Abstract
To compare intrapartum results associated with differing degrees of ketonuria in nulliparous women with gestational diabetes mellitus (GDM), we implemented a retrospective cohort study comparing clinical characteristics among differing degrees of ketonuria and the duration and distribution of ketonuria at different stages of labor. We also analyzed adverse maternal and neonatal outcomes for each group. A total of 570 GDM deliveries were included; of these, 238 had negative ketonuria (41.8%), 180 had moderate ketonuria (31.6%), and 152 had ketosis (26.6%). The proportion of patients with a family history of diabetes significantly increased as the degree of ketonuria increased (P < 0.001). Moreover, a significantly lower level of HOMA-IR (the insulin resistance index) was observed for the Negative group (P < 0.001). The triglyceride (TG) level was significantly higher in the Ketosis group (P < 0.001), and the total cholesterol (TC) levels significantly increased as the degree of ketonuria progressed (P < 0.001). There were also higher maternal blood sugar levels and a significantly higher proportion of oxytocin augmentation in ketonuria cases (P < 0.001). Over three-fourths of patients (75.6%) had a ketonuria duration of ≤2 hours in the Moderate group, 61.2% had a ketonuria duration of between 3 and 4 h in the Ketosis group, and most of the ketonuria cases resolved in the first stage of labor. As the degree of ketonuria progressed, we observed a significantly higher number of cases with fetal heart rate pattern III (FHR pattern III), meconium-stained amniotic fluid III (MSAF III), postpartum hemorrhages, prolonged labor, neonatal hypoglycemia, an umbilical cord arterial pH of <7.2, low Apgar scores, increased neonatal intensive care admissions, augmented forceps-assisted deliveries, and conversions to cesarean sections. The results showed that ketonuria is common during the intrapartum period and that the risk of adverse maternal and neonatal outcomes may increase when complicated with ketonuria.
Highlights
Gestational diabetes mellitus (GDM), the most common medical complication during pregnancy, is associated with adverse maternal and neonatal outcomes [1]. e incidence of GDM is positively correlated with ketone levels in otherwise healthy pregnant women [2]
variable rate intravenous insulin infusion (VRIII) was started if two consecutive blood sugar levels (BSLs) readings were above 7 mmol/L; 0.9% NaCl with 5% glucose was used as the substrate fluid with VRIII. e fluid was administered at 50 ml/h generally
The total cholesterol (TC) level significantly increased as the degree of ketonuria progressed (2.21 ± 0.70 in the Negative group, 3.60 ± 1.58 in the Moderate group, and 4.86 ± 1.52 in the Ketosis group; P < 0.001)
Summary
Gestational diabetes mellitus (GDM), the most common medical complication during pregnancy, is associated with adverse maternal and neonatal outcomes [1]. e incidence of GDM is positively correlated with ketone levels in otherwise healthy pregnant women [2]. Gestational diabetes mellitus (GDM), the most common medical complication during pregnancy, is associated with adverse maternal and neonatal outcomes [1]. Ketone bodies are formed from free fatty acids (FFA), and accelerated lipolysis and increased FFA are responsible for increased ketogenesis during the second half of pregnancy. Maternal ketonuria is a hyperosmolar condition, and ketone bodies act as acidic compounds that bind blood bicarbonates and lower serum pH [4]. In 1970, Felig and Lynch first described a type of exaggerated fasting that could result in ketone overproduction during the second trimester of pregnancy [5]. Onyeije et al found that maternal ketonuria among patients with postterm pregnancy was associated with a significant increase in the occurrence of oligohydramnios and a significant deceleration of fetal heart rate [6]. Ketones diffuse freely across the placenta and can be used as a source of energy by the fetus
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