DIABETIC KETOACIDOSIS IN PREGNANCY AND MATERNAL AND FETAL OUTCOMES IN KORLE BU TEACHING HOSPITAL

Abstract

Introduction Diabetic ketoacidosis (DKA) is a state of relative or absolute insulin deficiency that results in major metabolic changes including increased glucose production accompanied by decreased peripheral uptake and enhanced protein catabolism and lipolysis. It affects 1 to 3% of diabetic pregnancies. It most commonly complicates type 1 diabetes mellitus (DM) but also affects type 2 DM and more occasionally gestational DM. The incidence is higher in the second and third trimesters of pregnancy when insulin resistance peaks. Diagnosis is based on a triad of hyperglycaemia, ketonaemia or ketonuria, and metabolic acidosis. In pregnancy, DKA tends to occur at lower blood glucose levels. Euglycaemic DKA is a rare condition in which ketoacidosis occurs at normal blood glucose levels. This occurs more commonly in pregnancy. DKA in pregnancy significantly increases the risk of maternal and fetal morbidity and mortality. Management can be very challenging and must involve a multidisciplinary team in a high-dependency or intensive care unit. Maternal complications include acute kidney injury, adult respiratory distress syndrome, cerebral oedema, coma, and death. Fetal complications include fetal heart rate abnormalities, fetal demise, prematurity, and long-term neurodevelopmental delay. The objective of this study was to determine the incidence of DKA in pregnancy in KBTH and maternal and fetal outcomes. Methods This was a prospective cohort study. The study population was pregnant women with diabetes admitted at KBTH. Pregnant women who met the eligibility criteria were screened for ketonuria every time they were seen at the obstetrics emergency room or admitted to the maternity ward or labour ward. Women with urine ketones ≥2+ were tested for bicarbonate and/or pH. Women with pH<7.3 or bicarbonate <15mmol/l became the DKA cases. All the women were followed up for maternal and fetal outcomes including maternal mortality, fetal demise, preterm birth, etc. The association between DKA and maternal and fetal outcomes was determined with logistic regression using a confidence interval (CI) of 95%. Odds ratios were obtained and measurements with p-value <0.05 were deemed statistically significant. Multivariate analysis was done to control for confounders and adjusted odds ratios were determined. viii Results We screened 234 women, representing 91% of pregnant women with diabetes who were admitted at KBTH from 1 st September 2021 to 28th February 2022. Forty-four of them had significant ketonuria and six had DKA, giving an incidence of 2.6%. Two-thirds of the cases occurred in the second and third trimesters. Half occurred in women with GDM. A third had euglycaemic DKA. All the cases were managed according to the KBTH management protocol for DKA in pregnancy. They all recovered. There was no maternal mortality among the DKA cases. We found no significant effect of DKA on maternal and fetal outcomes. Conclusions The incidence of DKA in pregnancy in KBTH is similar to what has been reported in other parts of the world. Universal screening of all pregnant women with diabetes for DKA led to early diagnosis and prompt treatment. The pregnancy outcomes in pregnant women with DKA were comparable to those without DKA.