O&G · Critical care in obstetrics and gynaecology
Diabetic ketoacidosis in pregnancy
Also known as DKA in pregnancy · Euglycaemic diabetic ketoacidosis · Obstetric ketoacidosis · Ketoacidosis in the pregnant patient · Hyperglycaemic crisis in pregnancy
Exam-exhaustive FRANZCOG fellowship reference on diabetic ketoacidosis in pregnancy — why it happens faster and at lower glucose, euglycaemic DKA, the 2024 ADA/EASD/JBDS diagnostic triad, fluid and fixed-rate insulin regimens with rates, potassium thresholds, the abnormal CTG that recovers with maternal correction, precipitants including corticosteroids and beta-agonists, and the decision to stabilise rather than deliver. RANZCOG-primary, globally tagged to MRCOG and ABOG.
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Red flags
- A normal or near-normal glucose does not exclude ketoacidosis in pregnancy — up to about a third of cases are euglycaemic
- Vomiting in a woman with type 1 diabetes is ketoacidosis until a ketone and a gas say otherwise
- An abnormal CTG during ketoacidosis is usually a maternal problem — correcting the mother is the fetal resuscitation
- Potassium under 3.5 mmol/L: hold the insulin and replace potassium first, or you will cause an arrhythmia
- Stopping basal insulin because she is not eating — the commonest avoidable precipitant on a maternity ward
- Corticosteroids and beta-agonist tocolysis both precipitate ketoacidosis, and both are drugs we prescribe
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]
| Component | Criterion |
|---|---|
| Hyperglycaemia | Plasma glucose 11.1 mmol/L or more — or a known history of diabetes at any glucose |
| Ketonaemia | Beta-hydroxybutyrate 3.0 mmol/L or more (or significant ketonuria) |
| Acidosis | Venous pH below 7.30 or bicarbonate below 18 mmol/L |
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]
References20ShowHide
- [1]Sibai BM, Viteri OA Diabetic ketoacidosis in pregnancy. Obstet Gynecol, 2014.PMID 24463678
- [2]Umpierrez GE, Davis GM, ElSayed NA, et al. Hyperglycemic Crises in Adults With Diabetes: A Consensus Report. Diabetes Care, 2024.PMID 39052901
- [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]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]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]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]Spencer NR, Clark SM, Harirah HM Management of Diabetic Ketoacidosis in Pregnancy. Clin Obstet Gynecol, 2023.PMID 36657054
- [8]Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care, 2009.PMID 19564476
- [9]Bryant SN, Herrera CL, Nelson DB, et al. Diabetic ketoacidosis complicating pregnancy. J Neonatal Perinatal Med, 2017.PMID 28304323
- [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]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]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]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]Dude A Intrapartum Management of Diabetes and Diabetic Ketoacidosis in Pregnancy. Clin Obstet Gynecol, 2026.PMID 41924940
- [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]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]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]Palmer BF, Clegg DJ Pathophysiology of Ketoacidosis: Core Curriculum 2026. Am J Kidney Dis, 2026.PMID 42340294
- [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]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