Of gravidas with DA, fewer than 1 percent die, but perinatal mortality rates from a single episode of DKA may reach 35 percent (Guntupalli, 2015). Noncompliance is a prominent factor, and this and ketoacidosis were historically considered prognostically bad signs in pregnancy (Pedersen, 1974). Importantly, pregnant women usually develop ketoacidosis at lower blood glucose thresholds than when nonpregnant. In a study from Parkland Hospital, the mean glucose level for pregnant women with DKA was 380 mg/dL, and the mean HbA]c value was 10 percent (Bryant, 2017). Euglycemic ketoacidosis during pregnancy is possible but rare (Sibai, 2014).
One management protocol for diabetic ketoacidosis is shown in Table 57-7. An important cornerstone of management is vigorous rehydration with crystalloid solutions of normal saline or Ringer lactate.
Infections. The rates of many infections are higher in diabetic pregnancies. Common ones include candidal vulvovaginitis, urinary and respiratory tract infections, and puerperal pelvic sepsis. However, in one study of more than 1250 diabetic gravidas screened before 16 weeks' gestation, rates of bacterial vaginosis or vaginal colonization with Candida or Tricho monas species were not increased (Marschalek, 2016). But, in their population-based study of almost 200,000 pregnancies, Sheiner and coworkers (2009) found a twofold greater risk of asymptomatic bacteruria in women with diabetes. Similarly, Alvarez and associates (2010) reported positive urine culture results in 25 percent of diabetic women. In a 2-year analysis of pyelonephritis at Parkland Hospital, 5 percent of women with diabetes developed pyelonephritis compared with 1.3 percent of the nondiabetic population (Hill, 2005). Fortunately, these latter infections can be minimized by screening and eradication of asymptomatic bacteriuria (Chap. 53, p. 1027). Finally, Johnston and colleagues (2017) reported that 16.5 percent of women with pregestational diabetes had postoperative wound complications following cesarean delivery.
• Management of Diabetes in Pregnancy
Because of the close relationship between pregnancy complications and maternal glycemic control, eforts to achieve glucose targets are typically more aggressive during pregnancy. Management preferably should begin before pregnancy and include speciic goals during each trimester.
To minimize early pregnancy loss and congenital malformations in ofspring of diabetic mothers, optimal medical care and education are recommended before conception (Chap. 8, p. 147). he National Preconception Health and Healthcare Initiative Clinical Workgroup for the CDC established values
TABLE 57-7. Management of Diabetic Ketoacidosis During Pregnancy
Obtain arterial blood gases to document degree of acidosis present; measure glucose, ketones, and electrolyte levels at 1-to 2-hour intervals
Low-dose, intravenous Loading dose: 0.2-0.4 U/kg Maintenance: 2-10 U/hr
Total replacement in first 12 hours of 4-6 L 1 L in first hour
If initially normal or reduced, an infusion rate up to 15-20 mEq/hr may be required; if elevated, wait until levels decrease into the normal range, then add to intravenous solution in a concentration of 20-30 mEq/L
Add one ampule (44 mEq) to 1 L of 0.45 normal saline if pH is <7.1
Data from Bryant, 20017; Landon, 2002; Sibai, 2014.