Management of Diabetic Ketoacidosis in Pregnancy

Management of Diabetic Ketoacidosis in PregnancyCheck capillary glucose and serum/urine ketones to confirm hyperglycemia and ketonemia/ketonuria.Start IV fluids: 1.0 L of 0.9% NaCl per hour. Keep patient NPO.Use BETAMETHASONE WITH CAUTION and only with attending approval. AVOID Terbutaline.Continuous fetal monitoring until resolution of DKA as defined below.DKA alone is generally NOT an indication for delivery. While fetal testing may be abnormal during acute DKA, fetal status should improve as the mother is treatedSTAT labs: Arterial blood gas, CBC with diff, urinalysis, serum glucose, Na, Cl, K, HCO 3 , serum ketones, plasma osmolality, BUN, creatinine, andEKG. (Additional testing to search for precipitating event should be individualized and may include: cultures of urine and blood, serum lipase, and CXR).IV Fluids(average fluid loss is 3-6 L)Determine hydration statusInsulin Potassium Assessneed forbicarbonateInsulin: Regular0.1 U/kg as IV bolusEstablish adequaterenal function (urineoutput ~50 ml/hr)SeverehypovolemiaAdminister 0.9%NaCl (1.0 L/hr)Sodium normal(135-145 mmol/L)or high (>145)0.45% NaCl(250-500 ml/hr)MildhypovolemiaCalculatecorrected*serum sodiumSodium low(5.3pH6.9-7.0pH>7.0NoHCODilute NaHCO 3 (50mmol) in 200 ml H 2 Owith 10 mEq KCL.Infuse over 1 hourIf pH 7.0.3Monitor serum K.When serum glucose reaches200 mg/dl, change to5% dextrose with 0.45% NaClat 150-250 ml/hr• Check electrolytes, BUN, venous pH, creatinine and glucose every 2-4 hrs until stable.• After resolution of DKA (see below) and when patient is able to eat, initiate SC multidose insulinregimen.• Continue IV insulin for 1-2 hr after SC insulin begun to ensure adequate plasma insulin levels.Continue monitoring on L&D for at least 2-4 hours after first SC insulin dose.DKA diagnostic criteria: Serum glucose >250 mg/dl, Arterial pH

**Anion gap= (Na + K) – (Cl + HCO 3 )(all units mmol/L)ReferencesAdapted from UpToDate®. Kitabchi AE et al: Treatment of diabetic ketoacidosis and hyperosmolar hyperglycemicstate in adults. Accessed 11/03/2008.Cullen MT et al. Am J Perinatol 1996 Oct; 13(7): 449-51.Eleven episodes of DKA were diagnosed during the 10-year study period. Plasma glucose levels of less than 200mg/dL were present in 4 of 11 patients (36%), 10 (90%) of whom presented with nausea, vomiting, and decreasedcaloric intake.Approved 11-20-08Copyright November 2008UNC School of Medicine