From the Guidelines
The workup for diabetic ketoacidosis (DKA) in pregnancy should prioritize prompt diagnosis and management due to high maternal and fetal mortality risks, with initial evaluation including serum glucose, arterial blood gases, serum bicarbonate, and positive serum/urine ketones, as recommended by the most recent standards of care in diabetes-2025 1. The initial evaluation for DKA in pregnancy should include:
- Serum glucose (typically >250 mg/dL)
- Arterial blood gases showing metabolic acidosis (pH <7.3)
- Serum bicarbonate (<15 mEq/L)
- Positive serum/urine ketones Additional laboratory tests should include:
- Complete blood count
- Comprehensive metabolic panel
- Serum osmolality
- Urinalysis
- Cultures if infection is suspected Continuous fetal monitoring is essential if gestational age is viable. Management involves:
- Aggressive fluid resuscitation with isotonic saline (1-2 L in first hour, then 250-500 mL/hr)
- Regular insulin (0.1 units/kg IV bolus followed by 0.1 units/kg/hr infusion)
- Electrolyte replacement (particularly potassium when levels fall below 5.3 mEq/L)
- Glucose administration (switch to D5W or D10W when glucose reaches 200 mg/dL) Blood glucose should be monitored hourly, with electrolytes and pH checked every 2-4 hours. The insulin infusion should continue until acidosis resolves, even after glucose normalizes, and identifying and treating the precipitating cause (often infection, medication non-compliance, or new-onset diabetes) is crucial, as emphasized in the standards of care in diabetes-2021 1 and diabetes-2020 1. Pregnant women require more aggressive management than non-pregnant patients due to physiologic insulin resistance of pregnancy and the fetus's dependence on maternal glucose levels. It is essential to note that DKA carries a high risk of stillbirth, and women in DKA who are unable to eat often require 10% dextrose with an insulin drip to adequately meet the higher carbohydrate demands of the placenta and fetus in the third trimester to resolve their ketosis, as highlighted in the standards of care in diabetes-2025 1.
From the Research
Workup for DKA in Pregnancy
- The workup for diabetic ketoacidosis (DKA) in pregnancy involves immediate hospitalization and aggressive management, including intravenous fluids, insulin, and electrolyte replacement 2, 3.
- A high index of suspicion is required, as DKA onset in pregnancy can be insidious and progress rapidly, often at lower glucose levels 3.
- The clinical picture of DKA in pregnancy can vary, with some cases presenting as euglycemic DKA, which can result in delayed diagnosis and treatment 2.
- Precipitating factors for DKA in pregnancy include infection, intractable vomiting, inadequate insulin management, and steroid administration for fetal lung maturation 3.
Key Components of Workup
- Aggressive volume replacement with intravenous fluids, such as isotonic normal saline or balanced solutions 4.
- Initiation of intravenous insulin therapy, with continuous monitoring of glucose and ketone levels 3, 4.
- Correction of acidosis and electrolyte abnormalities, including potassium, phosphate, and magnesium replacement 3, 4.
- Identification and treatment of underlying precipitating factors, such as infection or inadequate insulin management 3, 5.
Monitoring and Management
- Continuous monitoring of maternal-fetal response to treatment, including fetal heart rate and maternal glucose and ketone levels 3.
- Management of precipitating factors, such as infection or steroid administration, and prevention of complications, such as cerebral edema 3, 4.
- Early initiation of oral nutrition and consideration of sodium bicarbonate therapy in severe cases of acidosis 4.
- Multidisciplinary approach, including a maternal-fetal medicine physician, medical endocrinology specialists, and skilled nursing, to ensure optimal management of DKA in pregnancy 3.