Prenatal, postpartum diabetic ketoacidosis rose for mothers with pregestational diabetes

Key takeaways:

• From 2010 to 2020, cases of diabetic ketoacidosis at delivery rose with a mean annual percentage change of 10.8%.
• Prenatal and postpartum diabetic ketoacidosis cases also rose within the same period.

In the U.S., diabetic ketoacidosis frequency at prenatal and delivery hospitalizations increased from 2010 to 2020 for mothers with pregestational diabetes, according to study results published in Obstetrics & Gynecology.

“There is a sense that with greater public health focus and preventions, our management of diabetes and pregnancy is safer and has improved over the past decade, and some of that has to do with improved screening, improved medication management and increasing use of technology,” Kartik Venkatesh, MD, PhD, FACOG, associate professor of obstetrics, gynecology and epidemiology, director of the Diabetes in Pregnancy Program in the department of obstetrics and gynecology in the division of maternal-fetal medicine at The Ohio State University, told Healio. “However, that does not mean that diabetic ketoacidosis has necessarily decreased; in fact, the rate of diabetic ketoacidosis has increased. This is cause for concern because the rate of type 1 and type 2 diabetes in pregnancy has continued to increase and will continue to increase due to obesity and increasing maternal age in pregnancy.”

Venkatesh and colleagues conducted a serial, cross-sectional study using data from 392,796 pregnant women and girls aged 15 to 54 years with pregestational diabetes hospitalized for delivery from 2010 to 2020 from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project Nationwide Readmissions Database. Researchers evaluated sociodemographic, clinical and hospital risk factors for diabetic ketoacidosis (DKA).

Primary outcomes were DKA at delivery hospitalization, maternal morbidity and adverse pregnancy outcomes. Secondary outcomes were DKA at prenatal and postpartum hospitalizations.

Overall, 27.2% of mothers had type 1 diabetes and 72.8% had type 2 diabetes. Thirty percent of deliveries were to mothers aged 30 to 34 years, 97.9% were singleton births, 48.1% of mothers had Medicaid and 71.4% delivered at metropolitan teaching hospitals, the researchers reported.

DKA at delivery was observed among 89.1% of mothers with type 1 diabetes and 10.9% of mothers with type 2 diabetes. DKA frequency at delivery was 1.2%, with a mean annual percentage change of 10.8%.

Frequency of DKA at delivery rose from 2.9% in 2010 to 5% in 2020 for mothers with type 1 diabetes while rising from 0% in 2010 to 0.8% in 2020 for mothers with type 2 diabetes. Mothers with type 1 diabetes had a significantly higher likelihood of DKA at delivery compared with mothers with type 2 diabetes (adjusted OR = 23.99; 95% CI, 20.81-27.65), according to the researchers.

DKA likelihood was greater for mothers were aged 15 to 19 vs. 25 to 29 years (aOR = 1.31; 95% CI, 1.06-1.6) and those who had Medicaid (aOR = 2.25; 95% CI, 2-2.52) or self-pay (aOR = 2.94; 95% CI, 1.88-4.61) vs. private insurance and lower vs. higher income (aOR = 2.04; 95% CI, 1.73-2.41).

DKA at delivery was associated with increased risks for:

• nontransfusion severe maternal morbidity (aOR = 8.18; 95% CI, 7.2-9.29);
• critical care procedures (aOR = 15.83; 95% CI, 12.59-19.9);
• cardiac complications (aOR = 8.87; 95% CI, 7.32-10.76);
• acute renal failure (aOR = 9.78; 955 CI, 8.16-11.72);
• transfusion (aOR = 2.27; 95% CI, 1.87-2.75);
• preterm birth (aOR = 2.41; 95% CI, 2.17-2.69); and
• hypertensive disorders of pregnancy (aOR = 1.11; 95% CI, 1-1.23).

In secondary analyses, frequency of prenatal DKA was 3.1%, with a mean annual percentage change of 4.1%. In addition, the frequency of postpartum DKA was 0.4%, with a mean annual percentage change of 3.5%. Of 3,092 prenatal hospitalizations among mothers with DKA, 15.7% had recurrent DKA at delivery. Of 1,419 postpartum hospitalizations among mothers with DKA, 20% had DKA at delivery, the researchers wrote.

Risk factors for DKA at delivery were similar to those observed for DKA at prenatal and postpartum hospitalizations.

According to Venkatesh, to make pregnancy safer and improve outcomes in this population, researchers should redouble their focus on improving glucose and glycemic control, which drives the risk for DKA.

“These data speak to the need for improved pregnancy surveillance because the rate of diabetes in pregnancy is going up. These data seem to suggest that potentially the risk of serious complications in pregnancy in this population is going up, namely diabetic ketoacidosis,” Venkatesh said. “We need better mechanisms to collect these types of data, to better understand what’s going on at the ground level, and then we still need to continue to develop better integrated care programs for pregnant individuals with type 1 and type 2 diabetes to improve glucose control and, thereby, pregnancy outcomes.”

For more information:

Kartik Venkatesh, MD, PhD, FACOG can be reached at kartik.venkatesh@osumc.edu.