Pregnancy Outcomes Following Diabetic Ketoacidosis: A Systematic Review

Cozzi-Glaser GD, et al. Am J Obstet Gynecol MFM. 2025 May 28:101711. Epub ahead of print. PMID: 40447103.

This systematic review evaluates maternal and neonatal outcomes following diabetic ketoacidosis (DKA) in pregnancy—a rare but serious complication affecting 0.2–3% of pregnancies with pregestational diabetes—and finds a paucity of high-quality publications on pregnancy outcomes. The review included seven observational studies (no RCTs met inclusion criteria), encompassing 282 pregnant individuals and 324 DKA episodes from 1972 to 2021. No meta-analysis was performed due to heterogeneity in study design. Key findings include:

• Stillbirth rates ranged from 7–35%, with more recent studies reporting lower rates (<17%), suggesting a temporal improvement.
• Preterm birth (PTB) occurred in 25–83% of cases, and NICU admissions ranged from 40–65%.
• Cesarean delivery was common (49–67%), though not clearly elevated compared to diabetic pregnancies without DKA.
• Only one study included a comparator group (DKA vs. no DKA), showing significantly higher rates of stillbirth (16% vs. 2%), PTB (83% vs. 34%), and NICU admission (65% vs. 46%) in the DKA group.
• Maternal ICU admission was reported in 6.5–39.4% of cases; no maternal deaths were reported.
• Other neonatal complications included hypoglycemia (13–60.4%), jaundice (4.2–31%), and respiratory distress syndrome (30.4%).

The authors found high risk of bias across all included studies due to small sample sizes, lack of standardized DKA definitions, and inconsistent outcome reporting. DKA in pregnancy remains associated with significant maternal and neonatal morbidity, though stillbirth rates may be improving. The review underscores the urgent need for large, prospective studies with standardized definitions and comparator groups to better quantify risks and guide management strategies.