Four Case Studies Of Severe Metabolic Acidosis In Pregnancy
Summarized from Frise C, Mackillop L, Joash K et al. Starvation ketoacidosis in pregnancy. Eur J Obstet Gynecol 2012. Available online ahead of publication at: Arterial blood gas analysis in cases of metabolic acidosis reveals primary decrease in pH and bicarbonate, and secondary (compensatory) reduction in pCO2. The most common cause of metabolic acidosis is increased production of endogenous metabolic acids, either lactic acid, in which case the condition is called lactic acidosis, or keto-acids, in which case the condition is called ketoacidosis. Ketoacidosis most commonly occurs as an acute and life-threatening complication of type I diabetes, due to severe insulin deficiency and resulting reduced glucose availability for energy production within cells (insulin is required for glucose to enter cells). Keto-acids accumulate in blood as a result of metabolism of fats mobilized to fill the energy gap created by reduced availability of glucose within cells. Starvation is also associated with reduced availability of (dietary) glucose and potential for ketoacidosis, although compared with diabetic ketoacidosis, starvation ketoacidosis is rare, usually mild and not life-threatening. Except, that is, when it occurs during pregnancy. In a recently published paper the authors outline four cases of severe starvation ketoacidosis, all occurring in the third trimester of pregnancy, following prolonged vomiting over a period of days. All four women presented for emergency admission in a very poorly state and still vomiting with severe partially compensated metabolic acidosis (bicarbonate in the range of 8-13 mmol/L and base deficit in the range of 14-22 mmol/L). All four required transfer to intensive care and premature delivery of their babies by emergency Cesarean section. Fort Continue reading >>
Starvation Ketoacidosis In Pregnancy - Sciencedirect
Volume 167, Issue 1 , March 2013, Pages 1-7 Author links open overlay panel Charlotte J.Frisea LucyMackillopa KarenJoashb CatherineWilliamsonc Get rights and content Starvation ketosis outside pregnancy is rare and infrequently causes a severe acidosis. Placental production of hormones, including glucagon and human placental lactogen, leads to the insulin resistance that is seen in pregnancy, which in turn increases susceptibility to ketosis particularly in the third trimester. Starvation ketoacidosis in pregnancy has been reported and is usually precipitated by a period of severe vomiting. Ketoacidosis is likely to have important implications for fetal survival as ketoacidosis in women with type 1 diabetes mellitus is associated with intrauterine death. This article features four cases of women with vomiting in the third trimester of pregnancy associated with a severe metabolic acidosis. The mechanism underlying ketogenesis, the evidence for accelerated ketogenesis in pregnancy and other similar published cases are reviewed. A proposed strategy for management of these women is presented. Continue reading >>
Extreme Gestational Starvation Ketoacidosis: Case Report And Review Of Pathophysiology
A case of severe starvation ketoacidosis developing during pregnancy is presented. The insulinopenic/insulinresistant state found during fasting in late gestation predisposes to ketosis. Superimposition of stress hormones, which further augment lipolysis, exacerbates the degree of ketoacidosis. In our patient, gestational diabetes, twin pregnancies, preterm labor, and occult infection were factors that contributed to severe starvation ketoacidosis. Diagnosis was delayed because starvation ketosis is not generally considered to be a cause of severe acidosis, and because the anion gap was not elevated. Improved understanding of the complex fuel metabolism during pregnancy should aid in prevention, early recognition, and appropriate therapy of this condition. Continue reading >>
Prime Pubmed | Starvation Ketoacidosis: A Cause Of Severe Anion Gap Metabolic Acidosis In Pregnanc
Pregnancy is a diabetogenic state characterized by relative insulin resistance, enhanced lipolysis, elevated free fatty acids and increased ketogenesis. In this setting, short period of starvation can precipitate ketoacidosis. This sequence of events is recognized as "accelerated starvation." Metabolic acidosis during pregnancy may have adverse impact on fetal neural development including impaired intelligence and fetal demise. Short periods of starvation during pregnancy may present as severe anion gap metabolic acidosis (AGMA). We present a 41-year-old female in her 32nd week of pregnancy, admitted with severe AGMA with pH 7.16, anion gap 31, and bicarbonate of 5 mg/dL with normal lactate levels. She was intubated and accepted to medical intensive care unit. Urine and serum acetone were positive. Evaluation for all causes of AGMA was negative. The diagnosis of starvation ketoacidosis was established in absence of other causes of AGMA. Intravenous fluids, dextrose, thiamine, and folic acid were administered with resolution of acidosis, early extubation, and subsequent normal delivery of a healthy baby at full term. Rapid reversal of acidosis and favorable outcome are achieved with early administration of dextrose containing fluids. Sinha, Nupur, et al. "Starvation Ketoacidosis: a Cause of Severe Anion Gap Metabolic Acidosis in Pregnancy." Case Reports in Critical Care, vol. 2014, 2014, p. 906283. Sinha N, Venkatram S, Diaz-Fuentes G. Starvation ketoacidosis: a cause of severe anion gap metabolic acidosis in pregnancy. Case Rep Crit Care. 2014;2014:906283. Sinha, N., Venkatram, S., & Diaz-Fuentes, G. (2014). Starvation ketoacidosis: a cause of severe anion gap metabolic acidosis in pregnancy. Case Reports in Critical Care, 2014, p. 906283. doi:10.1155/2014/906283. Sinh Continue reading >>
Life-threatening Ketoacidosis In A Pregnant Woman With Psychotic Disorder
Obesity is an increasingly common problem in pregnancy. It poses a number of challenges for physicians caring for pregnant women. One of the biggest issues is that of increased insulin resistance. This is evidenced by the increasing prevalence of gestational diabetes mellitus (GDM) and the number of women requiring oral hypoglycaemic agents or insulin during pregnancy. Pregnancy is also a time at which mental health may deteriorate, and psychiatric disorders are an important cause of maternal death in the UK.1 Newer classes of antipsychotics, in particular the ‘atypical’ or second-generation antipsychotics, are increasingly being used. Olanzapine, a commonly used atypical antipsychotic, is known to be associated with significant metabolic disturbances in the non-pregnant population, in particular weight gain and type 2 diabetes mellitus.2,3 Of concern is also the reported association of olanzapine use and unheralded diabetic ketoacidosis, which has been fatal in a number of cases.4 Ketoacidosis is most commonly seen in pregnancy in the setting of diabetes mellitus, but a number of cases of ketoacidosis with euglycaemia have also been reported following short periods of starvation.5,6 Starvation ketoacidosis is associated with a more severe acidosis than is seen in non-pregnant individuals. We describe a woman who was on olanzapine from 20 weeks of gestation, and then developed ketoacidosis after a short period of reduced oral intake. However, treatment was more challenging than in other reported cases and we attribute this to very profound insulin resistance as a consequence of concurrent olanzapine use. We speculate that olanzapine in combination with the insulin resistance attributable to pregnancy contributed to the presentation in this case. A 27-year-old female Continue reading >>
Acute Starvation In Pregnancy: A Cause Of Severe Metabolic Acidosis
Abstract We report a case of starvation-induced metabolic ketoacidosis in a previously healthy 29-year-old, nulliparous woman at 32 weeks of gestation. She was admitted to hospital with mild preeclampsia associated with persistent nausea and vomiting that progressed to severe preeclampsia requiring urgent control of hypertension before caesarean delivery. Prolonged and severe vomiting limited oral caloric intake and led to starvation ketoacidosis, characterised by ketonuria and a raised anion gap metabolic acidosis that required intensive care support. Despite significant metabolic derangement the patient appeared clinically well. Intravascular volume was replenished. Fluid restriction used as part of our preeclampsia treatment regimen delayed the therapeutic administration of sufficient dextrose, which rapidly corrected her metabolic derangement when commenced after delivery. Electrolyte supplementation was given to prevent re-feeding syndrome. Both mother and baby were discharged without sequelae. Continue reading >>
Diabetic Ketoacidosis In Pregnancy
Diabetic ketoacidosis is a serious metabolic complication of diabetes with high mortality if undetected. Its occurrence in pregnancy compromises both the fetus and the mother profoundly. Although predictably more common in patients with type 1 diabetes, it has been recognised in those with type 2 diabetes as well as gestational diabetes, especially with the use of corticosteroids for fetal lung maturity and β2-agonists for tocolysis.1–3 Diabetic ketoacidosis usually occurs in the second and third trimesters because of increased insulin resistance, and is also seen in newly presenting type 1 diabetes patients. With increasing practice of antepartum diabetes screening and the availability of early and frequent prenatal care/surveillance, the incidence and outcomes of diabetic ketoacidosis in pregnancy have vastly improved. However, it still remains a major clinical problem in pregnancy since it tends to occur at lower blood glucose levels and more rapidly than in non-pregnant patients often causing delay in the diagnosis. The purpose of this article is to illustrate a typical patient who may present with diabetic ketoacidosis in pregnancy and review the literature on this relatively uncommon condition and provide an insight into the pathophysiology and management. MAGNITUDE OF THE PROBLEM In non-pregnant patients with type 1 diabetes, the incidence of diabetic ketoacidosis is about 1–5 episodes per 100 per year with mortality averaging 5%–10%.4 The incidence rates of diabetic ketoacidosis in pregnancy and the corresponding fetal mortality rates from different retrospective studies5–8 are summarised in the table 1. As is evident from the table, both the incidence and rates of fetal loss in pregnancies have fallen in recent times compared with those before. In 1963 Continue reading >>
Ketoacidosis In Diabetic Pregnancy
Diabetic ketoacidosis (DKA) is a serious medical and obstetrical emergency previously considered typical of type 1 diabetes but now reported also in type 2 and GDM patients. Although it is a fairly rare condition, DKA in pregnancy can compromise both fetus and mother. Metabolic changes occurring during pregnancy predispose to DKA in fact it can develop even in setting of normoglycemia. This article will provide the reader with information regarding the pathophysiology underlying DKA, in particular euglycemic DKA, and will provide information regarding all possible effects of ketones on the fetus. Continue reading >>
A Rare Cause Of Metabolic Acidosis: Ketoacidosis In A Non-diabetic Lactating Woman
Gordon Sloan1, Amjad Ali1 and Jonathan Webster1[1] Department of Diabetes and Endocrinology, Sheffield Teaching Hospital, Sheffield, UK Summary Ketoacidosis occurring during lactation has been described infrequently. The condition is incompletely understood, but it appears to be associated with a combination of increased metabolic demands during lactation, reduction in carbohydrate intake and acute illness. We present a case of a 27-year-old woman, 8 weeks post-partum, who was exclusively breastfeeding her child whilst following a low carbohydrate diet. She developed gastroenteritis and was unable to tolerate an oral diet for several days. She presented with severe metabolic acidosis on admission with a blood 3-hydroxybutyrate of 5.4 mmol/L. She was treated with intravenous dextrose and intravenous sodium bicarbonate, and given dietary advice to increase her carbohydrate intake. She made a rapid and full recovery. We provide a summary of the common causes of ketoacidosis and compare our case with other presentations of lactation ketoacidosis. Learning points: Ketoacidosis in the lactating woman is a rare cause of raised anion gap metabolic acidosis. Low carbohydrate intake, starvation, intercurrent illness or a combination of these factors could put breastfeeding women at risk of ketoacidosis. Ketoacidosis in the lactating woman has been shown to resolve rapidly with sufficient carbohydrate intake and intravenous dextrose. Early diagnosis and prompt treatment are essential because the condition is reported to be reversible with a low chance of recurrence with appropriate dietary advice. Background Ketoacidosis is a common cause of raised anion gap metabolic acidosis. It most frequently occurs in individuals with type 1 diabetes. Starvation commonly causes ketosis but ra Continue reading >>
Starvation Ketoacidosis In Pregnancy
Introduction: Starvation ketosis outside pregnancy is a rare phenomenon and is unlikely to cause a severe acidosis. Pregnancy is an insulin resistant state due to placental production of hormones including glucagon and human placental lactogen. Insulin resistance increases with advancing gestation and this confers a susceptibility to ketosis, particularly in the third trimester. Starvation ketoacidosis in pregnancy has been reported and is usually precipitated by a period of severe vomiting. Ketoacidosis has been associated with intrauterine death. Case report: A 22-year-old woman in her third pregnancy presented at 32 weeks gestation with a 24 h history of severe vomiting. She had been treated for an asthma exacerbation with prednisolone and erythromycin the day prior to presentation. She was unwell, hypertensive (145/70 mmHg) with a sinus tachycardia and Kussmaul breathing. Urinalysis showed ++++ ketones, + protein and pH 5. Fingerprick glucose was 4 mmol/l and ketones were 4.0 mmol/l. Arterial blood gas showed pH 7.27, PaCO2 1.1 kPa, base excess −23, bicarbonate 8.6 mmol/l and lactate 0.6 mmol/l. The anion gap was 20. Serum ethanol, salicylates and paracetamol levels were undetectable. She was fluid resuscitated but her biochemical parameters did not improve. She was intubated and underwent emergency caesarean section. A healthy boy was delivered and her acidosis resolved over the subsequent 8 h. Discussion: We believe this case is explained by starvation ketoacidosis. There was no evidence of diabetes mellitus or other causes of a metabolic acidosis. In view of the hypertension, proteinuria and raised urate the differential diagnosis was an atypical presentation of pre-eclampsia. This case illustrates the metabolic stress imposed by the feto-placental unit. It als Continue reading >>
Starvation Ketoacidosis: A Cause Of Severe Anion Gap Metabolic Acidosis In Pregnancy
Copyright © 2014 Nupur Sinha et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Pregnancy is a diabetogenic state characterized by relative insulin resistance, enhanced lipolysis, elevated free fatty acids and increased ketogenesis. In this setting, short period of starvation can precipitate ketoacidosis. This sequence of events is recognized as “accelerated starvation.” Metabolic acidosis during pregnancy may have adverse impact on fetal neural development including impaired intelligence and fetal demise. Short periods of starvation during pregnancy may present as severe anion gap metabolic acidosis (AGMA). We present a 41-year-old female in her 32nd week of pregnancy, admitted with severe AGMA with pH 7.16, anion gap 31, and bicarbonate of 5 mg/dL with normal lactate levels. She was intubated and accepted to medical intensive care unit. Urine and serum acetone were positive. Evaluation for all causes of AGMA was negative. The diagnosis of starvation ketoacidosis was established in absence of other causes of AGMA. Intravenous fluids, dextrose, thiamine, and folic acid were administered with resolution of acidosis, early extubation, and subsequent normal delivery of a healthy baby at full term. Rapid reversal of acidosis and favorable outcome are achieved with early administration of dextrose containing fluids. 1. Introduction A relative insulin deficient state has been well described in pregnancy. This is due to placentally derived hormones including glucagon, cortisol, and human placental lactogen which are increased in periods of stress [1]. The insulin resistance increases with gestational age Continue reading >>
Starvation Ketoacidosis In Pregnancy
Starvation ketoacidosis in pregnancy. / Frise, Charlotte J; Mackillop, Lucy; Joash, Karen; Williamson, Catherine. In: European Journal of Obstetrics Gynecology and Reproductive Biology, Vol. 167, No. 1, N/, 03.2013, p. 1-7. Research output: Contribution to journal Article Frise, CJ, Mackillop, L, Joash, K & Williamson, C 2013, 'Starvation ketoacidosis in pregnancy' European Journal of Obstetrics Gynecology and Reproductive Biology, vol 167, no. 1, N/, pp. 1-7. DOI: 10.1016/j.ejogrb.2012.10.005 Frise, C. J., Mackillop, L., Joash, K., & Williamson, C. (2013). Starvation ketoacidosis in pregnancy. European Journal of Obstetrics Gynecology and Reproductive Biology, 167(1), 1-7. [N/]. DOI: 10.1016/j.ejogrb.2012.10.005 Frise CJ, Mackillop L, Joash K, Williamson C. Starvation ketoacidosis in pregnancy. European Journal of Obstetrics Gynecology and Reproductive Biology. 2013 Mar;167(1):1-7. N/. Available from, DOI: 10.1016/j.ejogrb.2012.10.005 Frise, Charlotte J; Mackillop, Lucy; Joash, Karen; Williamson, Catherine / Starvation ketoacidosis in pregnancy. In: European Journal of Obstetrics Gynecology and Reproductive Biology, Vol. 167, No. 1, N/, 03.2013, p. 1-7. Research output: Contribution to journal Article @article{1b3d69ab18a2416d900c5db1f2ad026e, title = "Starvation ketoacidosis in pregnancy", abstract = "Starvation ketosis outside pregnancy is rare and infrequently causes a severe acidosis. Placental production of hormones, including glucagon and human placental lactogen, leads to the insulin resistance that is seen in pregnancy, which in turn increases susceptibility to ketosis particularly in the third trimester. Starvation ketoacidosis in pregnancy has been reported and is usually precipitated by a period of severe vomiting. Ketoacidosis is likely to have important i Continue reading >>
Euglycaemic Ketoacidosis In Patients With And Without Diabetes
Euglycaemic ketoacidosis in patients with and without diabetes Gladstone Centre, Maelor Hospital, Wrexham LL13 7TD, UK Search for more papers by this author Please review our Terms and Conditions of Use and check box below to share full-text version of article. I have read and accept the Wiley Online Library Terms and Conditions of Use Use the link below to share a full-text version of this article with your friends and colleagues. Learn more. Get access to the full version of this article. View access options below. You previously purchased this article through ReadCube. View access options below. Unlimited viewing of the article/chapter PDF and any associated supplements and figures. Ketoacidosis in individuals with diabetes is usually associated with a raised plasma glucose concentration. However, ketoacidosis in diabetes can occur with normal (11mmol/L) plasma glucose levels. Ketoacidosis is also seen in patients who do not have diabetes, most commonly in pregnancy or following alcoholic binges, rarely with starvation, anorexia nervosa or inborn errors of metabolism. The aim of this review is to compare the clinical features, pathophysiology and management of these conditions. Common clinical features due to a raised anion gap metabolic acidosis are seen. Reduced carbohydrate intake is a usual contributor to ketogenesis. Treatment is primarily with intravenous glucose, insulin if there is insulin deficiency and potassium as needed. The value of using bedside monitors to measure hydroxybutyrate levels both for diagnosis and monitoring of response to treatment is emphasised. Early recognition of ketoacidosis and treatment with glucose rather than saline is important for optimum outcome. Copyright 2013 John Wiley & Sons. Practical Diabetes 2013; 30(4): 167171 Continue reading >>
Life Threatening Starvation Ketoacidosis In Pregnancy
We are pleased to present the winning entry from the March 2017 OAA Cases & Controversies meeting… Harrison J, Churchill S, Stacey M, Collis R Department of Anaesthetics, University Hospital of Wales, Cardiff Introduction Acid-Base disturbances in pregnancy can have significant consequences for mother and fetus. Metabolic acidosis with a high anion gap has a number of causes, including lactic acidosis, diabetic ketoacidosis and toxic ingestion. Cases of starvation ketoacidosis in late pregnancy have been described.1,2,3 We describe a case of life threatening metabolic ketoacidosis with normal lactate and a high anion gap in a previously healthy non diabetic woman. Case Presentation A 28 year old (G2P1) lady was admitted at 35 weeks gestation with severe vomiting of uncertain aetiology. She had required admission twice during pregnancy with hyperemesis requiring IV fluids, IV antiemetics, omeprazole and ranitidine. On admission she appeared clinically well but was vomiting frequently and tolerating nothing orally. Urine dipstick revealed ++ ketones. She was managed with IV antiemetics, including hydrocortisone and crystalloids. During the next three days she remained stable despite ongoing vomiting. On day 4 her condition deteriorated over a 4-hour period; vomiting worsened, associated with tachypnea (respiratory rate rose from 18 to 32) and tachycardia (90 to 140). Saturations remained 100% in air. There were no other new symptoms and no chest or leg pain. Corticosteroids were given for fetal lung maturation. Chest examination and x-ray were unremarkable. Arterial blood gas on air showed: pH 7.15, PO2 16.7, PCO2 1.34, Cl 110, HCO3- 7.5, BE –24.5, Lactate 1.4, anion gap 22.5. Urine dipstick showed +++ ketones and blood ketones were 6.5. Fluid resuscitation with 10% d Continue reading >>
Starvation Ketoacidosis In Pregnancy
Abstract Starvation ketosis outside pregnancy is rare and infrequently causes a severe acidosis. Placental production of hormones, including glucagon and human placental lactogen, leads to the insulin resistance that is seen in pregnancy, which in turn increases susceptibility to ketosis particularly in the third trimester. Starvation ketoacidosis in pregnancy has been reported and is usually precipitated by a period of severe vomiting. Ketoacidosis is likely to have important implications for fetal survival as ketoacidosis in women with type 1 diabetes mellitus is associated with intrauterine death. This article features four cases of women with vomiting in the third trimester of pregnancy associated with a severe metabolic acidosis. The mechanism underlying ketogenesis, the evidence for accelerated ketogenesis in pregnancy and other similar published cases are reviewed. A proposed strategy for management of these women is presented. Continue reading >>
