Diabetes in pregnancy (GDM, T1DM, and T2DM) Quiz: Ace Your Exams

A 25-year-old primigravid woman with pregestational type 1 diabetes mellitus (T1DM) presents at 27 weeks estimated gestational age (EGA) with worsening abdominal pain, nausea, vomiting, and confusion over the past six hours. She also notes her perception of fetal movement has decreased, but she reports no contractions, loss of fluid, vaginal bleeding, headaches, shortness of breath, chest pain, or fevers. Her T1DM is managed with an insulin pump and is typically well-controlled. Aside from T1DM, her pregnancy and past medical history are unremarkable, and her only other medication is a prenatal vitamin. Temperature is 36.9°C (98.4°F), pulse is 118/min, respirations are 24/min, and blood pressure is 104/64 mmHg. On exam, the patient appears to be in mild distress but remains conversant. Her oral mucosa is dry, her breath has a fruity odor, and her abdomen is mildly tender to palpation; a pelvic exam is unremarkable. The fetal heart rate is in the 130s with minimal variability and occasional variable decelerations. Lab results are shown in the table below. IV fluids are initiated. Which of the following is the best next step in management?

Laboratory Value	Result	Reference Range
Serum Chemistry
Sodium	135 mEq/L	136-1465 mEq/L
Potassium	5.1 mEq/L	3.5-5 mEq/L
Chloride	95 mEq/L	95-105 mEq/L
Bicarbonate	12 mg/dL	22-28 mg/dL
Creatinine	0.8 mg/dL	0.6-1.2 mg/dL
Glucose	280 mg/dL	70-110 mg/dL
Arterial Blood Gas
Arterial pH	7.18	7.35-7.45
Urine
Bacteria	Few	Negative
Leukocyte esterase	Positive	Negative
Nitrites	Positive	Negative
Glucose	2+	Negative
Ketones	Positive	Negative