Dr Priya Sekar1, Associate Professor Ashin Sinha1, Dr Nirjhar Nandi1
1Cairns Hospital, Cairns, Australia
Biography:
Priya is a first year endocrinology advanced trainee at Cairns Hospital with the plan to train in obstetric medicine. Her interests lie in general endocrinology and diabetes, and pregnancy. Priya is passionate about medical education for students and junior doctors. At home she is mum to a cheeky 1yo son.
Abstract:
Case-Presentation: A 32-year-old multiparous woman, presented with 3-days epigastric/abdominal pain and tachypnoea at 39/40 gestation, and 1 week polyuria and polydipsia. She underwent a category 1 C-Section for an abnormal cardiotocogram (CTG) resulting in fetal demise. She was found to be in diabetic ketoacidosis (DKA): pH 7.08, ketones 6.0mmol/L, bicarbonate 5mmol/L, BGL 29mmol/L. She had no history of gestational or type 2 diabetes mellitus (GDM, T2DM) with 2 normal oral glucose tolerance tests (OGTT) during this pregnancy, normal OGTT in previous pregnancies and normal postpartum glycosylated haemoglobin (HbA1c). Initial management was an insulin/dextrose infusion, which was transitioned to subcutaneous insulin. Diagnosis of fulminant type 1 diabetes mellitus (FT1DM) was made based on presentation, C-peptide 0.1nmol/L and HbA1c 6.8%.
Pregnancy related DKA occurs mostly in women with known type 1 diabetes mellitus (T1DM) and less frequently in those with T2DM, GDM and newly diagnosed T1DM. It is extremely rare to see DKA in pregnant women with normal OGTT. Case reports describe FT1DM presenting in late 3rd trimester, as a cause for DKA in women with normal OGTT. FT1DM is a subtype of non-autoimmune type 1 diabetes (type 1B), characterised by rapid pancreatic beta cell destruction, resulting in acute onset DKA with normal or near-normal HbA1c, and an absence of islet cell antibodies. The exact cause of destruction is unknown, however patients often have preceding viral prodrome, and there is an association with late 3rd trimester presentation. Diagnosis can be made on the presence of 3 criteria. 1) onset of DKA shortly after the appearance of hyperglycaemic symptoms. 2) Plasma glucose at presentation >16mmol/L and HbA1c <8.7%. 3) Fasting C-peptide <0.1nmol/L, or post glucagon (or meal), <0.17nmol/L. Patients require lifelong insulin therapy due to complete loss of beta cell function. Given the rarity and acute onset, there are currently no screening recommendations.
Keywords
"Diabetic ketoacidosis", "Pregnancy", "Fulminant Type 1 Diabetes Mellitus"
References
Xu J, Liu C, Zhao W, Lou W. Case Series of Diabetic Ketoacidosis in Late Pregnancy with Normal Glucose Tolerance. International Journal of Women’s Health. 2023 Nov 1;Volume 15:1857–64.
Li CY, Li Y, You ZY, Liu YR, Wang YJ, Mu T, et al. Fulminant type 1 diabetes mellitus in pregnancy. Brazilian Journal of Medical and Biological Research. 2020;53(9).
Himuro H, Sugiyama T, Nishigori H, Saito M, Nagase S, Sugawara J, et al. A case of a woman with late-pregnancy-onset DKA who had normal glucose tolerance in the first trimester. Endocrinology, Diabetes & Metabolism Case Reports. 2014 Apr 1;2014.