What is the management of Diabetic Ketoacidosis (DKA) in a pregnant patient?

Management of Diabetic Ketoacidosis (DKA) in Pregnancy

Pregnant patients with DKA require immediate simultaneous administration of continuous intravenous insulin infusion AND 10% dextrose, even when blood glucose is normal or only mildly elevated, because pregnancy creates a ketogenic state where DKA occurs at lower glucose thresholds and the placenta demands continuous glucose supply. 1

Critical Diagnostic Considerations

• Maintain high clinical suspicion for DKA even with glucose <200 mg/dL, as up to 35% of DKA cases in pregnancy present with euglycemia (normal to mildly elevated glucose) 2
• Pregnancy creates accelerated starvation, insulin resistance, and respiratory alkalosis that promote ketosis at lower glucose levels than non-pregnant states 1, 3
• Look for classic symptoms: nausea, vomiting, abdominal pain, Kussmaul respirations, altered mental status, and dehydration 1
• Do not wait for hyperglycemia to diagnose DKA in pregnancy—relying solely on glucose levels will cause missed diagnoses 1
• Measure β-hydroxybutyrate levels (preferred over urine ketones) to confirm diagnosis and monitor treatment response 1

Immediate Management Protocol

Dual Insulin-Dextrose Therapy (Most Critical)

• Start continuous IV insulin infusion immediately, regardless of blood glucose level 1, 3
• Simultaneously administer 10% dextrose IV to meet the higher carbohydrate demands of the placenta and fetus, particularly in the third trimester 1, 3
• This dual approach is mandatory because the insulin drip resolves ketosis while dextrose prevents hypoglycemia and meets fetal metabolic needs 1
• Never give insulin without dextrose in pregnant women with DKA—this fails to meet fetal metabolic requirements and can perpetuate ketosis 1
• The placenta and fetus have continuous high carbohydrate demands that persist even during maternal ketoacidosis 1

Aggressive Fluid Resuscitation

• Begin aggressive IV fluid replacement immediately as a cornerstone of DKA treatment to restore tissue perfusion and dilute ketone bodies 1, 4, 5
• Volume replacement is essential due to significant dehydration that occurs with DKA 5, 2

Electrolyte Management

• Check serum potassium before starting insulin if possible 1
• Monitor and replace potassium aggressively, as insulin therapy drives potassium intracellularly and can precipitate life-threatening hypokalemia 1, 6
• Maintain potassium levels in safe range throughout treatment 1
• Monitor electrolytes every 2-4 hours during acute management 1

Monitoring Requirements

• Measure β-hydroxybutyrate levels to monitor treatment response—resolution of acidosis or reduction in blood β-hydroxybutyrate marks successful treatment 1
• Monitor arterial blood gases and serum glucose hourly 1
• Check electrolytes every 2-4 hours 1
• Continuous fetal monitoring is essential, as DKA carries a high risk of stillbirth 3

Post-Delivery Considerations

• Anticipate dramatic improvement in insulin sensitivity and rapid resolution of ketoacidosis after delivery of the fetus and placenta 1
• Insulin requirements decrease dramatically after placental delivery 7

Prevention and Patient Education

• Educate patients with type 1 diabetes to check ketones regularly, especially during illness, poor oral intake, or hyperemesis 1, 3
• Prescribe ketone test strips and provide clear instructions on when to seek emergency care 1
• Advise patients to obtain ketone test strips and receive education on DKA prevention and detection 3
• Patients should never stop or hold basal insulin even if not eating—provide detailed instructions on insulin dose adjustments during illness or fasting 3

Common Pitfalls to Avoid

• Do not delay treatment waiting for hyperglycemia—euglycemic DKA is common in pregnancy and requires the same aggressive management 1, 2
• Do not administer insulin without simultaneous dextrose—this is a critical error unique to pregnancy management 1
• Do not underestimate the severity based on glucose levels alone—clinical presentation and ketone levels are more important 2
• Do not neglect potassium monitoring and replacement—hypokalemia can cause respiratory paralysis, ventricular arrhythmia, and death 6

Risk Factors Specific to Pregnancy

• Up to 2% of pregnancies with pregestational diabetes (most often type 1 diabetes) are complicated by DKA 3
• The incidence of DKA in gestational diabetes is low (<0.1%) 3
• Pregnant individuals may present with mixed acid-base disturbances, particularly with hyperemesis, which can hinder diagnosis 3