Diabetic Ketoacidosis (DKA) in Pregnancy — Inpatient Order Set (Example)

1. Location & Level of Care

• Admit to: ☐ ICU   ☐ Step-down / high-acuity OB unit   ☐ Delivery suite / HDU (per institutional protocol)
• Continuous cardiac telemetry and pulse oximetry.
• Nursing level of care: ☐ 1:1   ☐ 1:2 (per acuity).
• OB/MFM service: ☐ Primary team   ☐ Consulted
• Consults: ☐ Endocrinology   ☐ Critical care   ☐ Anesthesia   ☐ Nephrology (if AKI/ESRD).

2. Diagnosis & Initial Orders

• Working diagnosis: Diabetic ketoacidosis (DKA) in pregnancy (anion gap metabolic acidosis, elevated ketones, volume depletion, usually BG > 250 mg/dL, may be euglycemic in pregnancy/SGLT2 use).
• Document precipitating factors:
  • ☐ Infection (urinary, respiratory, wound, chorioamnionitis, etc.)
  • ☐ Omission or reduction of insulin
  • ☐ Vomiting, dehydration, steroid use, beta-agonists
  • ☐ New-onset diabetes or poor control
  • ☐ SGLT2 inhibitor, cocaine/illicit drugs, other stressors
• Vital signs at least every 15–30 minutes until hemodynamically stable, then hourly: HR, BP, RR, SpO₂, temperature.
• Point-of-care blood glucose: hourly until anion gap closed and insulin drip discontinued.
• Strict intake and output; record urine output hourly.
• Place: ☐ Foley catheter (if critically ill or oliguric)   ☐ Peripheral IV ×2   ☐ Central line (if pressors/poor access).

3. Labs & Diagnostic Studies

Serial Labs

• BMP (Na, K, Cl, CO₂, BUN, Cr) and venous blood gas: q 2–4 hours until anion gap closure and clinical stability.
• Magnesium and phosphate: q 6–12 hours and PRN replacement.
• Serum ketones or β-hydroxybutyrate: q 4–6 hours until normalizing (per lab capability).

4. IV Fluids & Volume Resuscitation

Aim to restore circulating volume in first 24 hours while avoiding pulmonary edema, especially in preeclampsia, cardiomyopathy, or renal disease. Adjust for maternal weight, cardiac status, and fetal considerations.

• Initial bolus (if hypovolemic and no overt fluid overload):
  • 0.9% NaCl (normal saline) IV 1 L over 1 hour (or 15–20 mL/kg) — adjust rate if cardiac compromise or severe preeclampsia.
• Ongoing fluids (first 4–6 hours):
  • If corrected Na is low/normal: continue 0.9% NaCl IV 250–500 mL/hour.
  • If corrected Na is high: use 0.45% NaCl IV 250–500 mL/hour.
• Add dextrose when blood glucose ≤ 200–250 mg/dL:
  • Switch to D5 0.45% NaCl IV 150–250 mL/hour (or institutional DKA protocol) while continuing insulin infusion.
• Target: Gradual BG decrease ~50–70 mg/dL/hour and closure of anion gap over 12–24 hours.
• Consider lower total fluid volumes and slower rates in women with preeclampsia, cardiomyopathy, or renal insufficiency; involve cardiology/nephrology early.

5. Potassium & Electrolyte Management

Assume total body potassium deficit even if initial serum K is normal or high. Insulin will drive K intracellularly, increasing risk of hypokalemia.

• Do not start insulin infusion if serum K < 3.3 mEq/L. First:
  • Hold insulin, give 20–40 mEq KCl IV per hour (via appropriate access and pump) until K ≥ 3.3; stop if K > 5.5 mEq/L or renal failure.
• If serum K 3.3–5.2 mEq/L and adequate urine output:
  • Add 20–30 mEq KCl to each liter of IV fluid (max per institutional policy and line type).
• If serum K > 5.2 mEq/L:
  • Hold K replacement; recheck K and BMP q 2 hours until < 5.2, then replace as above.
• Magnesium replacement per institutional protocol (e.g., MgSO₄ 2 g IV over 1 hour if Mg < lower limit of normal or if arrhythmias).
• Phosphate replacement if < 1.0 mg/dL or if respiratory/cardiac dysfunction (e.g., 15–30 mmol KPhos IV over 2–4 hours), balancing risk of hypocalcemia.

6. IV Insulin Therapy (Regular Insulin)

Start insulin after initial K assessment and at least partial volume resuscitation. Fixed-rate infusion is preferred; avoid bolus in hemodynamic instability per institutional protocol.

• If K ≥ 3.3 mEq/L:
  • Option A (classic): Regular insulin IV bolus 0.1 units/kg then 0.1 units/kg/hour IV infusion.
  • Option B (no bolus): Start regular insulin IV infusion 0.14 units/kg/hour (skip bolus) per institutional practice.
• If blood glucose does not fall by at least 50–70 mg/dL in first hour:
  • Give additional 0.1 units/kg IV bolus OR increase infusion rate (e.g., to 0.14–0.2 units/kg/hour) per protocol.
• When BG reaches 200–250 mg/dL:
  • Decrease insulin infusion to 0.02–0.05 units/kg/hour and add dextrose to IV fluids to maintain BG 140–200 mg/dL until anion gap closed.
• Hemodynamically unstable or high-risk patients: manage insulin titration in ICU with institutional DKA protocol.
• Do not stop insulin infusion until:
  • Anion gap closed, pH ≥ 7.3, bicarbonate ≥ 18 mEq/L, and patient clinically improved.

7. Transition to Subcutaneous Insulin

• Criteria to transition:
  • Anion gap closed and acidosis resolved.
  • Patient alert, eating, and hemodynamically stable.
• Determine total daily insulin dose (TDD) in pregnancy:
  • Use pre-pregnancy or current regimen if known, or weight-based dosing per endocrinology.
• Start basal and prandial SQ insulin:
  • Administer first dose of basal insulin (e.g., NPH, glargine, detemir) 1–2 hours before stopping IV insulin.
  • Order rapid-acting insulin with meals using pregnancy-appropriate carb ratio and correction scale.
• Ensure endocrinology consult finalizes outpatient regimen prior to discharge.

8. Bicarbonate & Other Special Considerations

• Sodium bicarbonate:
  • Generally avoid unless pH < 6.9, life-threatening hyperkalemia, or refractory shock — consult ICU/endocrinology before ordering.
• Avoid overly rapid correction of hyperglycemia or osmolality to reduce risk of cerebral edema (especially in younger patients).
• Hold SGLT2 inhibitors and metformin (if used) during acute illness; resume only after recovery and per specialist guidance.
• Review concurrent medications (steroids, beta-agonists, atypical antipsychotics) and adjust as feasible.

9. Pregnancy-Specific & Fetal Monitoring

• Confirm gestational age, fetal number (singleton vs multiples), and maternal diabetes type (T1DM, T2DM, GDM, other).
• Fetal surveillance:
  • Pre-viable: intermittent Doppler FHR documentation.
  • Viable: continuous or frequent electronic fetal monitoring when maternal status and resources allow.
• Avoid emergent delivery solely for non-reassuring fetal heart rate tracing until maternal condition optimized, unless obstetric indication (e.g., abruption, cord prolapse).
• Schedule MFM ultrasound (biometry, AFI, ± Dopplers) after maternal stabilization, especially if there is concern for growth restriction or polyhydramnios.
• Counsel regarding risk of recurrence of DKA and importance of sick-day management, frequent BG/ketone checks, and early triage in future illness.

10. Nutrition, Nausea/Vomiting & Symptom Management

• NPO initially if vomiting, altered mental status, or high aspiration risk; advance to clear liquids then diabetic diet once nausea controlled and acidosis resolving.
• Antiemetics safe in pregnancy (e.g., ondansetron, metoclopramide) PRN.
• Pain control with pregnancy-appropriate analgesia; consider regional or neuraxial options when hemodynamically stable.
• Bowel regimen (e.g., stool softener ± gentle laxative) if opioids or immobility.

11. Ongoing Monitoring & ICU Reassessment

• Continue hourly BG checks until DKA resolved and IV insulin discontinued.
• Repeat BMP and VBG q 2–4 hours until anion gap closed, then spacing per clinical course.
• Monitor for complications:
  • Hypoglycemia, hypokalemia, cerebral edema, ARDS, pulmonary edema, arrhythmias, AKI.
• Criteria for transfer from ICU to antepartum/OB ward:
  • Hemodynamic stability (no pressors), gap closed, stable electrolytes and BG, improving mental status, and appropriate level of nursing care available.

12. Discharge Planning & Postpartum Considerations

• Confirm follow-up appointments:
  • Endocrinology/diabetes education within 1–2 weeks.
  • MFM/OB follow-up per gestational age and clinical status.
• Provide written insulin regimen (basal/bolus doses, correction scale), hypoglycemia management, and sick-day rules (including ketone testing and when to seek care).
• Review impact of pregnancy and postpartum hormonal changes on insulin requirements; plan for postpartum dose adjustment and breastfeeding considerations.
• Screen for social determinants of health that may affect insulin access, nutrition, and follow-up; arrange case management support as needed.

References

1. Ali HMAE, Syeda N. Diabetic ketoacidosis in pregnancy. BMJ Case Rep. 2023;16(2):e253198. doi:10.1136/bcr-2022-253198. PubMed.
2. Eshkoli T, Barski L, Faingelernt Y, et al. Diabetic ketoacidosis in pregnancy – case series, pathophysiology, and review of the literature. Eur J Obstet Gynecol Reprod Biol. 2022;269:41–46. doi:10.1016/j.ejogrb.2021.12.011.
3. 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;39(7):e14743. doi:10.1111/dme.14743.
4. Coetzee A, Hall DR, Langenegger EJ, van de Vyver M, Conradie M. Pregnancy and diabetic ketoacidosis: fetal jeopardy and windows of opportunity. Front Clin Diabetes Healthc. 2023;4:1266017. doi:10.3389/fcdhc.2023.1266017.
5. Stathi D, et al. Diabetic Ketoacidosis in Pregnancy: A Systematic Review. J Multidiscip Healthc. 2025 (in press). doi:10.1177/11795514241312849.
6. American Diabetes Association Professional Practice Committee. 15. Management of Diabetes in Pregnancy: Standards of Care in Diabetes—2024. Diabetes Care. 2024;47(Suppl 1):S282–S296. ADA Standards of Care.
7. Blumer I, Hadar E, Hadden DR, et al. Diabetes and pregnancy: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2013;98(11):4227–4249. doi:10.1210/jc.2013-2465.
8. National Institute for Health and Care Excellence (NICE). Diabetes in Pregnancy: Management from Preconception to the Postnatal Period (NICE Guideline NG3). London: NICE; 2015 (updated 2020). Available at: NICE NG3.
9. Webber J. Diabetes in pregnancy: management of diabetes and its complications from preconception to the postnatal period (NICE guideline NG3). Br J Diabetes Vasc Dis. 2015;15(3):107–111.

Disclaimer

This OBPharm order set is an educational template intended for instructional purposes only. It does not replace institutional DKA protocols, ADA Standards of Care, or consultation with endocrinology, maternal–fetal medicine, anesthesia, critical care, and other appropriate specialists.

Medication doses, fluid rates, and monitoring schedules must be verified against current institutional policies, pharmacy guidance, and patient-specific factors (e.g., renal/hepatic function, gestational age, comorbidities, and fetal status). For EHR implementation (e.g., Cerner), each bullet should be mapped to local orderables and adjusted to match system-specific naming, dosing defaults, and routing.