A 32 yr old pregnant woman with insulin dependent diabetes presents to a regional hospital in WA at 27 weeks gestation, with probable premature rupture of her membranes, threatened preterm labour and a low grade fever. She is given a dose of celestone (betamethasone) intramuscularly, some nifedipine for tocoloysis and has an urgent areomedical transfer organised. During the flight she has a salbutamol infusion to provide further tocolysis and minimise the risk of delivery of a 27 week foetus in the back of the plane which the retrieval team are very keen to avoid!
On arrival at your tertiary hospital she is febrile (T 38.4) but the most striking thing noted is the fact she is breathing very heavily but yet has clear lungs and normal SpO2 of 99%.
The team assessing her do some blood tests including an arterial blood gas and obtain the following results:
pH 7.26, pCO2 16, pO2 128, HCO3 7.5, Na 141, K 4.8, Cl 101, Gluc 19.0, Urea 8.1, Crn 0.09
Urine analysis: Glucose 4+, Ketones 1+
What is going on? How are you going to manage this patient?
This week I am joined by my colleague Dr Graeme Johnson and we discuss the ins / outs of DKA during pregnancy. Diabetes is an increasingly common condition both in the general population but also in pregnancy. DKA is an important and life threatening critical illness which can develop in any pregnant unwell diabetic patient. All healthcare workers who may be involved in the care of a diabetic pregnant patient will benefit from understanding the basic physiological process which leads to DKA, how to recognise it, and the principles of management. Join Graeme and I as we discuss a hypothetical case.
You can listen to the audio only on the blubrry podcast or if you prefer follow along with us watching the screencast which has the slides containing visual aids & diagrams. This does probably make it somewhat easier to follow the discussions we have about the metabolic pathways & ketone production.
Here are the links to the two main articles used in putting together this weeks podcast:
The Management of DKA
A Hallett, A Modi, N Levy; Developments in the management of diabetic ketoacidosis in adults: implications for anaesthetists, BJA Education, Volume 16, Issue 1, 1 January 2016, Pages 8–14, https://doi.org/10.1093/bjaceaccp/mkv006
Mohan M, Baagar KAM, Lindow S. Management of diabetic ketoacidosis in pregnancy. The Obstetrician & Gynaecologist 2017;19: 55–62.
Want to Brush up on Arterial Blood Gas Analysis? Check out these amazing sites:
1 – Kerry Brandis’ amazing Acid Base textbook available here on the anaesthesiamcq site:
2 – For those of you who like the super deep dive into a topic, I recommend Alex Yartsev’s super detailed discussions on metabolic syndromes and blood gas analysis on his great ICU website below: