DKA in pregnancy linked to high perinatal mortality rates
medwireNews: Diabetic ketoacidosis (DKA) affects around one in 60 pregnant women with type 1 diabetes and is associated with “exceptionally high” perinatal mortality rates, shows research published in Diabetic Medicine.
Between April 2019 and September 2020, Marian Knight (University of Oxford, UK) and colleagues identified 82 pregnant women with DKA using the UK Obstetric Surveillance System. Of these, 85.4% had type 1 diabetes, 6.1% had type 2 diabetes, and 8.5% had gestational diabetes.
The incidence of DKA was 6.3 cases per 100,000 maternities overall but was much higher when only considering women with type 1 and type 2 diabetes, at 16.6 and 1.1 cases per 1000 women giving birth, or approximately one in 60 and one in 900 women giving birth, respectively. Twelve (15%) women had more than one DKA episode during their pregnancy.
Knight and team report that there were no maternal deaths during the study, but the perinatal mortality rate was 16%, with 11 stillbirths and one neonatal death. By comparison, the overall stillbirth rate in pregnant women with type 1 or type 2 diabetes was 1.37% between 2014 and 2018.
Among the stillbirths recorded, seven (63.6%) occurred at the time of the DKA episode and four (35.4%) occurred later in the pregnancy, typically at 35–37 weeks’ gestation in women who had their DKA in their second trimester.
The majority (71%) of DKA episodes occurred during the third trimester of pregnancy, and were associated with infection (21%), vomiting (21%), steroid therapy (13%), or medication errors (10%).
Of note, 51% of 76 women with adequate data had euglycemic DKA. This is uncommon in the general population, occurring in around 3% of cases, leading the investigators to suggest “that DKA occurs more often at lower glucose levels in pregnancy.”
When the researchers compared data from 70 women with DKA in type 1 diabetes with that from 69 women with type 1 diabetes whose pregnancies were not complicated by DKA, they found that the women with DKA were significantly more likely to have at least one microvascular diabetes complication prepregnancy (44 vs 14%). Furthermore, women with DKA, and their partners, were more likely to be without paid employment at the time of their first antenatal visit than those without DKA (37 vs 12%).
In addition, women with DKA who had live-born infants were significantly more likely to experience preterm births than those without DKA (83% of 52 vs 34% of 67) and to have their infants admitted to a neonatal unit (64 vs 46%).
Knight et al also point out that just under half (48%) of the women with DKA were treated in a medical or obstetric ward, despite “the requirements for monitoring (both maternal and fetal), the high prevalence of metabolic disturbance and the substantial risks of stillbirth.”
They therefore conclude: “Guidelines are needed on prepregnancy care as well as the optimum management of DKA in pregnancy (including location of care) and on appropriate obstetric/diabetes management following episodes of DKA, given the high risk of recurrent DKA, preterm birth and stillbirth.”
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