Dr Zoe Gavey1,2,3, Dr Ling Li1,2
1Obstetric Medicine, Cairns Hospital, Cairns, Australia, 2Endocrinology, Cairns Hospital, Cairns, Australia, 3Endocrinology, Logan Hospital, Logan, Australia
Biography:
Dr Zoe Gavey is an Advanced Trainee currently undertaking dual training in Endocrinology and Obstetric Medicine. She is currently in her first year of Endocrinology training at Logan Hospital, having completed a year of Obstetric Medicine training at Cairns Hospital in 2023.
Abstract:
Diabetic ketoacidosis (DKA) in pregnancy is known to cause poor foetal outcomes, and can occur in women with both pre-existing and gestational diabetes (GDM). Even without diabetes, pregnant women are more prone to ketosis from starvation or recurrent vomiting. All forms of diabetes also increase the woman’s risk of developing pre-eclampsia.
We describe an unusual case of ketoacidosis as a presenting feature of severe pre-eclampsia. A 33-year-old primigravida presented at 33 weeks gestation with symptomatic COVID-19 infection, on a background of diet-controlled GDM. At presentation, ketones were 5.8 with blood glucose 7.2mmol/L. Serum pH was 7.23 with bicarbonate level <5 mmol/L. Her euglycaemic ketoacidosis was presumed secondary to reduced oral intake, vomiting and COVID-19 infection, and managed with an insulin/dextrose infusion and sodium bicarbonate supplementation. Bloods also demonstrated new acute kidney injury and liver enzyme derangement.
The patient showed initial clinical and biochemical improvement with treatment of COVID-19 and resolution of DKA. Her blood pressure was normal. On day 5 she developed evidence of haemolysis with rising lactate dehydrogenase, elevated reticulocytes and low haptoglobin, but a normal platelet count. Her sFlt-1/PGLF ratio returned significantly elevated at 5310. Subsequently she developed worsening ketosis despite adequate insulin treatment and normal oral intake. Her ketosis was attributed to pre-eclampsia and she proceeded to emergency Caesarean section at 33+5 weeks gestation. The patient developed neurological irritability 12 hours after delivery, requiring intravenous magnesium sulfate. Her ketosis resolved despite ceasing insulin immediately following delivery, and her remaining biochemical derangements resolved by day 5 postpartum.
This case is an unusual presentation of ketoacidosis, initially presumed secondary to starvation and acute illness, however eventually attributed to severe pre-eclampsia requiring pre-term delivery. This case highlights the need to promptly recognise and treat ketoacidosis in pregnancy to prevent adverse foetal outcomes, while maintaining a broad differential for the precipitant.
Keywords
Pre-eclampsia, diabetic ketoacidosis
References
Coetzee A, Hall D, Langenegger E, van der Vyver M, Conradie M. Pregnancy and diabetic ketoacidosis: fetal jeopardy and windows of opportunity. Frontiers in Clinical Diabetes and Healthcare. 2023; 4: 1-12