Diabetic ketoacidosis in pregnancy

It is 02:00 and a 24-year-old with type 1 diabetes is on the antenatal ward at 31 weeks, admitted this morning with vomiting and given betamethasone yesterday for threatened preterm labour. The midwife calls you: the CTG has reduced variability and repeated late decelerations. Her glucose is 9.8 mmol/L. The reflex is theatre. The right move is a venous gas — and this topic is about why. [1][5]

Overview and definition

Ketoacidosis is uncontrolled ketogenesis from insulin deficiency plus counter-regulatory hormone excess, producing a high anion gap metabolic acidosis. Pregnancy makes it more likely, faster, and harder to see.[2][18]

The 2024 ADA/EASD/JBDS/AACE/DTS consensus requires all three components: [2]

[2]

Note what changed in 2024. The glucose criterion was lowered from over 13.9 mmol/L to 11.1 mmol/L or more, and a known diabetes history now counts irrespective of the glucose. That change exists precisely because of patients like the one above.[2]

References20Show ledgerHide ledger

1. [1]Sibai BM, Viteri OA Diabetic ketoacidosis in pregnancy. Obstet Gynecol, 2014.PMID 24463678
2. [2]Umpierrez GE, Davis GM, ElSayed NA, et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care, 2024.PMID 39052901
3. [3]Dhanasekaran M, Mohan S, Erickson D, et al. Diabetic Ketoacidosis in Pregnancy: Clinical Risk Factors, Presentation, and Outcomes. J Clin Endocrinol Metab, 2022.PMID 35917830
4. [4]Diguisto C, Strachan MWJ, Churchill D, et al. A study of diabetic ketoacidosis in the pregnant population in the United Kingdom: Investigating the incidence, aetiology, management and outcomes. Diabet Med, 2022.PMID 34778994
5. [5]Rowe JC 4th, Scaglione M, Ma'ayeh M, et al. Diagnosis and Management of Euglycemic Diabetic Ketoacidosis in Pregnancy. Obstet Gynecol, 2026.PMID 41380162
6. [6]Cozzi-Glaser GD, Davis AM, Bell M, et al. Pregnancy outcomes following diabetic ketoacidosis: a systematic review. Am J Obstet Gynecol MFM, 2025.PMID 40447103
7. [7]Spencer NR, Clark SM, Harirah HM Management of Diabetic Ketoacidosis in Pregnancy. Clin Obstet Gynecol, 2023.PMID 36657054
8. [8]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care, 2009.PMID 19564476
9. [9]Bryant SN, Herrera CL, Nelson DB, et al. Diabetic ketoacidosis complicating pregnancy. J Neonatal Perinatal Med, 2017.PMID 28304323
10. [10]Rougerie M, Czuzoj-Shulman N, Abenhaim HA Diabetic ketoacidosis among pregnant and non-pregnant women: a comparison of morbidity and mortality. J Matern Fetal Neonatal Med, 2019.PMID 29486630
11. [11]Bitar G, Sibai BM, Chen HY, et al. Trends and Outcomes among Pregnancy and Nonpregnancy-Related Hospitalizations with Diabetic Ketoacidosis. Am J Perinatol, 2025.PMID 38806155
12. [12]Jones A, Gong JY, Lee IL, et al. Proactive Insulin Escalation for Antenatal Betamethasone-Induced Hyperglycaemia in Women With Diabetes: A Prospective Cohort Study. Aust N Z J Obstet Gynaecol, 2025.PMID 40242934
13. [13]Jones AS, Lee IL, Kevat D, et al. Maternal glycaemic responses to antenatal glucocorticoids: a scoping review. J Gynecol Obstet Hum Reprod, 2025.PMID 40935291
14. [14]Dude A Intrapartum Management of Diabetes and Diabetic Ketoacidosis in Pregnancy. Clin Obstet Gynecol, 2026.PMID 41924940
15. [15]Rudland VL, Price SAL, Callaway L ADIPS position paper on pre-existing diabetes and pregnancy. Aust N Z J Obstet Gynaecol, 2020.PMID 33135798
16. [16]Rudland VL, Price SAL, Hughes R, et al. ADIPS 2020 guideline for pre-existing diabetes and pregnancy. Aust N Z J Obstet Gynaecol, 2020.PMID 33200400
17. [17]Liu Y, Zhang J, Xu X, et al. Comparison of balanced crystalloids versus normal saline in patients with diabetic ketoacidosis: a meta-analysis of randomized controlled trials. Front Endocrinol (Lausanne), 2024.PMID 38836222
18. [18]Palmer BF, Clegg DJ Pathophysiology of Ketoacidosis: Core Curriculum 2026. Am J Kidney Dis, 2026.PMID 42340294
19. [19]Wilkie G, Orr L, Leung K, et al. Comparison of intrapartum glycemic management strategies in pregnant women with type 1 diabetes mellitus. J Matern Fetal Neonatal Med, 2022.PMID 34871147
20. [20]Benhalima K, Durnwald C, Sweeting A, et al. Application of continuous glucose monitoring and automated insulin delivery technologies for pregnant women with type 1, type 2, or gestational diabetes: an international consensus statement. Lancet Diabetes Endocrinol, 2026.PMID 41421368