Management of euglycemic ketoacidosis in gestational diabetes

Abstract

Objective Incidence of GDM is increasing. The incidence of diabetes is 9%. The risk of diabetic ketoacidosis is foetal distress and adverse neurological outcome. Foetal mortality rates at 27%–35%, hypoxia and recurrent late decelerations. Euglycemic DKA is characterised with relatively low blood sugar levels. Diagnosis is based on biochemical triad blood sugar <11 increased anion gap metabolic acidosis, ketonemia. Incidence is 0.8% and 1.1% of all pregnant DKA. It is commonly seen in type 2 diabetes but recently the incidence of euglycemic DKA is increasingly seen in women with gestational diabetes. it is an obstetric and medical emergency. It is Diagnostic challenge as euglycemia often leading providers to believe ketoacidosis is less severe, frequently go unrecognized leading onto maternal and foetal morbidity and mortality.

Case 35 Year old Primigravida with BMI of 38 with Gestational diabetes on insulin and metformin came in spontaneous labour at 3 cm dilatation slight raised BP was kept in for observation. The women had skipped insulin during labour. During process of labour it was noted that she was becoming ketotic with 3 + ketones in urine and blood sugar of 8.9 and blood ketones: 3.6. Multidisciplinary input with medical review euglyacemic Diabetic ketoacidosis was done with ph: 7.53, co2: 1.7 on arterial blood gas. She was transferred to intensive unit. Insulin sliding scale was started and IV fluids was started. There were initial CTG changes which settled down with fluids and insulin. She had emergency LSCS for failure to progress at 5 cm. she recovered well in intensive unit and transferred to ward at 20 h after delivery to high dependency unit.

Discussion Prompt recognition is needed as it is associated with foetal demise 35% without appropriate treatment. It is important to counsel women about intensive metabolic control, prenatal care in a combined obstetric and diabetic clinic. obstetric and midwifery staff needs to have High index of suspicion to identify early in the course of illness since the development of DKA can be rapid and can also occur at lower blood glucose levels compared to non-pregnant women. Blood ketone strips help in the differentiation of these euglycemic ketoacidosis and dehydration. Early hospitalisation if there are signs of decompensation. Use of Steroids for foetal lung maturity with caution.

Conclusion It is important to increase awareness of euglycemic diabetic ketoacidosis among obstetric staff and women diagnosed with gestational diabetes. Multidisciplinary input is need to ensure good outcome.