A Case of Ketoacidosis in Pregnancy

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SAT 498-531-Female Repro Endocrinology & Case Reports
Saturday, June 15, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SAT-518
Anna Louise Ross*1, Gillian Boyd-Woschinko2 and Grishma Parikh1
1Mount Sinai School of Medicine, New York, NY, 2Icahn School of Medicine at Mount Sinai, New York, NY
Background: Pregnant women are predisposed to accelerated starvation due to continuous nutrient demands by the fetus, and they have increased susceptibility to ketogenesis during periods of caloric deprivation [1, 2]. We report a case of starvation ketoacidosis in a patient with gestational diabetes on a carbohydrate-restricted diet.

Clinical case: A 30 year-old woman, gravida 5, para 2, with a history of spina bifida and hydrocephalus status post ventriculoperitoneal shunt, presented at 37 weeks of gestation with dyspnea. Her pregnancy had been complicated by gestational diabetes mellitus treated with a carbohydrate-restricted diet of 30 g a day. Due to a previous pregnancy complicated by late intrauterine fetal demise, a caesarean section was planned at 37 weeks of gestation after administration of steroids to induce fetal lung maturity.  On admission, the patient’s blood pressure was 116/69 mm Hg, heart rate 106 beats per minute, oral temperature 36 °C, pulse ox 97%, and respiratory rate 20 breaths per minute. Laboratory tests showed a mixed metabolic acidosis and respiratory alkalosis with pH 7.3 (7.33 - 7.43), HCO3 7.3 meq/l (20 - 27 meq/l), positive urinary ketones, and glucose of 75 mg/dl (65 – 139 mg/dl). Her glycosylated hemoglobin was 5.8% (4.0 - 6.0 %), C-peptide level 14.3 ng/ml (0.6 - 12.0 ng/ml), total insulin level 4.1 uU/ml (5 to 25 uU/ml), and lactate 1.8 mmol/l (0.5 - 2.2 mmol/l). Her dyspnea progressed, requiring intubation followed by emergent caesarean section. Afterwards, she was transferred to the surgical intensive care unit. She was treated with intravenous fluids containing dextrose and bicarbonate; she never received insulin and her blood glucose ranged from 65 to 139 mg/dl. By hospital day 3, the metabolic acidosis resolved, and she was extubated. A diagnosis of euglycemic diabetic ketoacidosis (DKA) was considered, but as her acid-base status improved without insulin, her illness was attributed to extreme starvation ketoacidosis. The patient remained euglycemic on a diabetic diet, and she was discharged in good condition on hospital day 6. There were no complications with the newborn infant.

Conclusion:  This case shows the importance of adequate intake of carbohydrates in pregnant patients with gestational diabetes in order to prevent ketoacidosis. Clinical assessment can distinguish between starvation ketoacidosis, which can be extreme in pregnancy, and euglycemic DKA, as the latter will require administration of dextrose and insulin to reverse the acidosis.

1.   Felig P, Lynch V.  Starvation in human pregnancy: hypoglycemia, hypoinsulinemia, and hyperketonemia.  Science 1970; 170:990-992. 2. Metzger BE, Ravnikar V, Vileisis RA, Freinkel N. "Accelerated starvation" and the skipped breakfast in late normal pregnancy. Lancet 1982; 1:588-592.

Nothing to Disclose: ALR, GB, GP

*Please take note of The Endocrine Society's News Embargo Policy at http://www.endo-society.org/endo2013/media.cfm