Clinical Presentation and Outcomes of Diabetic Ketoacidosis in Pregnancy

Author:

Grasch Jennifer L.,Lammers Sydney,Scaglia Drusini Florencia,Vickery Selina S.,Venkatesh Kartik K.,Thung Stephen,McKiever Monique E.,Landon Mark B.,Gabbe Steven

Abstract

OBJECTIVE: To examine the presentation, management, and outcomes of pregnancies complicated by diabetic ketoacidosis (DKA) in a contemporary obstetric population. METHODS: This is a case series of all admissions for DKA during pregnancy at a single Midwestern academic medical center over a 10-year period. Diabetic ketoacidosis was defined per the following diagnostic criteria: anion gap more than 12 mEq/L, pH less than 7.30 or bicarbonate less than 15 mEq/L, and elevated serum or urine ketones. Demographic information, clinical characteristics, and maternal and neonatal outcomes were assessed. Patient characteristics and clinical outcomes were compared between individuals with type 1 and those with type 2 diabetes mellitus. RESULTS: Between 2012 and 2021, there were 129 admissions for DKA in 103 pregnancies in 97 individuals. Most individuals (n=75, 77.3%) admitted for DKA during pregnancy had type 1 diabetes. The majority of admissions occurred in the third trimester (median gestational age 29 3/7 weeks). The most common precipitating factors were vomiting or gastrointestinal illness (38.0%), infection (25.6%), and insulin nonadherence (20.9%). Median glucose on admission was 252 mg/dL (interquartile range 181–343 mg/dL), and 21 patients (17.6%) were admitted with euglycemic DKA. Fifteen admissions (11.6%) were to the intensive care unit. Pregnancy loss was diagnosed during admission in six individuals (6.3%, 95% CI, 2.3–13.7%). Among pregnant individuals with at least one admission for DKA, the median gestational age at delivery was 34 6/7 weeks (interquartile range 33 2/7–36 3/7 weeks). Most neonates (85.7%, 95% CI, 76.8–92.2%) were admitted to the neonatal intensive care unit and required treatment for hypoglycemia. The cesarean delivery rate was 71.9%. Despite similar hemoglobin A1C values before pregnancy and at admission, individuals with type 1 diabetes had higher serum glucose (median [interquartile range], 256 mg/dL [181–353 mg/dL] vs 216 mg/dL [136–258 mg/dL], P=.04) and higher serum ketones (3.78 mg/dL [2.13–5.50 mg/dL] vs 2.56 mg/dL [0.81–4.69 mg/dL] mg/dL, P=.03) on admission compared with those with type 2 diabetes. Individuals with type 2 diabetes required intravenous insulin therapy for a longer duration (55 hours [29.5–91.5 hours] vs 27 hours [19–38 hours], P=.004) and were hospitalized longer (5 days [4–9 days] vs 4 days [3–6 days], P=.004). CONCLUSION: Diabetic ketoacidosis occurred predominantly in pregnancies affected by type 1 diabetes. Individuals with type 1 diabetes presented with greater DKA severity but achieved clinical resolution more rapidly than those with type 2 diabetes. These results may provide a starting point for the development of interventions to decrease maternal and neonatal morbidity related to DKA in the modern obstetric population.

Funder

National Center for Advancing Translational Sciences

Publisher

Ovid Technologies (Wolters Kluwer Health)

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