A 25-year-old G3P2 with type 1 diabetes presents at 31 weeks with vomiting, dehydration and Kussmaul breathing. Blood glucose is 210 mg/dL, pH 7.08, bicarbonate 6 mEq/L, ketones strongly positive. Which statement about her management is correct?
- A Diabetic ketoacidosis is unlikely at this glucose level, so another diagnosis should be sought
- B Intravenous regular insulin and aggressive fluid resuscitation are the mainstay, with fetal monitoring ✓
- C Sodium bicarbonate infusion is indicated because the pH is below 7.1
- D Subcutaneous insulin glargine should be started immediately instead of intravenous insulin
Correct answer: B. Intravenous regular insulin and aggressive fluid resuscitation are the mainstay, with fetal monitoring
Explanation
Ketoacidosis in pregnancy develops faster and at lower glucose levels than outside pregnancy, often between 150 and 250 mg/dL, because the fetoplacental unit buffers maternal glucose and pregnancy is a ketogenic state. Treatment is intravenous isotonic fluids and intravenous regular insulin infusion, with potassium replacement and continuous fetal heart monitoring, since maternal acidosis threatens the fetus. Bicarbonate is reserved for pH persistently below 7.0 despite therapy. Subcutaneous regimens cannot correct DKA acutely.
Reference: Williams Obstetrics, 26th ed.
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