Diabetic Ketoacidosis (DKA) in Pregnancy
Diabetic ketoacidosis (DKA) in pregnancy is uncommon but a life‑threatening emergency for both mother and fetus. Pregnancy increases susceptibility (particularly in type 1 diabetes), alters physiology so presentations may be atypical (including euglycaemic DKA), and requires prompt multidisciplinary management with maternal resuscitation as the priority (NICE NG3; NG17; MHRA).
Pathophysiology and pregnancy‑specific points
- DKA arises from absolute or relative insulin deficiency with excess counter‑regulatory hormones, causing hyperglycaemia, lipolysis, ketogenesis and a high anion‑gap metabolic acidosis.
- Pregnancy reduces maternal buffering (lower bicarbonate), increases metabolic demands and produces respiratory changes (mild chronic respiratory alkalosis), so acidosis may develop faster and at lower absolute glucose levels than in non‑pregnant patients.
- Be alert for euglycaemic DKA (modest or near‑normal glucose with significant ketonaemia), particularly if SGLT2 inhibitors, insulin pump failure, starvation or vomiting are implicated (MHRA; NICE NG3).
Who is at risk
- Most cases occur in women with pre‑existing diabetes, especially type 1 diabetes.
- DKA can also complicate gestational diabetes or newly diagnosed diabetes in pregnancy.
- Common precipitants include insulin omission or pump/device failure, infection, vomiting/dehydration (e.g. hyperemesis), corticosteroids (including for fetal lung maturation), myocardial ischaemia, labour, and SGLT2 inhibitor use (avoid these drugs in pregnancy).