Abstract
Diabetic ketoacidosis (DKA) in pregnancy is associated with high fetal mortality rates. A small percentage of DKA occurs in the absence of high glucose levels seen in traditional DKA. Prompt recognition and management is crucial. We report a case of a 30-year-old pregnant woman with type 1 diabetes mellitus admitted with euglycemic DKA (blood glucose <200 mg/dL). Initial laboratory testing revealed a severe anion gap acidosis with pH 7.11, anion gap 23, elevated β-hydroxybutyric acid of 9.60 mmol/L, and a blood glucose of 183 mg/dL—surprisingly low given her severe acidosis. The ketoacidosis persisted despite high doses of glucose and insulin infusions. Due to nonresolving acidosis, her hospital course was complicated by spontaneous intrauterine fetal demise. Euglycemia and severe acidosis continued to persist until delivery of fetus and placenta occurred. It was observed that the insulin sensitivity dramatically increased after delivery of fetus and placenta leading to rapid correction of ketoacidosis. This case highlights that severe ketonemia can occur despite the absence of severely elevated glucose levels. We discuss the mechanism that leads to this pathophysiologic state and summarize previously published case reports about euglycemic DKA in pregnancy.
Highlights
Euglycemic diabetic ketoacidosis (EDKA) is a biochemical triad consisting of blood glucose level less than 200 mg/dL, increased anion gap metabolic acidosis, and ketonemia [1]
Prompt recognition of EDKA is critical in pregnancy, since fetal demise can be as high as 35% without appropriate treatment [3]
Despite a normal presenting blood glucose level, it is i mperative to have a high suspicion for ketoacidosis in an acidotic pregnant patient with diabetes mellitus or gestational diabetes
Summary
Euglycemic diabetic ketoacidosis (EDKA) is a biochemical triad consisting of blood glucose level less than 200 mg/dL, increased anion gap metabolic acidosis, and ketonemia [1]. E incidence of EDKA is reportedly between 0.8% and 1.1% of all pregnant DKA cases [2]. Euglycemia presents a diagnostic challenge o en leading providers to believe ketoacidosis is less severe. Prompt recognition of EDKA is critical in pregnancy, since fetal demise can be as high as 35% without appropriate treatment [3]. We report a case of EDKA in the third trimester of pregnancy and discuss the management challenges in a patient with euglycemia and a high ketone burden. We summarize other reported cases of EDKA (Table 1)
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