Despite intensified insulin treatment and strict surveillance of metabolic control in diabetic women during pregnancy, diabetic ketoacidosis (DKA) complicates 2–9% of diabetic pregnancies (1) and represents the leading cause of fetal loss, with a fetal mortality rate of 30–90% (1–3).
From August 1991 to December 2001, 2,025 pregnant women with diabetes were admitted to the University of Tennessee Women’s Hospital. Of these, 888 women (44%) received insulin therapy, and 11 women (1.2%) presented with DKA (blood glucose: 377 ± 27 mg/dl, pH: 7.22 ± 0.01, bicarbonate 7.9 ± 3 mEq/l, and positive serum ketones). White’s diabetic classification included class A2, four patients (27%); class B, five patients (45%); class C, one patient (9%); and class D, one patient (9%). The four women with gestational diabetes mellitus (GDM) were African-American, had a mean age of 25 ± 1 year, a BMI of 34 ± 3 kg/m2, and an estimated gestational age of 29 ± 1 weeks. Patients with a previous history of diabetes had a mean duration of diabetes of 6 ± 1 year, a mean age of 27 ± 1 year, a BMI of 30 ± 2 kg/m2, and a gestational age of 28 ± 1 weeks.
Infection (27%) and a history of the omission of insulin therapy (18%) were the most common precipitating causes. There were no maternal deaths, and the mean maternal length of hospital stay was 7 ± 2 days. Two patients presented with intrauterine fetal demise, and there was one additional fetal death giving an overall fetal death rate of 27%. During labor, four patients had nonreassuring fetal heart rate tracings in the form of late decelerations that resolved with correction of DKA. At birth, the mean (5 min) Apgar was 8.7 ± 0.4, and fetal weight was 1,278 ± 202 g.
Four obese women with DKA had newly diagnosed diabetes; one of them presented with an intrauterine fetal demise, and the remaining three reached full-term pregnancy. Insulin therapy was discontinued in all four patients after delivery; and two women remained off insulin after 6 months and 6 years of follow-up. GDM presenting with DKA is unusual (3). Our study indicates that DKA could be the clinical presentation of GDM and that many of these women can discontinue insulin treatment shortly after delivery. The four women with GDM and DKA were obese African-Americans resembling the phenotypic characteristics of patients with atypical diabetes (4).
In conclusion, DKA remains an important cause of fetal loss in diabetic pregnancies. Strict surveillance of glucose homeostasis and aggressive management might reduce the high perinatal mortality associated with DKA.
References
Address correspondence Guillermo Umpierrez, MD, Associate Professor of Medicine, Obstetrics and Gynecology, University of Tennessee Health Science Center, 951 Court Ave., Room 335M, Memphis, TN 38163. E-mail: [email protected].
