Normoglycemic Diabetic Ketoacidosis in a Pregnant Patient with Type II Diabetes Mellitus Presenting for Emergent Cesarean Delivery

Diabetic Ketoacidosis in Pregnancy: A Systematic Review of the Reported Cases

Background

Diabetic ketoacidosis (DKA) is a rare but serious complication that can develop during pregnancy, with up to 30% of patients presenting with euglycemia, making prompt recognition challenging. It is associated with increased perinatal mortality rates, although the exact risk of maternal mortality remains unclear. The purpose of this systematic review was to examine the available literature and provide an overview of reported cases of DKA during pregnancy.

Methods

PubMed, Web of Science and Scopus library databases were screened from inception until January 2024. Included studies provided data on classic or euglycemic DKA during pregnancy. All study designs were considered eligible for inclusion.

Results

We identified 66 eligible articles, which included 57 case reports and case series with individual patient data, and 9 studies without individual patient data. The mean age at diagnosis was 28.8 years, and the average gestational age at diagnosis was 29.5 weeks. The majority of women had type 1 diabetes mellitus (T1DM) (45.9%), followed by gestational diabetes (GDM) (40.5%). Most cases were classified as classic DKA (70.3%), with nearly one-third developing euglycemic DKA (29.7%). The most common trigger factors were infections (28%), followed by poor adherence to treatment (13.5%). The most frequent symptoms included nausea (32.4%), vomiting (32.4%), osmotic symptoms (21.6%), and abdominal pain (20.2%). All cases were treated with intravenous insulin and fluids. The vast majority (98.9%) of women eventually fully recovered, with only 1 reported death due to organ failure (1.3%). Intrauterine death or stillbirth occurred in one-third of cases (35.2%), including 1 instance of a twin pregnancy.

Conclusions

DKA is a condition that clinicians may encounter during pregnancy. Although rare, increased awareness and early recognition are crucial for optimal management and improved maternal and neonatal outcomes.

Euglycemic diabetic ketoacidosis in a pregnant woman

Background

Euglycemic diabetic ketoacidosis (EDKA) carries serious risks for mortality and morbidity for both the mother and the baby, and it is essential to recognize it early and start immediate treatment.

Case Presentation

We present a case of EDKA in a 28-week pregnant woman known to have type 1 diabetes. She was found to have severe acidosis with a blood sugar level of 10.6 mmol/L (190.8 mg/dL) and normal anion gap. She was found to have EDKA, which was confirmed later with a depressed venous pH and bicarbonate level and an increased serum ketone level. The patient's acidosis was not improving significantly with 0.05 units/kg/h of insulin infusion, so a full dose of 0.1 unit/kg/h of insulin infusion was started following a full diabetic ketoacidosis (DKA) protocol regardless of her blood sugar level. The patient showed gradual improvement and was discharged home after 4 days, with follow-up with endocrinology and obstetrics.

Conclusion

In conclusion, EDKA is a critical complication of diabetes, especially in pregnant women. Therefore, it is crucial to treat it early and potentially consider following a full DKA protocol using 0.1 unit/kg/h insulin infusion instead of 0.05 unit/kg/h.

Euglycemic Diabetic Ketoacidosis in Pregnancy: A Case Report and Review of Current Literature

Diabetic ketoacidosis (DKA) in pregnancy is associated with high fetal mortality rates. A small percentage of DKA occurs in the absence of high glucose levels seen in traditional DKA. Prompt recognition and management is crucial. We report a case of a 30-year-old pregnant woman with type 1 diabetes mellitus admitted with euglycemic DKA (blood glucose <200 mg/dL). Initial laboratory testing revealed a severe anion gap acidosis with pH 7.11, anion gap 23, elevated β-hydroxybutyric acid of 9.60 mmol/L, and a blood glucose of 183 mg/dL—surprisingly low given her severe acidosis. The ketoacidosis persisted despite high doses of glucose and insulin infusions. Due to nonresolving acidosis, her hospital course was complicated by spontaneous intrauterine fetal demise. Euglycemia and severe acidosis continued to persist until delivery of fetus and placenta occurred. It was observed that the insulin sensitivity dramatically increased after delivery of fetus and placenta leading to rapid correction of ketoacidosis. This case highlights that severe ketonemia can occur despite the absence of severely elevated glucose levels. We discuss the mechanism that leads to this pathophysiologic state and summarize previously published case reports about euglycemic DKA in pregnancy.

Euglycemic Diabetic Ketoacidosis in the ICU: 3 Case Reports and Review of Literature

Diabetic ketoacidosis (DKA) is an acute complication of diabetes mellitus, both type I and type II, as well as other types with diabetes such gestacional diabetes mellitus. It is characterized by blood glucose levels greater than 250 mg/dL and metabolic acidosis (pH < 7.3 and serum bicarbonate < 15 mEq/dL) with an increased anion gap and the presence of ketone bodies in the blood or urine. Within this pathology, there is a subgroup of pathologies which are characterized by being present with no signs of hyperglycemia, posing a diagnostic challenge due to the absence of the main sign of the pathology and the diversity of their pathophysiology. In this article, we will present 3 clinical cases with 3 different forms of clinical presentation: a case of DKA in pregnancy, a case of DKA associated with the use of sodium-glucose cotransporter 2 (SGLT-2) inhibitors, and a third case related to sepsis, together with a narrative review of the literature on the topic.

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.