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Clinical algorithms for the management of intrapartum maternal urine abnormalities

Cheung KW, Tan LN, Meher S, WHO Intrapartum Care Algorithms Working Group

BJOG, 2024 Aug;131 Suppl 2:79-89.
PMID: 35415941 DOI: 10.1111/1471-0528.16726

AIM: To develop evidence-based clinical algorithms for management of common intrapartum urinary abnormalities.
POPULATION: Women with singleton, term pregnancies in active labour and immediate postnatal period, at low risk of complications.
SETTING: Healthcare facilities in low- and middle-income countries.
SEARCH STRATEGY: A systematic search and review were conducted on the current guidelines from WHO, NICE, ACOG and RCOG. Additional search was done on PubMed and The Cochrane Database of Systematic Reviews up to May 2020.
CASE SCENARIOS: Four common intrapartum urinary abnormalities were selected: proteinuria, ketonuria, glycosuria and oliguria. Using reagent strip testing, glycosuria was defined as ≥2+ on one occasion or of ≥1+ on two or more occasions. Proteinuria was defined as ≥2+ and presence of ketone indicated ketonuria. Oliguria was defined as hourly urine output ≤30 ml. Thorough initial assessment using history, physical examination and basic investigations helped differentiate most of the underlying causes, which include diabetes mellitus, dehydration, sepsis, pre-eclampsia, shock, anaemia, obstructed labour, underlying cardiac or renal problems. A clinical algorithm was developed for each urinary abnormality to facilitate intrapartum management and referral of complicated cases for specialised care.
CONCLUSIONS: Four simple, user-friendly and evidence-based clinical algorithms were developed to enhance intrapartum care of commonly encountered maternal urine abnormalities. These algorithms may be used to support healthcare professionals in clinical decision-making when handling normal and potentially complicated labour, especially in low resource countries.
TWEETABLE ABSTRACT: Evidence-based clinical algorithms developed to guide intrapartum management of commonly encountered urinary abnormalities.

Matched MeSH terms: Ketosis/diagnosis; Ketosis/etiology; Ketosis/therapy
Siddha fasting in obese acute decompensated heart failure may improve hospital outcomes through empowerment and natural ketosis

Chockalingam A, Kumar S, Ferrer MS, Gajagowni S, Isaac M, Karuparthi P, et al.

Explore (NY), 2021 12 23;18(6):714-718.
PMID: 34987003 DOI: 10.1016/j.explore.2021.12.003

BACKGROUND: Morbid obesity (BMI > 35 kg/m2 with comorbid conditions) is present in 25 - 35% of acute decompensated heart failure (AHF) patients. Prevalence of HF increases with duration of morbid obesity from 30% at 15 years to over 90% at 30 years. There is a need to develop pragmatic therapies that address the unique physical and mental challenges faced by obese AHF patients. Siddha is 5,000 year old Tamil Medicine using yoga and mind-body methods towards higher consciousness. Hunger gratitude Experience (HUGE) is intuitive Siddha fasting method which may improve in-hospital AHF outcomes independent of weight reduction.
CASE SUMMARY: We present 5 cases of morbidly obese patients with cardiorenal syndrome (CRS) that began intermittent fasting either during their AHF hospitalization or in the outpatient setting for refractory symptoms despite hospitalization. Initiation of fasting correlated with reduction of respiratory distress and edema as well as improvements in psychological wellbeing and functional capacity.
DISCUSSION: Siddha fasting mediates hemodynamic and anti-inflammatory effects through natural ketosis and psychological benefits through empowerment in AHF. Potential role of fasting in reducing myocardial workload, coronary steal, angina, volume overload, and CRS needs further study in cardiac patients.

Matched MeSH terms: Ketosis*
An evaluation of beta-hydroxybutyrate in milk and blood for prediction of subclinical ketosis in dairy cows

Samiei A, Liang JB, Ghorbani GR, Hirooka H, Yaakub H, Tabatabaei M

Pol J Vet Sci, 2010;13(2):349-56.
PMID: 20731192

The first objective of this study was to investigate the relationship between concentrations of beta-hydroxybutyrate (BHBA) in milk and blood to assess the reliability of the BHBA concentrations in milk measured by a semi quantitative keto-test paper to detect subclinical ketosis (SCK) in 50 fresh high-producing Iranian Holstein cows in Golestan Province, Iran. The second objective was the effects of SCK on milk yield and components. Concentrations of nonesterified fatty acids (NEFA) and BHBA were analyzed quantitatively in blood plasma and commercial keto-test paper was used for semi quantitative determination of BHBA concentration in milk. Milk yield was measured until 60 d after calving but milk compositions were measured until 30 d after calving. The mean plasma BHBA, milk BHBA, plasma NEFA, milk yield, milk fat percentage and milk fat: protein ratio were 1,234 micromol/L, 145 micromol/L, 0.482 mEq/L, 29.5 kg, 3.9% and 1.4, respectively. Fifty eight percent of the cows had SCK during the first month of lactation. High correlation coefficients were observed between blood BHBA and blood NEFA, and between blood and milk BHBA. The milk yield of cattle with SCK decreased (P < 0.01) but the fat percentage and milk fat: protein ratio increased (P < 0.01). The commercial keto-test paper used had a low false positive result at a cut-off point of 200 fmol of BHBA/L of milk. The results showed that the best time to assess SCK using the commercial keto-test paper was d 10, 14 and 17 after calving.

Matched MeSH terms: Ketosis/blood; Ketosis/diagnosis; Ketosis/veterinary*
Prosthetic gene networks as an alternative to standard pharmacotherapies for metabolic disorders

Heng BC, Aubel D, Fussenegger M

Curr Opin Biotechnol, 2015 Dec;35:37-45.
PMID: 25679308 DOI: 10.1016/j.copbio.2015.01.010

Synthetic biology makes inroads into clinical therapy with the debut of closed-loop prosthetic gene networks specifically designed to treat human diseases. Prosthetic networks are synthetic sensor/effector devices that could functionally integrate and interface with host metabolism to monitor disease states and coordinate appropriate therapeutic responses in a self-sufficient, timely and automatic manner. Prosthetic networks hold particular promise for the current global epidemic of closely interrelated metabolic disorders encompassing obesity, type 2 diabetes, hypertension and hyperlipidaemia, which arise from the unhealthy lifestyle and dietary factors in the modern urbanised world. This review will critically examine the various attempts at constructing prosthetic gene networks for the treatment of these metabolic disorders, as well as provide insight into future developments in the field.

Matched MeSH terms: Ketosis/metabolism
Fulltext Hartman's solution or normal saline in the treatment of hyperemesis gravidarum among South East Asian population: a randomised controlled trial

Adibah, I., Khursiah, D., Ahmad, A.I., Zaki, N.N.M.

International Medical Journal Malaysia, 2008;7(2):21-24.
MyJurnal

Introduction: The aim of treatment for hyperemesis gravidarum is to stop vomiting, correction of dehydration, starvation and electrolytes imbalance. The common types of fluid used for fluid replacement are isotonic solutions like normal saline and hartman's solutions. The absence of potassium in normal saline makes hartman's solution superior but there is a possibility that the lactate component in hartman's solution could worsen the starvation state of the patients. This study is to evaluate which of these two solutions is more effective for fluid replacement in hyperemesis gravidarum. The objectives are to compare which solution corrects dehydration, hypokalaemia and acetonuria faster and to evaluate whether the ketosis state is aggravated by lactate component in hartman's solution. Materials and Methods: Patients with hyperemesis gravidarum were randomised to receive either Hartman's solution or normal saline at the rate of 125mls/hour. Blood urea and serum electrolytes, haematocrit, lactate and urine acetone were taken during admission and repeated every 12 hours. The volume of fluid required to correct dehydration, hypokalaemia and acetonuria were compared. Comparison of the pre and post treatment level of serum lactate were also done. Results: Both hartman's solution and normal saline are both effective in correcting dehydration (11.52Â±3.28 pints versus 11.94 Â± 2.30pints respectively) and acetonuria (11.64 Â± 2.75 pints versus 11.64 Â± 2.54 pints respectively).
A lower volume of hartman's solution was needed to correct hypokalaemia (8.34 Â± 2.44 pints versus 8.88 Â± 2.63 pints) but was not statistically significant. Ketonaemia was not made worse after treatment with hartman's solution. Conclusion: Normal saline and hartman's solution are equally effective in treating complications of hyperemesis gravidarum.

Matched MeSH terms: Ketosis
Inborn errors of metabolism

Thong, M.K., Choy, Y.S., Rawi, R.M.

Malaysian Journal of Paediatrics and Child Health, 2001;13(1):19-26.
MyJurnal

Inborn errors of metabolism (IEM) are a group of disorders that causes abnormal function of biochemical pathways. Archibald Garrod des-cribed the first inborn error of metabolism in 1893. He described alkaptonuria in a patient whose urine turned black on standing and the development of arthritis in adult life.' Subse-quently, Garrod encapsulated the idea of IEM in 1908 with the concept of 'chemical indivi-duality'. Beadle and Tatum proposed the concept of one gene - one enzyme in 1945.2 Phenyl-ketonuria (PKU) was described in 1934 and amongst the first to be recognised as a cause of mental handicap with a biochemical basis.' Effective treatment for PKU with low pheny-lalanine diet was introduced in 1955. Molecular characterisation of genetic defects localised to alleles in various chromosomes were performed in the last two decades

Matched MeSH terms: Ketosis
Treatment Options for Patients with Type 2 Diabetes Mellitus during the Fasting Month of Ramadan

Loh HH, Kamaruddin NA

Ann Acad Med Singap, 2020 Jul;49(7):468-476.
PMID: 33000110

During Ramadan, Muslims fast from sunrise (Sahur) to sunset (Iftar) and are required to abstain from food and fluids, including oral and injectable medications. Patients with diabetes who fast during Ramadan are at risk of developing hyperglycemia with increased risk of ketoacidosis, hypoglycemia, dehydration and thrombosis. Pre-Ramadan education and preparation of a fasting patient are essential to reduce severe complications. This review paper summarizes studies to date on oral and injectable medications available for patients with type 2 diabetes during Ramadan fasting, as well as recommendations on management of these patients during Ramadan. Although there is limited data on the use of Metformin, Acarbose and Thiazolidinedione in Ramadan, they appear to be safe. Sulphonylurea, especially Glibenclamide, is associated with higher risk of hypoglycemia during Ramadan fasting, hence may need adjustment in dosing and timing. The incretin group and SGLT2 inhibitor use during Ramadan fasting is associated with low risk of hypoglycemia with no increased adverse events. Insulin regimes need to be individualized for patients who fast during Ramadan.

Matched MeSH terms: Ketosis
Beta-ketothiolase deficiency in a Malaysian infant

Rajan D, Constance LSL, Brandon P

Med J Malaysia, 2019 04;74(2):174-175.
PMID: 31079130

Methylacetoacetyl-coenzyme A thiolase (MAT) deficiency is an autosomal recessive disease caused by a defect of mitochondrial acetoacetyl-CoA thiolase (T2). There is an error of isoleucine catabolism and ketone body utilization due to mutations in the acetyl-Coenzyme A acetyltransferase 1 (ACAT1) gene. We report a case of a 14 months old Sabahan boy with beta deficiency who presented with severe sepsis and ketoacidosis who subsequently recovered.

Matched MeSH terms: Ketosis/etiology
Fulltext Decision making in hyperglycaemia seen in pregnancy

Kavitha Nagandla, Sivalingam Nalliah

International e-Journal of Science, Medicine & Education, 2014;8(1):8-18.
MyJurnal

Delay in childbearing, family history of type 2 diabetes mellitus and obesity in childbearing years increases a possibility of glucose intolerance or overt diabetes in pregnancy which may remain unrecognised unless an oral glucose tolerance test is done.The International Association of Diabetes and Pregnancy Study Group (IADPSG, 2010) recommended the detection and diagnosis of hyperglycaemic disorders in pregnancy at two stages of pregnancy, the first stage looking for ‘overt diabetes’ in early pregnancy based on risk factors like age, past history of gestational diabetes and obesity and the second stage where ‘gestational diabetes’ at 24-28 weeks with 75 g oral glucose tolerance test. Although the one step approach with 75 g of glucose offers operational convenience in diagnosing gestational diabetes, there are concerns raised by the National Institute of Health in the recent consensus statement, supporting the two step approach (50-g, 1-hour loading test screening 100-g, 3-hour oral glucose tolerance test) as the recommended approach for detecting gestational diabetes. Medical nutrition therapy (MNT) with well-designed meal plan and appropriate exercise achieves normoglycemia without inducing ketonemia and weight loss in most pregnant women with glucose intolerance. Rapidly acting insulin analogues, such as insulin lispro and aspart are safe in pregnancy and improve postprandial glycemic control in women with pre-gestational diabetes. The long acting analogues (Insulin detemir and glargine) though proven to be safe in pregnancy, do not confer added advantage if normoglycemia is achieved with intermediate insulin (NPH). Current evidence indicates the safe use of glyburide and metformin in the management of Type 2 diabetes and gestational diabetes as other options. However, it is prudent to communicate to the women that there is no data available on the long-term health of the offspring and the safety of these oral hypoglycemic drugs are limited to the prenatal period.

Matched MeSH terms: Ketosis
Fulltext Ischaemic haemorrhagic stroke in a child with new onset type 1 diabetes mellitus

Mohd Nor NS, Fong CY, Rahmat K, Vanessa Lee WM, Zaini AA, Jalaludin MY

Eur Endocrinol, 2018 Apr;14(1):59-61.
PMID: 29922355 DOI: 10.17925/EE.2018.14.1.59

Cerebral oedema is the most common neurological complication of diabetic ketoacidosis (DKA). However, ischaemic and haemorrhagic brain injury has been reported infrequently. A 10-year old girl who was previously well presented with severe DKA. She was tachycardic with poor peripheral perfusion but normotensive. However, two fast boluses totalling 40 ml/kg normal saline were given. She was transferred to another hospital where she was intubated due to drowsiness. Rehydration fluid (maintenance and 48-hour correction for 7.5% dehydration) was started followed by insulin infusion. She was extubated within 24 hours of admission. Her ketosis resolved soon after and subcutaneous insulin was started. However, about 48 hours after admission, her Glasgow Coma Scale score dropped to 11/15 (E4M5V2) with expressive aphasia and upper motor neuron signs. One dose of mannitol was given. Her symptoms improved gradually and at 26-month follow-up she had a near-complete recovery with only minimal left lower limb weakness. Serial magnetic resonance imaging brain scans showed vascular ischaemic injury at the frontal-parietal watershed regions with haemorrhagic transformation. This case reiterates the importance of monitoring the neurological status of patient's with DKA closely for possible neurological complications including an ischaemic and haemorrhagic stroke.

Matched MeSH terms: Ketosis