A 31‐year‐old woman with history of type 1 diabetes mellitus who was 35 weeks' pregnant came to the ER with chief complaints of nausea, vomiting, and severe retrosternal burning sensation for 3 days. Symptoms started after she missed a few doses of her twice daily NPH insulin. Physical exam revealed mild epigastric tenderness. Vitals were stable except for mild tachycardia. Laboratory work showed: white count 7300/mm3, hemoglobin 13.3 g/dL, sodium 135 mEq/L, potassium 4.5 mEq/L, chloride 100 mEq/L, bicarbonate 10 mEq/L, BUN 8 meq/L, creatinine 0.8 mg/dL, blood glucose 97 mg/dL. An ABG showed a pH of 7.35, CO2 of 23 mm Hg. A diagnosis of high–anion gap metabolic acidosis was made. Serum ketones and alcohol levels were sent for further evaluation of high–anion‐gap metabolic acidosis. Serum and urine ketones were found to be high. Blood and urine toxicology were negative. Even though glucose was normal, a provisional diagnosis of diabetic ketoacidosis was made. Patient was admitted to the ICU and started on D5NS with potassium drip intravenously. The blood glucose did not improve; symptoms worsened, and follow‐up electrolyte panel in 2 hours showed further decrease in serum bicarbonate. Fluids were changed to D10 0.45% NS which minimally increased blood sugar to 120 mg/dL Patient received 4 units of intravenous insulin in 24 hours, and minimal improvement in bicarbonate to 12 mEq/L was seen. Patient received multiple ampules of D50 intravenously and 1 dose of 1 mg of glucagon intramuscularly. Subsequently, blood sugars increased, and patient received more IV insulin. Vomiting subsided, bicarbonate improved to 20 mEq/L, and anion gap closed. Patient was restarted on oral feeds and subcutaneous insulin glargine. Patient was educated about DKA and complications.
There have been very few case reports of euglycemia and diabetic ketoacidosis in pregnancy. The fetus and placenta can consume blood glucose, preventing hyperglycemia even in the presence of DKA. Moreover, in pregnancy there is increased production of ketones. It is important that physicians recognize DKA with normoglycemia to start timely treatment. Delay in treatment can lead to severe maternal and fetal complications.
Diabetic ketoacidosis should be suspected in any diabetic patient with high–anion gap metabolic acidosis irrespective of serum glucose levels. Pregnancy can lead to euglycemia due to accelerated glucose consumption. Sometimes, it may be difficult to raise blood sugars before giving insulin. All modalities that can be used to increase blood sugars quickly may be considered.
To cite this abstract:Samavedam S, Burke T, Ravi V. Complicated Euglycemic Diabetic Ketoacidosis in Pregnancy. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 239. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/complicated-euglycemic-diabetic-ketoacidosis-in-pregnancy/. Accessed April 5, 2020.