How do you recognize and treat diabetic ketoacidosis (DKA)?
How do you manage newly diagnosed or uncontrolled diabetic patients who are admitted for glycemic control during the antepartum period?
How do you recognize, manage, and prevent labor complications in patients with diabetes?
How do you manage and counsel postpartum patients with gestational diabetes mellitis (GDM) and pregestational diabetes?
An 18-year-old G1P0 at 29 0/7 weeks by stated last menstrual period presents to the obstetrical triage unit with the chief complaint of nausea, dysuria, and “not feeling well.” Her pregnancy is complicated by absent prenatal care.
She reports that she has been having dysuria for the past four days, and starting today, she had had nausea and vomiting. She has noted decreased energy for months, but she has really been feeling fatigued this week. She did not find out that she was pregnant until two weeks ago, but she has not yet had her first prenatal appointment.
Her vital signs reveal a temperature of 38.9°C, a heart rate of 112, a respiratory rate of 20, and a blood pressure of 125/70. Physical exam is significant for a slight fruity odor to the patient's breath, mild suprapubic tenderness, and left-sided flank pain. A bedside ultrasound is used to perform fetal biometry and confirms her gestational age by dates. A spot urinalysis first returns displaying abnormal findings, including 1+ protein, 3+ glucose, 3+ ketones, moderate leukocyte esterase, positive nitrites, and positive white blood cells. Serum labs then return with a complete metabolic panel revealing mild hyponatremia, mild hypokalemia, and a blood glucose level of 387 mg/dL. Her blood urea nitrogen, creatinine, and liver function tests are within normal limits. A CBC shows an elevated WBC count of 21, mild microcytic anemia, and normal platelets.
According to the Centers for Disease Control and Prevention (CBC) in 2016, there are 29 million Americans living with diabetes and another 86 million with insulin resistance or prediabetes.1 The rapid increase in patients with this disease spectrum is especially relevant in our patient population, given pregnancy's inherent insulin resistance and the role that this can play in maternal and fetal morbidity and mortality. More than 6% to 7% of deliveries are now occurring in patients with either pregestational diabetes or gestational diabetes mellitus (GDM).2 To care for these patients safely, the OB/GYN providers must be familiar with the common complications of diabetes during pregnancy as well as the antepartum, intrapartum, and postpartum management of patients with all classifications of diabetes (Fig. 24-1).
Diabetic classifications. Data from American Diabetes Association: 2. Classification and Diagnosis of Diabetes, Diabetes Care. 2016 Jan;39 Suppl 1:S13-S22.
MATERNAL COMPLICATIONS OF DIABETES
Apart from the associated complications surrounding delivery, as elaborated upon in the section entitled “Intrapartum Considerations,” later ...