table, both the incidence and rates of fetal loss in pregnancies have fallen in recent times compared with those before. In buy canada goose jacket cheap 1963 Kyle published an extensive review and reported a fetal loss rate of 30% with maternal acidosis and a rate of 64% if complicated by coma.9 Canada Goose Outlet With improvement in overall diabetes and pregnancy care these figures have dropped significantly and according to recent reports the incidence of diabetic ketoacidosis in pregnancy is 1% 3%10 with fetal loss rate of 9%.11 The majority (78% 90%) of presentations occur in the second and third trimesters of pregnancy.6,8 The exact rate of maternal mortality due to this condition is unknown but previous reports suggest it to be around 4% 15%.12,13 Confidential inquiries into maternal deaths in the UK for the period between 1979 and 1990 revealed 10 diabetes related deaths, of which three were due to diabetic ketoacidosis.14View this table:View inlineView popupCase reportA 28 year old woman with type 1 diabetes of five years’ duration, and with no evidence of Canada Goose sale diabetic canada goose coats microvascular or macrovascular complications, presented at 36 weeks’ gestation in her fifth pregnancy with a two day history of persistent vomiting and decreased fetal movements. On direct questioning she admitted to have skipped her last two doses of insulin because of persistent vomiting. She had Canada Goose Jackets previous admissions for diabetes and had, in general, been an infrequent attendee at the diabetes clinic and took poor care of her diabetes. During this unplanned pregnancy, she had defaulted on the majority of her diabetes specialist nurse clinic appointments and her glycaemic control as measured by glycated haemoglobin (HbA1c) had been poor throughout with readings of 11.5%, 6.4%, and 7.5% (upper reference range 5.5%) in the first, second, and third trimesters respectively. On examination she was tachypnoeic, hyperventilating, tachycardic, and dehydrated. Systemic examination was normal and there were no foci of infection. canada goose outlet Fetal heart sounds were absent.FACTORS CONTRIBUTING TO INCREASED RISK OF DIABETIC KETOACIDOSIS IN PREGNANCYThe metabolic changes that accompany pregnancy predispose to ketosis. Insulin sensitivity has been demonstrated to fall by as much as 56% through canada goose deals 36 weeks of gestation.16 The production of insulin antagonistic hormones like human placental lactogen, prolactin and cortisol, all contribute to this. The insulin requirement, for this reason, progressively rises during pregnancy explaining the higher incidence of diabetic ketoacidosis in the second and third trimesters. The fetus and the placenta use large amounts of maternal glucose as a major source of energy and this leads to decreased maternal fasting glucose. This, associated with relative insulin deficiency leads to an increase in free fatty acids, which are then converted to ketones in the liver.Effect of emesisNausea and vomiting are common due to increased human chorionic gonadotrophin in early pregnancy and increased oesophageal reflux in later stages. The resulting stress and fasting state in turn increases insulin antagonistic hormones. The net result is a lowered buffering capacity when exposed to an acid load like ketones.The clinical implication of these metabolic changes is not only that pregnant diabetics are at risk of developing ketoacidosis, but this can occur rapidly and at a much lower glucose level compared to non pregnant diabetics as seen in our illustrated case above.The usual precipitating factors include intercurrent illness, infections especially of the urinary tract, emesis and canada goose clearance dehydration, non compliance, insulin pump failure, and undiagnosed pregnancy. Unrecognised new onset diabetes accounted for 30% of the cases of diabetic ketoacidosis.17 A retrospective survey conducted by Rodgers canada goose and Rodgers to identify the precipitant of diabetic ketoacidosis in pregnant women, revealed non compliance to be the cause in 17% and a contributory factor in a further 25%.18 This certainly was a major factor in our illustrated case.Premature onset of labour in pregnancies complicated by diabetes pose a risk for diabetic ketoacidosis because of the need for tocolysis and systemic steroids for fetal lung maturation.1 3 2 Agonists, used to suppress premature uterine contractions, cause an increase in blood glucose, free fatty acids and ketones through stimulation of gluconeogenesis, glycogenolysis, and activation of lipolysis leading to hyperglycaemia and ketosis. Similarly, the use of corticosteroids in diabetic canada goose clearance sale pregnancy for fetal lung maturation may worsen hyperglycaemia and insulin canada goose coats on sale resistance leading to ketosis.FACTORS CONTRIBUTING TO INCREASED FETAL LOSSThe exact mechanism by which maternal diabetic ketoacidosis affects the fetus is unknown. Ketoacids as well as glucose readily cross the placenta. Whether it is the maternal acidosis, hyperglycaemia, severe volume depletion, or electrolyte imbalance that has the most detrimental effect on the fetus is unclear.15 Cardiotocography done during diabetic ketoacidosis in pregnancy has shown absence of baseline heart rate variability, persistent canadian goose jacket late deceleration, and non reassuring biophysical profile all suggesting fetal distress.19 The high mortality rate associated with diabetic ketoacidosis certainly suggests a canadagooseoutlets.biz hostile intrauterine environment.Decrease in uteroplacental blood flow due to: (a) osmotic diuresis leading to volume depletion and (b) maternal acidosis20 that can cause fetal hypoxic insult.Maternal acidosis could lead to fetal acidosis and electrolyte imbalance.Maternal hypokalaemia and fetal hyperinsulinaemia if severe could cause fetal hypokalaemia leading to fetal myocardial suppression and fatal arrhythmia.21Maternal hypophosphataemia associated with diabetic ketoacidosis can cause decrease in 2,3 diphosphoglycerate leading to impaired delivery of oxygen to the fetus.22.
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