What is the diagnosis for a pregnant patient presenting with diabetic ketoacidosis (DKA), vomiting, ketonuria, and euglycemia (blood glucose level of 94 mg/dL)?

From the Guidelines

The patient should be immediately evaluated in an emergency setting for confirmation and treatment of euglycemic diabetic ketoacidosis (DKA), given the presentation of vomiting, ketonuria, and a finger stick glucose of 94 in a pregnant patient. This condition is a medical emergency that requires prompt attention to prevent serious complications for both the mother and the fetus. The diagnosis of euglycemic DKA in pregnancy is supported by the patient's symptoms and the fact that pregnancy is a ketogenic state, as noted in the study by 1.

Key Considerations

• Euglycemic DKA can occur in pregnancy despite normal blood glucose levels, as the placenta increases glucose utilization, keeping blood glucose levels lower than in typical DKA.
• Initial management includes:
  • IV fluids (typically normal saline at 15-20 mL/kg/hr for the first hour)
  • Insulin therapy (regular insulin 0.1 units/kg/hr IV infusion)
  • Electrolyte replacement, particularly potassium
• Laboratory tests should include serum ketones, electrolytes, arterial blood gas, and anion gap calculation to confirm the diagnosis.
• Continuous fetal monitoring is essential during treatment, as euglycemic DKA in pregnancy poses significant risks to both mother and fetus, including fetal distress and preterm labor, as highlighted by the risks of stillbirth associated with DKA in the study by 1.

Treatment Approach

Given the high risk of stillbirth associated with DKA, as noted in the study by 1, it is crucial to manage the patient aggressively. This includes administering 10% dextrose with an insulin drip if the patient is unable to eat, to adequately meet the higher carbohydrate demands of the placenta and fetus in the third trimester. The goal is to resolve ketosis promptly and prevent complications. After resolution, identifying the underlying cause of DKA, which may include infection, medication non-compliance, or increased insulin requirements due to pregnancy, is essential for preventing future episodes.

From the Research

Diagnosis of DKA in Pregnancy

• Diabetic ketoacidosis (DKA) in pregnancy is a life-threatening emergency for both the mother and the fetus 2.
• The pathophysiology of DKA in pregnancy has its own characteristics due to multiple factors, such as insulin resistance, accelerated starvation, and respiratory alkalosis, thus creating a ketosis-prone state 2.
• DKA can occur at milder degrees of hyperglycemia, even in normoglycemic levels, which can result in delayed diagnosis and treatment with potential for adverse metabolic consequences 2.

Symptoms of DKA in Pregnancy

• Nausea and vomiting are prominent presenting features of DKA in pregnancy 3.
• Ketonuria is a significant symptom, but it is not associated with the diagnosis or severity of hyperemesis gravidarum (HG) 4.
• Other symptoms of DKA in pregnancy include abdominal pain, osmotic symptoms, and fever 5.

Diagnosis and Treatment of DKA in Pregnancy

• The diagnosis of DKA in pregnancy is verified by hyperglycemia, anion gap, pH, HCO3, and the presence of ketones 3.
• The treatment of DKA in pregnant women must be started immediately and must be accentuated on intravenous fluids, insulin, and electrolyte replacement 2.
• Aggressive insulin and resuscitation can improve hyperglycemia and acidosis rapidly 3.
• A multidisciplinary approach, including a maternal-fetal medicine physician, medical endocrinology specialists, an obstetric anesthesiologist, and skilled nursing, is paramount for the management of DKA in pregnancy 6.

Finger Stick Glucose Level

• A finger stick glucose level of 94 mg/dL is considered normoglycemic, but DKA can occur at milder degrees of hyperglycemia, even in normoglycemic levels 2.
• Euglycemic DKA, which occurs in up to 30% of patients, can make prompt recognition challenging 5.

Pregnancy Considerations

• DKA in pregnancy is associated with increased perinatal morbidity and mortality 6.
• Fetal status should be continuously monitored when DKA occurs after 24 weeks of gestation, given associated fetal hypoxemia and acidosis 6.
• The decision for delivery can be challenging and must be based on gestational age as well as maternal-fetal responses to therapy 6.