Diabetic Ketoacidosis In Pregnancy Research Articles

Clinical Presentation and Outcomes of Diabetic Ketoacidosis in Pregnancy.

To examine the presentation, management, and outcomes of pregnancies complicated by diabetic ketoacidosis (DKA) in a contemporary obstetric population. 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. 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). 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.

Management and Challenges of Diabetic Ketoacidosis in Pregnancy: A Multidisciplinary Approach

Management and Challenges of Diabetic Ketoacidosis in Pregnancy: A Multidisciplinary Approach

FRI629 A Mysterious Case Of Mother's Battle With Diabetic Ketoacidosis During Pregnancy

Abstract Disclosure: P.D. Sittirat: None. S.J. Choi: None. A. Gutierrez: None. M. Bashyam: None. Introduction: Changes in hormone regulatory mechanisms during pregnancy can increase the likelihood of diabetic ketoacidosis (DKA) in pregnant individuals. Despite the increased risk, the likelihood of DKA in pregnant individuals with diabetes mellitus is still low at around 0.5-3%. Management involves aggressive treatment following standard DKA protocols. We delve into a mysterious case of DKA in the second trimester of pregnancy. Case Presentation: A 31-year-old G1P0 woman at 24 weeks gestation with no past medical history presented with nausea, constipation associated with back and abdominal pain. Admission labs were significant for blood glucose 369 mg/dL, CO2 11 meq/L, anion gap 19 mEq/L, white blood cell 17.2 K/uL, HbA1c 9.5%, and serum ketones 3.9 mmol/L. Within 12 hours of admission into the intensive care unit for DKA, the patient was at 5-6 cm cervical dilation without signs of fetal distress. The newborn was delivered prematurely with complications of retinopathy and patent ductus arteriosus. Mother's lab studies showed negative for anti-GAD antibody, insulinoma associated 2 autoantibodies, islet cell antibody, and zinc transporter 8 antibody. C-peptide was low at 0.9 ng/mL (normal range 1.1 to 5.5 ng/mL). The patient was maintained on subcutaneous insulin which eventually tapered off at 2 months post-partum due to hypoglycemia. At 4 and 11-month follow-ups, her HbA1C was 5.8% and 5.5%, respectively. Her blood glucose was well controlled with a regular diet. She did get post-prandial spikes with a high carbohydrate diet. Discussion: Physiological changes in pregnancy make pregnant individuals more susceptible to DKA. Even so, the likelihood of DKA in pregnancy is rare. It is even rarer to have a new diagnosis of diabetes leading to DKA in pregnancy just before evaluation at the standard 28 weeks like the events precipitated in this case. DKA in pregnancy puts both the mother and fetus at risk for long-term complications. The maternal mortality rate in pregnancy with DKA is 5% to 15%, while the fetal mortality rate is 30% to 90%. The patient’s demographic background of being a young Caucasian, thin woman who presented with a new onset DKA and had a low C-peptide was more consistent with type 1 diabetes; however, all her antibodies were normal. It’s questionable if this patient has autoantibody negative new onset type 1 diabetes and is currently in remission. It's worth to mention that she had a history of mild Covid-19 infection at 8 weeks gestation but this new onset DKA developed at 24 weeks gestation. The chance of gestational diabetes was low due to low c-peptide on presentation. Annual follow-up of the patient is necessary to monitor her HbA1C while she is off diabetes medications. Presentation: Friday, June 16, 2023

THU304 Diabetic Ketoacidosis In Pregnancy: A Nationwide Analysis Of Trend In Hospitalizations, Comorbidities And Outcomes

Abstract Disclosure: V. Master: None. M. Faisaluddin: None. S. Fatima: None. D. Parekh: None. S. Charatz: None. Introduction: Diabetic Ketoacidosis (DKA) is an obstetric emergency associated with high materno-fetal morbidity and mortality. Aim: To analyse the trend of DKA hospitalizations among pregnant women, and to evaluate the comorbidities and in hospital outcomes associated with DKA events in United States. Methods: A national population- based study was conducted in the US. Hospitalizations during pregnancy from 2015 - 2020 were identified using ICD- 10 codes (E101) from Healthcare Cost and Utilization Project (HCUP), National Inpatient Sample (NIS) database. Pregnant women with DKA and without DKA formed the two comparison cohorts. Demographic characteristics, baseline comorbidities, and outcomes such as maternal mortality, fetal mortality, length of stay (LOS), and cost of hospitalization were compared. A two- tailed p-value of p< 0.05 was used to determine the statistical significance. Results: 11,215 out of 14,613,248 hospitalizations during pregnancy were identified with DKA from 2015 - 2020. An increasing trend in DKA hospitalizations per 100,000 pregnancy related hospitalizations was noted, highest in 2017 and 2020. Demographic distribution was similar in both groups. Comorbidities such as pre-eclampsia, eclampsia, gestational hypertension, tobacco and alcohol use were more common in the DKA group (p<0.0001). DKA was associated with higher maternal (0.18% vs 0.01%) and fetal mortality rates (2.9% vs 0.7%) compared to non-DKA group (p<0.0001). The median length of hospital stay was higher (3 days vs 2 days), along with the median cost of hospitalization ($25,248 vs $18,306) among pregnant DKA patients. Other in hospital outcomes such as need for mechanical ventilation, cardiac arrest, cardiac arrhythmias, acute kidney injury, need for dialysis, and septic shock, were all higher in DKA patients (p<0.0001). Conclusion: DKA in pregnancy is associated with high maternal and fetal mortality, longer LOS, higher cost of hospitalizations, and other maternal morbidities, as compared to non-DKA hospitalizations during pregnancy. A high index of suspicion for DKA should be maintained in all pregnant women, along with prompt evaluation and treatment. Presentation: Thursday, June 15, 2023

SAVING LIVES WITH MULTIDISCIPLINARY CARE OF DIABETIC KETOACIDOSIS IN PREGNANCY- A CASE REPORT

Diabetic Ketoacidosis (DKA) in pregnancy has serious implications on maternal and fetal outcomes. Increased incidence of diabetes worldwide has led to more number of pregnancies being susceptible to this complication, necessitating a multidisciplinary team management in a critical care setting. There are several challenges with respect to diagnosis and management of this condition. An understanding of the physiological changes in pregnancy, the impact of precipitating events as well as patient education and emphasis on adherence to treatment are key elements in care provision. Infection and poor compliance to insulin are the most common triggers for ketoacidosis and can occur at even lower blood sugar thresholds in pregnancy. Prevention, early diagnosis, aggressive treatment and timely indicated delivery form the pillars of successful management of DKA in pregnancy. This case report demonstrates that increased awareness of DKA with immediate recognition and a successful multidisciplinary approach are mandatory for positive pregnancy outcomes.

Management of Diabetic Ketoacidosis in Pregnancy.

Diabetic ketoacidosis (DKA) is a rare, but potentially life-threatening complication of diabetes. Certain physiological changes during pregnancy predispose pregnant individuals to developing DKA. Early recognition and aggressive treatment are essential to avoid maternal and fetal morbidity and mortality. Although laboratory values can help to support, pregnant patients with DKA may not meet the usual criteria and the diagnosis can be made clinically. The key components to treatment include volume replacement, insulin infusion, correction of serum potassium, and fetal monitoring. With appropriate treatment, maternal mortality is low. After recovery, steps should be taken to avoid recurrence.

Diabetic Ketoacidosis in Pregnancy: An Overview of Pathophysiology, Management, and Pregnancy Outcomes

Diabetic ketoacidosis (DKA) is an obstetrical emergency that is associated with an elevated risk of adverse pregnancy outcomes. This includes pregnancy loss in up to 1 in 3 cases. Due to the normal metabolic changes that occur during pregnancy, females who are pregnant are more vulnerable to DKA, and it can occur at lesser than expected degrees of hyperglycaemia. Presenting symptoms can be non-specific and include nausea and vomiting, fatigue, polydipsia, and polyuria. DKA may be the first presentation of previously undiagnosed diabetes. Therefore, high index of suspicion, along with prompt diagnosis and management, is essential. The cornerstones of management include intravenous insulin, intravenous fluids, and electrolyte replacement. Treatment generally follows the principles for DKA management outside of pregnancy, with some additional considerations. Close maternal and fetal monitoring is essential, and intensive care unit admission is typically required to adequately achieve this goal. In all situations, a thorough investigation should occur to address the underlying cause of the DKA and prevent further episodes. This review article outlines the potential etiopathogenesis, clinical presentation, and management of DKA in pregnancy.

Diabetic Ketoacidosis in Pregnancy: Clinical Risk Factors, Presentation, and Outcomes.

Diabetic ketoacidosis (DKA) in pregnancy is an obstetric emergency with risk of maternofetal death. This work aimed to evaluate DKA events in pregnant women admitted to our inpatient obstetric service, and to examine associated clinical risk factors, presentation, and pregnancy outcomes. A retrospective cohort study was conducted at the Mayo Clinic, Rochester, Minnesota, USA, and included women aged 17 to 45 years who were treated for DKA during pregnancy between January 1, 2004 and December 31, 2021. Main outcome measures included maternal and fetal death along with a broad spectrum of maternal and fetal pregnancy outcomes. A total of 71 DKA events were identified in 58 pregnancies among 51 women, 48 (82.8%) of whom had type 1 diabetes. There were no maternal deaths, but fetal demise occurred in 10 (17.2%) pregnancies (6 miscarriages and 4 stillbirths). Maternal social stressors were frequently present (n = 30, 51.0%), and glycemic control was suboptimal (median first trimester glycated hemoglobin A1c = 9.0%). Preeclampsia was diagnosed in 17 (29.3%) pregnancies. Infants born to women with DKA were large for gestational age (n = 16, 33.3%), suffered from neonatal hypoglycemia (n = 29, 60.4%) and required intensive care unit admission (n = 25, 52.1%). DKA is associated with a high rate of maternofetal morbidity and fetal loss. Prenatal education strategies for women with diabetes mellitus should include a strong focus on DKA prevention, and clinicians and patients should have a high index of suspicion for DKA in all pregnant women who present with symptoms that could be attributed to this condition.

Fulminant type 1 diabetes mellitus in a GDM pregnancy: early recognition is vital for maternal and fetal outcomes.

SummaryFulminant type 1 diabetes mellitus (FT1DM) is characterised by extremely rapid destruction of pancreatic beta cells. An association between FT1DM and pregnancy has been reported and can lead to unfavourable pregnancy outcomes without timely treatment. We report a case of FT1DM in a pregnancy with gestational diabetes mellitus (GDM), the first of its kind in the English literature to date. A 27-year-old woman with insulin-requiring GDM presented with rapidly deteriorating glycaemic control in her third trimester of pregnancy despite good concordance to treatment. The investigation identified the hallmarks of FT1DM: hyperglycaemia with acute metabolic decompensation and non-immune-mediated beta-cell failure. She received prompt treatment with intravenous insulin therapy and was transitioned to subcutaneous insulin once biochemical improvement had been achieved, albeit with higher insulin requirements than before. She had a good pregnancy outcome and delivered a healthy male infant 5 weeks later through induction of labour. Due to persistent beta-cell dysfunction, she remained on basal-bolus insulin postpartum. This case highlights the importance of early recognition and treatment of FT1DM in pregnancy to prevent adverse maternal and fetal prognoses.Learning pointsFulminant type 1 diabetes mellitus (FT1DM) is a subtype of type 1 diabetes characterised by extremely rapid beta-cell destruction, leading to abrupt-onset hyperglycaemia with ketosis or ketoacidosis.The pathognomonic characteristics of FT1DM include the development of diabetic ketosis or ketoacidosis typically within 7 days after the onset of symptoms of hyperglycaemia, a near-normal level of glycated haemoglobin despite elevated plasma glucose levels and the absence of islet cell autoantibodies.The pathophysiology of FT1DM is unclear but the association with genetic predisposition, viral infection and pregnancy has been reported.Due to its predilection for pregnancy, clinicians should have a high index of suspicion for FT1DM in pregnant women with rapidly progressing hyperglycaemic ketoacidosis.As diabetic ketoacidosis in pregnancy is associated with adverse maternal and fetal outcomes, immediate initiation of treatment in pregnant women with suspected FT1DM is extremely vital to prevent morbidity and mortality, even if investigations are still underway.Patients with FT1DM require lifelong insulin therapy due to the complete loss of beta-cell function.

A study of diabetic ketoacidosis in the pregnant population in the United Kingdom: Investigating the incidence, aetiology, management and outcomes.

AimTo estimate the incidence of diabetic ketoacidosis (DKA) among pregnant women, describe its clinical features, management and outcomes and identify the risk factors for the condition.MethodsA national population‐based case–control study was conducted in the UK using the UK Obstetric Surveillance System between April 2019 and September 2020 including all pregnant women with DKA irrespective of the level of blood glucose. The incidence rate of DKA in pregnancy was estimated. A case–control analysis limited to women with type 1 diabetes was performed comparing characteristics of women with DKA (cases) to those of women whose pregnancies were not complicated by DKA (controls).ResultsIn all, 82 women were identified with DKA in pregnancy; 6.3 per 100,000 maternities (95% CI: 5.0–7.9). No maternal deaths occurred, but perinatal mortality was 12/73 (16%) with 11 stillbirths and one neonatal death. DKA episodes mostly occurred in women with type 1 diabetes (85%) and in the 3rd trimester of pregnancy (71%). Episodes were mainly precipitated by infection (21%), vomiting (21%), steroid therapy (13%) and medication errors (10%). Fifteen percent of women had more than one episode of DKA during their pregnancy. Risk factors associated with DKA among women with type 1 diabetes identified through the case–control analysis were the woman and/or partner not being in a paid employment and having at least one microvascular complication of diabetes before pregnancy.ConclusionDKA in pregnancy was associated with high perinatal mortality and was linked with factors related to socio‐economic deprivation, mental health problems and long‐term difficulties with glycaemic control.

Awareness of euglycaemic diabetic ketoacidosis during pregnancy prevents recurrence of devastating outcomes: a case report of two pregnancies in one patient

BackgroundEuglycaemic diabetic ketoacidosis (DKA) during pregnancy is a life-threatening obstetric emergency. It requires early identification and prompt action. Obstetricians’ knowledge about symptoms, diagnostic pitfalls and management during pregnancy and delivery need to be improved. We report a case of a young diabetic woman developing severe euglycaemic DKA in two consecutive pregnancies; the first pregnancy resulted in the most deviating outcome (i.e., intrauterine death), while the second pregnancy resulted in the delivery of a healthy newborn. Thus, the novelty of the case presented here is the possibility to demonstrate how the management of DKA in pregnancy can dramatically change outcomes.Case presentationWe report a case of a young diabetic woman in whom DKA was concealed by hyperemesis and oesophageal reflux. This woman presented to our delivery unit with severe euglycaemic DKA during her first pregnancy. While the mother’s condition could be successfully stabilized, the foetus died shortly after admission. Two years later, the same woman presented with similar problems. Repeated episodes of mild euglycaemic DKA could be successfully managed with consequent interdisciplinary treatment and close observation, leading to a good pregnancy outcome, i.e., the birth of a healthy child.ConclusionAwareness of euglycaemic DKA needs to be increased to reduce the risk of severe complications during pregnancies in diabetic women. This case report demonstrates that increased awareness of DKA with immediate recognition and a successful multidisciplinary approach are mandatory for an positive pregnancy outcomes.

876 Diabetic ketoacidosis in pregnancy: disparities and trends over time

Recent population-based studies defining the frequency of and risk factors for diabetic ketoacidosis (DKA) in pregnancy are lacking. We aimed to identify sociodemographic and clinical factors associated with DKA in pregnancy. Repeated cross-sectional study with case-control analysis of women in the National Inpatient Sample (2012-Q3 2015) with pregestational diabetes (DM) admitted to the hospital during pregnancy. The primary outcome was DKA (ICD-9 codes 250.1, 250.10, 250.12, 250.13). DKA was compared over time using a test of trend. Demographic, hospital, and clinical characteristics were compared between women with and without DKA using chi-square and student’s t-test. Multivariable logistic regression assessed what characteristics were independently associated with DKA. Variables were included in the initial model if p < 0.20 in bivariable analysis and sequentially removed using likelihood ratio testing with p < 0.05 considered significant. Of 44,159 deliveries complicated by pregestational DM, there were 1,263 cases of DKA, or 286 cases per 10,000 DM deliveries. DKA increased from 2012 to 2015 (Figure). In addition to time, factors associated with higher adjusted odds of DKA included non-Hispanic Black (vs White) race, public (vs private) insurance, urban (vs rural) hospital, larger size hospital, anemia, substance use disorder, and antenatal depression (Table). Factors associated with a lower adjusted odds of DKA included older age, Hispanic or other race (vs White), and obesity (Table). Among these, the factors with the strongest associations were obesity (aOR 0.22, 95%CI 0.18-0.28) and time (aOR 3.40, 95%CI 2.67-4.32 for 2013; aOR 3.53, 95%CI 2.78-4.48 for 2014; aOR 3.87, 95%CI 3.03-4.94 for 2015 Q1-3; referent=2012). Hypertension, renal disease and US region were not associated with DKA. In a contemporary, nationwide US sample, DKA increased over time with sociodemographic and clinical disparities. Further investigation is needed to confirm the rise in DKA after 2012 and identify how to address the identified disparities to prevent DKA in the future.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Diabetic Ketoacidosis in Pregnancy: A Rare but Serious Threat to Mother and Fetus

Diabetic Ketoacidosis in Pregnancy: A Rare but Serious Threat to Mother and Fetus

Impact of Diabetic Ketoacidosis in Pregnancy

Impact of Diabetic Ketoacidosis in Pregnancy

SUN-LB029 A Case of Gestational Diabetes with Diabetic Ketoacidosis, Insulin Injection Site Reaction and Anti Insulin Antibodies in Pregnancy

Background: Gestational diabetes mellitus (GDM) is defined as “impairment of glucose tolerance with first recognition during pregnancy” and is rarely associated with diabetic ketoacidosis (DKA). The incidence of DKA in pregnancy is about 1-3% in those with type 1 or 2 DM. Complications include preterm birth and fetal demise rate of 10-25%. Clinical case: 35-year-old G2P1 Southeast Asian female diagnosed with GDM at 28 weeks of gestation (wGA) via 3hour oral glucose tolerance test. At 35wGA, she presented with asymptomatic hyperglycemia. Blood glucose (BG) was previously well-controlled on once daily detemir (started at 31wGA). Past medical history is significant for Hashimoto’s thyroiditis; pre-pregnancy BMI 22.5kg/m2. Family history is notable for a sister with GDM and pre-eclampsia and mother with pre-DM. She experienced fasting hypoglycemia (68, 57mg/dL) the 2 preceding mornings, addressed by decreasing detemir dose 20 to 16U QD. The am of her presentation, she awoke asymptomatic with a fasting BG of 200mg/dL and 1 hour post-prandial of 283mg/dL. By lunch, BG rose to 357mg/dL. Physical exam was notable for localized wheal-like reactions on her left thigh and gluteal area, and right arm. Labs demonstrated an anion gap 18, bicarbonate 11mEq/L and beta-hydroxybutyrate (BHB) 7.42mMol/L. The patient was started on intravenous (IV) insulin and was kept NPO per DKA protocol. Urinalysis and culture were negative with no other precipitants identified. C-peptide was undetectable at BG of 260mg/dL and T1DM related antibodies were obtained. After 18 hours on the DKA protocol, BG remained 180-250 mg/dL, bicarbonate 16meq/L, and BHB 1.13mMol/L; the protocol was modified for tighter BG ranges and to allow more frequent feeding for prevention of hypoalimentation ketosis. Allergy team was consulted and diagnosed localized insulin reaction and recommended daily oral H2-blocker, given no true IgE-mediated hypersensitivity or systemic findings. Patient was transitioned to NPH 18u BID and prandial lispro 5u TID (total of 0.88u/kg) on day 2 of admission. Following discharge, only anti-glutamic acid decarboxylase (38IU/ml) and anti-insulin (0.6IU/ml) returned elevated (negative IA-2 and anti-islet cell). At 37wGA, she had prelabor spontaneous rupture of membranes and delivered a 3730g healthy female via repeat cesarean section while receiving IV insulin. Newborn required 2 days of phototherapy for hyperbilirubinemia, no neonatal hypoglycemia. At 6 weeks postpartum, she was breastfeeding, administering 11u NPH BID and 3u of prandial lispro (0.53u/kg). Conclusion: Stress in the third trimester of pregnancy (insulin allergy, starvation ketosis, and physiologic increase in insulin resistance) can result in DKA in a patient with type 1 or 2 DM that initially presents as GDM. Insulin allergy or localized reaction to insulin may contribute to delay in insulin absorption thus precipitating insulinopenia. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Diabetic ketoacidosis in pregnancy

Diabetic ketoacidosis in pregnancy is a rare but potential life-threatening condition for the mother and the fetus. Although predictably DKP is more common in patients with type 1 diabetes, it has been reported too in those with type 2 diabetes as well as gestational diabetes. Diabetic ketoacidosis usually occurs in the second and third trimesters because of insulin resistance. Prompt recognition and aggressive treatment of this condition are essential in order to reduce perinatal mortality and morbidity. Despite improvement in its incidence rates and outcomes over the years, it still remains a major clinical problem that posesseveral challenges with respect to diagnosis and management.

Diabetic ketoacidosis among pregnant and non-pregnant women: a comparison of morbidity and mortality

Purpose: Diabetic ketoacidosis (DKA) is a critical diagnosis that can cause severe morbidity and mortality in the diabetic population. Although it is rare in pregnancy, the aim of this study is to compare DKA in pregnant women with age-matched non-pregnant women to determine if outcomes are influenced by pregnancy.Materials and methods: A population-based age-matched retrospective cohort was carried out using data from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1999 to 2013. Pregnant patients with DKA were age-matched with non-pregnant controls also admitted with DKA at a ratio of 1:10. Severe morbidities and mortality were compared among the two groups. Logistic regression was used to adjust for baseline characteristics and comorbidities.Results: We identified 4661 cases of DKA in pregnancy during our study period, which were age-matched to 46,610 non-pregnant controls. Pregnant women with DKA were more likely to stay in hospital for >3 d (odds ratios (OR) 2.15, 95% CI 2.06–2.25) and had more associated renal failure (OR 2.86, 95% CI 1.76–4.55); however, they were less likely to require ventilation (OR 0.70, 95% CI 0.62–0.79), experience systemic inflammatory response syndrome (OR 0.53, 95% CI 0.38–0.73), or seizures (OR 0.49, 95% CI 0.42–0.57). Among pregnant women, rates of coma (0.04%) and death (0.17%, OR 0.23, 95% CI 0.14–0.39) were lower than previously reported and lower than non-pregnant women.Conclusion: Pregnant women with DKA are admitted to hospital for longer periods than non-pregnant controls and are at higher risk for renal failure but otherwise have better outcomes and less mortality than non-pregnant controls.

Euglycemic Diabetic Ketoacidosis: A Review.

Diabetic ketoacidosis (DKA) is one of the most serious complications of diabetes. It is characterised by the triad of hyperglycemia (blood sugar >250 mg/dl), metabolic acidosis (arterial pH <7.3 and serum bicarbonate <18 mEq/L) and ketosis. Rarely these patients can present with blood glucose (BG) levels of less than 200 mg/dl, which is defined as euglycemic DKA. The possible etiology of euglycemic DKA includes the recent use of insulin, decreased caloric intake, heavy alcohol consumption, chronic liver disease and glycogen storage disorders. DKA in pregnancy has also been reported to present with euglycemia. The recent use of sodium glucose cotransporter 2 (SGLT2) inhibitors has shed light on another possible mechanism of euglycemic DKA. Clinicians may also be misled by the presence of pseudonormoglycemia. Euglycemic DKA thus poses a challenge to physicians, as patients presenting with normal BG levels in ketoacidosis may be overlooked, leading to a delay in appropriate management strategies. In this article, we review all the possible etiologies and the associated pathophysiology of patients presenting with euglycemic DKA. We also discuss the approach to diagnosis and management of such patients. Despite euglycemia, ketoacidosis in diabetic patients remains a medical emergency and must be treated in a quick and appropriate manner.

Diabetic ketoacidosis complicating pregnancy.

Although diabetic ketoacidosis (DKA) in pregnancy can result in significant adverse consequences for both mother and fetus, the response to treatment, time course of recovery, and perinatal outcomes have not been well studied in pregnancy. We examined the precipitating factors, laboratory abnormalities, treatment strategies, and clinical recovery in pregnancies complicated by DKA. This is a retrospective cohort study of pregnancies complicated by DKA between October 1999 and June 2015. The diagnosis was verified by hyperglycemia; anion gap >12 mEq/L, pH <7.3, HCO3 <15 mEq/L; and the presence of ketones. Each episode of DKA was reviewed and subsequent perinatal outcomes analyzed. During this period, we identified 33 women with 40 admissions (incidence: 0.2%). The majority of women had type 1 diabetes (67%), and almost all presented with nausea and vomiting (97%). Over half had poor compliance with prescribed insulin. The initial mean blood glucose was 380 mg/dL, within 6 hours, it was <200 mg/dL. By 12 hours, the acidosis had resolved in 90% of patients. Nausea and vomiting is a prominent presenting feature of DKA in pregnancy. With aggressive insulin and resuscitation, hyperglycemia and acidosis improve rapidly. With current treatment, good perinatal outcomes can be expected.

Abstract #266: A Three-Year Review of Diabetic Ketoacidosis in Pregnancy – Causes and Outcomes

Abstract #266: A Three-Year Review of Diabetic Ketoacidosis in Pregnancy – Causes and Outcomes