Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) e1
Contents lists available at ScienceDirect
Best Practice & Research Clinical Obstetrics and Gynaecology journal homepage: www.elsevier.com/locate/bpobgyn
Letter to the Editor
Endocrine emergencies in pregnancy
Dear Editors In the recent paper of Khoo and Lee [1] titled ‘Acute diabetes complications in pregnancy’ (p 887–8), there are some discrepancies with respect to the literature. 1. According to Ref. 21 (Savage) ‘Diabetic ketoacidosis is a medical emergency with a significant morbidity and mortality’ in Khoo and Lee, immediately life threatening is the most severe stage of ketoacidosis, which is coma. The authors write (p 887), “The acute management of DKA during pregnancy is similar to that non-pregnant and has been reviewed elsewhere (Carroll and Yeomans 2005 and Kamalakannan et al. 2003).” However, more recent studies have shown fundamental progress in the understanding of pathogenesis and therapy of coma. According to Edge et al. [2] and Nyenwe et al., [3] the immediate cause of decreased level of consciousness including coma is very low blood pH (¼ high concentration of hydrogen ions, Hþ). The glycolytic enzyme phosphofructokinase is pH-dependent, with decreasing pH also decreasing its activity and, thus, glucose utilisation in brain cells is impaired. This makes it possible to explain why infusions of sodium bicarbonate have decreased the lethality of coma in DKA to 0% (e. g., Ref. [4]). 2. The authors also write “Treatment includes insulin infusions... when the blood glucose falls below 14 mmol/l, infusions of dextrose solution should commence...” (p 887). Since the Nobel prize in 1977 to Rosalyn Yallow for new methods of biochemical analysis which make it possible to measure the concentration of insulin in human plasma, this is used worldwide. If in a diabetic patient hyperinsulinaemia is suspected, a necessary step is to measure the plasmatic concentration of insulin with adjustment of therapy to its result. References [1] Khoo CM, Lee KO. Endocrine emergencies in pregnancy. Best Pract Res Clin Obstet Gyn 2013;27(6):885–91. [2] Edge JA, Roy Y, Bergomi A, et al. Conscious level in children with diabetic ketoacidosis is related to severity of acidosis and not to blood glucose concentration. Pediat Diab 2006;7:11–5. [3] Nyenwe EA, Khan AE, Razavi LN, et al. Acidosis: the prime determinant of depressed sensorium in diabetic ketoacidosis. Diabetes Care 2010;33:1831–9. [4] Umpfierrez GE, Kelly JP, Navarrete JE, et al. Hyperglycemic crises in urban blacks. Arch Intern Med 1997;157:669–75.
Viktor Rosival, PhD, MD, Clinical Biochemist* SYNLAB Department of Laboratory Medicine, Dérer’s Hospital, Limbová 5, SK-833 05 Bratislava, Slovakia Tel.: þ421 33 5511831. E-mail address: [email protected] 1521-6934/$ – see front matter Ó 2014 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.bpobgyn.2014.01.004
Contents lists available at ScienceDirect
Best Practice & Research Clinical Obstetrics and Gynaecology journal homepage: www.elsevier.com/locate/bpobgyn
Letter to the Editor
Endocrine emergencies in pregnancy
Dear Editors In the recent paper of Khoo and Lee [1] titled ‘Acute diabetes complications in pregnancy’ (p 887–8), there are some discrepancies with respect to the literature. 1. According to Ref. 21 (Savage) ‘Diabetic ketoacidosis is a medical emergency with a significant morbidity and mortality’ in Khoo and Lee, immediately life threatening is the most severe stage of ketoacidosis, which is coma. The authors write (p 887), “The acute management of DKA during pregnancy is similar to that non-pregnant and has been reviewed elsewhere (Carroll and Yeomans 2005 and Kamalakannan et al. 2003).” However, more recent studies have shown fundamental progress in the understanding of pathogenesis and therapy of coma. According to Edge et al. [2] and Nyenwe et al., [3] the immediate cause of decreased level of consciousness including coma is very low blood pH (¼ high concentration of hydrogen ions, Hþ). The glycolytic enzyme phosphofructokinase is pH-dependent, with decreasing pH also decreasing its activity and, thus, glucose utilisation in brain cells is impaired. This makes it possible to explain why infusions of sodium bicarbonate have decreased the lethality of coma in DKA to 0% (e. g., Ref. [4]). 2. The authors also write “Treatment includes insulin infusions... when the blood glucose falls below 14 mmol/l, infusions of dextrose solution should commence...” (p 887). Since the Nobel prize in 1977 to Rosalyn Yallow for new methods of biochemical analysis which make it possible to measure the concentration of insulin in human plasma, this is used worldwide. If in a diabetic patient hyperinsulinaemia is suspected, a necessary step is to measure the plasmatic concentration of insulin with adjustment of therapy to its result. References [1] Khoo CM, Lee KO. Endocrine emergencies in pregnancy. Best Pract Res Clin Obstet Gyn 2013;27(6):885–91. [2] Edge JA, Roy Y, Bergomi A, et al. Conscious level in children with diabetic ketoacidosis is related to severity of acidosis and not to blood glucose concentration. Pediat Diab 2006;7:11–5. [3] Nyenwe EA, Khan AE, Razavi LN, et al. Acidosis: the prime determinant of depressed sensorium in diabetic ketoacidosis. Diabetes Care 2010;33:1831–9. [4] Umpfierrez GE, Kelly JP, Navarrete JE, et al. Hyperglycemic crises in urban blacks. Arch Intern Med 1997;157:669–75.
Viktor Rosival, PhD, MD, Clinical Biochemist* SYNLAB Department of Laboratory Medicine, Dérer’s Hospital, Limbová 5, SK-833 05 Bratislava, Slovakia Tel.: þ421 33 5511831. E-mail address: [email protected] 1521-6934/$ – see front matter Ó 2014 Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.bpobgyn.2014.01.004
