A 29-year-old woman with Type 1 diabetes presents at 20 weeks with vomiting, dehydration and Kussmaul breathing. Glucose is 240 mg/dL, pH 7.18, bicarbonate 12 mEq/L and ketones are strongly positive. Compared with diabetic ketoacidosis outside pregnancy, which statement about this episode is correct?

• A Bicarbonate should be given routinely once pH is below 7.3
• B Insulin is withheld until glucose exceeds 300 mg/dL
• C Fluid restriction is advised because of placental oedema risk
• D Ketoacidosis develops at lower glucose values because of accelerated starvation ✓

Explanation

Pregnancy is a state of accelerated starvation with lower fasting glucose and higher ketone tendency, so ketoacidosis can develop at glucose values near or even under 200 mg/dL, the so-called euglycaemic DKA. Management still follows standard principles: aggressive isotonic fluids first, then low dose insulin infusion, potassium monitoring and fetal monitoring. Insulin must not be delayed pending a glucose threshold, fluids are not restricted, and bicarbonate is reserved for pH below about 6.9.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.