Historical literature reports risk of fetal demise after diabetic ketoacidosis (DKA) in pregnancy as high as 25–60% (1,2). However, estimates have generally been based on small sample sizes, with limited investigation of other fetal outcomes or risk factors associated with poor fetal outcomes. We aimed to provide an updated assessment of the incidence and risk factors for fetal demise and other adverse outcomes in women with DKA during pregnancy.
This retrospective cohort study included pregnancies between 1996 and 2015 with at least one DKA event in women with type 1 diabetes at one of three teaching hospitals in Boston. Data were collected through medical record review. Pregnancies were excluded if information on birth status (live or demise) and gestational age at birth or demise were unknown.
Among the 77 DKA events in 64 pregnancies in 62 women included in the study, fetal demise, preterm birth, and neonatal intensive care unit (NICU) admissions occurred in 15.6%, 46.3%, and 59% of pregnancies, respectively. Mothers presented in DKA between 5 and 38 weeks of gestation. Fetal demise occurred at the time of or within 1 week of the DKA event and between 1 and 11 weeks afterward in 60% and 40% of cases, respectively.
Maternal ICU admission (P = 0.024) and higher serum osmolality (P = 0.045) during the DKA event were associated with increased risk of fetal demise (Table 1). Maternal smoking (P = 0.0005) and higher pre-DKA HbA1c levels (P = 0.032) were associated with higher risk of preterm birth. Maternal smoking (P = 0.0077), preeclampsia during pregnancy (P = 0.031), higher anion gap during the DKA event (P = 0.019), and preterm birth (P = 0.0003) were associated with higher risk of NICU admission.
The risk of fetal demise after DKA during pregnancy has decreased over time but remains substantially higher than the baseline risk (2–3%) in women with type 1 diabetes (3). Risks of preterm birth and NICU admissions were also elevated compared with the general population of pregnant women with diabetes (33% [4] and 47% [5], respectively). Factors associated with increased risk of fetal demise were primarily characteristics of the DKA event severity (e.g., maternal ICU admission and higher serum osmolality), lending support to a direct causal relationship. Factors associated with increased risk of preterm birth and NICU admissions, on the other hand, were more indicative of the mother’s overall health status and health behaviors. This finding suggests that the observed increased risk of preterm birth among women with DKA during pregnancy could be due to the higher prevalence of risk factors in this population.
DKA during pregnancy poses a risk to the fetus both at the time of the event and following. Further research is needed to identify effective methods for prevention, early recognition, and timely treatment of DKA in pregnancy to mitigate risk of fetal demise and other adverse fetal outcomes.
Article Information
Funding. Research reported in this publication was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under award number T32HD057780.
The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Duality of Interest. No potential conflicts of interest relevant to this article were reported.
Author Contributions. F.J.R.M., E.W.S., M.S., F.M.B., and A.T. contributed to the study concept and design. M.M., A.C., F.M.B., and A.T. contributed to the acquisition of data. F.J.R.M., E.W.S., M.S., and A.T. contributed to the analysis and interpretation of data. F.J.R.M. drafted the manuscript. F.J.R.M. and M.S. contributed to the statistical analysis. A.T. supervised the study. All authors contributed to the critical revision of the manuscript for important intellectual content. A.T. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Prior Presentation. Parts of this study were presented in abstract form at the 77th Scientific Sessions of the American Diabetes Association, San Diego, CA, 9–13 June 2017.
