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Starvation Ketosis And Pregnancy

Starvation Ketoacidosis In Pregnancy

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 >>

Pancreatic Ketoacidosis (kabadi Syndrome): Ketoacidosis Induced By High Circulating Lipase In Acute Pancreatitis

Pancreatic Ketoacidosis (kabadi Syndrome): Ketoacidosis Induced By High Circulating Lipase In Acute Pancreatitis

Broadlawns Medical Center, Des Moines University, Des Moines, Iowa and University of Iowa, Iowa City, Iowa, USA. *Corresponding Author: 17185, Berkshire Parkway Clive, Iowa, 50325, USA Phone +5152823041 E-mail [email protected] Visit for more related articles at JOP. Journal of the Pancreas Abstract Introduction Ketoacidosis is well established as a metabolic complication of both type 1 and type 2 diabetes Mellitus (Diabetic Ketoacidosis). It is often an initial presentation of type 1 diabetes in children and adolescents and occasionally in adults. Alternatively, it is induced of an onset of an acute disorder, e. g, sepsis, myocardial infarction, stroke, pregnancy etc. in subjects with type 1 and 2 diabetes. Ketoacidosis is also known to occur following an ethanol binge (Alcoholic Ketoacidosis). Finally, ketonemia with a rare progression to Ketoacidosis is documented to ensue following prolonged starvation. Methods The review of English literature for over 35 years from 01/1980 till 12/2015 for terms, 'ketonemia, ketonuria and ketoacidosis' 'pancreatic lipase' and 'acute pancreatitis'. Results 1) Description of individual patients presented as case reports, 2) Documentation of a series of consecutive subjects hospitalized for management of acute pancreatitis with special attention to establishing the prevalence of the disorder as well as examining the relationship between the severity of the disorder and occurrence of Ketoacidosis, 3) Studies demonstrating the relationship between progressively rising circulating pancreatic lipase concentrations with ketonuria, ketonemia and Ketoacidosis in subjects presenting with acute pancreatitis irrespective of the etiology and documenting resolution of ketonuria, ketonemia and ketoacidosis following the declining serum lipase leve Continue reading >>

Four Case Studies Of Severe Metabolic Acidosis In Pregnancy

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

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 >>

Gestational Diabetes: Once You’re Diagnosed

Gestational Diabetes: Once You’re Diagnosed

If you’re a pregnant woman, probably one of the last things you want to hear is that you have gestational diabetes. Your thoughts might range from, “What did I do to cause this?” to “Will my baby be OK?” First, keep in mind that it’s perfectly normal to feel scared and worried. Second, while gestational diabetes (GDM) is indeed serious, remember that, with proper management, you can have a healthy baby. Once you’re diagnosed If you find out that you have GDM, be prepared to learn a lot about diabetes! You’ll likely be referred to a diabetes educator and/or a dietitian. You might also be referred to an endocrinologist, a doctor who specializes in diabetes and other endocrine disorders. In most cases, you’ll be seen by a member of your health-care team about every two weeks. Be prepared to start checking your blood glucose with a meter, following a meal plan, checking your urine for ketones, recording your food and glucose levels, and possibly starting on insulin. In other words, be prepared to do some homework! Your team is there to support you and make sure that you receive the right treatment. Treating GDM There are a number of ways in which GDM is treated, and they all work together to help ensure that your blood glucose levels stay in a safe range throughout your pregnancy. Remember that the goal is to keep your blood glucose in a normal range; this is because, when blood glucose levels are too high, the extra glucose crosses the placenta to the baby. Too much glucose can cause your baby to be too large, and may cause other complications for both you and your baby during delivery and later on (such as Type 2 diabetes). Nutrition and meal planning. The saying that “you’re eating for two” during your pregnancy is partly correct. You ARE eating f Continue reading >>

What Is Ketosis?

What Is Ketosis?

"Ketosis" is a word you'll probably see when you're looking for information on diabetes or weight loss. Is it a good thing or a bad thing? That depends. Ketosis is a normal metabolic process, something your body does to keep working. When it doesn't have enough carbohydrates from food for your cells to burn for energy, it burns fat instead. As part of this process, it makes ketones. If you're healthy and eating a balanced diet, your body controls how much fat it burns, and you don't normally make or use ketones. But when you cut way back on your calories or carbs, your body will switch to ketosis for energy. It can also happen after exercising for a long time and during pregnancy. For people with uncontrolled diabetes, ketosis is a sign of not using enough insulin. Ketosis can become dangerous when ketones build up. High levels lead to dehydration and change the chemical balance of your blood. Ketosis is a popular weight loss strategy. Low-carb eating plans include the first part of the Atkins diet and the Paleo diet, which stress proteins for fueling your body. In addition to helping you burn fat, ketosis can make you feel less hungry. It also helps you maintain muscle. For healthy people who don't have diabetes and aren't pregnant, ketosis usually kicks in after 3 or 4 days of eating less than 50 grams of carbohydrates per day. That's about 3 slices of bread, a cup of low-fat fruit yogurt, or two small bananas. You can start ketosis by fasting, too. Doctors may put children who have epilepsy on a ketogenic diet, a special high-fat, very low-carb and protein plan, because it might help prevent seizures. Adults with epilepsy sometimes eat modified Atkins diets. Some research suggests that ketogenic diets might help lower your risk of heart disease. Other studies show sp Continue reading >>

Life-threatening Ketoacidosis In A Pregnant Woman With Psychotic Disorder

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 >>

Testing For Ketones

Testing For Ketones

Copyright © 1998 [email protected] All rights reserved. DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider. This particular web section is designed to present more than one view of a controversial subject, pro and con. It should be re-emphasized that nothing herein should be considered medical advice. Contents What are Ketones? What Causes Ketones? The Ketone Controversy Ketone Tests vs. Other Urine Tests Testing and Managing Ketones Kmom's Ketone Story Ketone References What are Ketones? Ketones are formed when your body's fat stores have to be accessed for energy. Normally, you eat food and then the body converts it to glucose/blood sugar for use as energy by your cells. Your insulin is then like a key, unlocking the door to the cell so it can access this blood sugar. In pregnancy, placental hormones make you more resistant to your own insulin (in essence 'warping' the key to the door) and make it harder to get that glucose from your blood into your cells. So while your blood remains high in blood sugar, your cells can be starving. The fetus absolutely must have energy, so if your pancreas cannot make enough insulin to overcome the hormone-caused resistance, the cells start accessing other sources of energy, like fat stores. The by-product of this is ketones. Ketones may be dangerous when pregnant, although this is controversial and still being studied and disputed. There were several studies that showed that babies exposed to a lot of ketones had learning problems and reduced IQ later in life. These have since been disputed by other studies, but just in case, everyone plays it safe during pregnancy, which is very prudent. What Causes Ketones? Ketones usually occur because you are ei Continue reading >>

Pregnancy Toxaemia And

Pregnancy Toxaemia And

Contents Industry Background Management Nutrition Animal Health Breeding Fibre Production Fibre Marketing Meat Production and Marketing Pasture and Weed Control Economic Analysis Tanning Skins ketosis in goats The diseases pregnancy toxaemia and ketosis can cause severe problems in goats. While the diseases are clinically different and occur during different stages of pregnancy and lactation, the basis of the disorder is essentially the same: a decrease in blood sugar levels and an increase in ketones. In ruminants, glucose is synthesised mainly from propionic acid (a volatile fatty acid produced in the rumen) and from amino acids. The amount of glucose that is absorbed directly depends on how much dietary carbohydrate escapes rumen fermentation and is digested in the small intestine. This form of glucose uptake varies with different feeds as well as their treatment. Ruminants can use products from rumen fermentation, such as volatile fatty acids, for most of their energy requirements. However, the nervous system, kidneys, mammary gland and foetus have a direct requirement for glucose. During periods of peak glucose requirement (late pregnancy and early lactation) problems may arise due to a glucose deficiency. The incidence of pregnancy toxaemia and ketosis varies with the two main types of goats. In dairy goats with a genetic potential for high milk production, ketosis may be a potential problem; in non-milch goats (Angora, Cashmere and meat) pregnancy toxaemia is more common. PREGNANCY TOXAEMIA Main causes The most important cause of pregnancy toxaemia is a decline in the plane of nutrition during the last six to eight weeks of pregnancy. This places the pregnant female in a difficult situation because the developing foetus imposes an unremitting drain on available m Continue reading >>

Of 'fasting Ketosis And Alcoholic Ketoacidosis'

Of 'fasting Ketosis And Alcoholic Ketoacidosis'

TI A case of severe starvation ketoacidosis developing during pregnancy is presented. The insulinopenic/insulin-resistant 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 >>

Starvation Ketoacidosis: A Cause Of Severe Anion Gap Metabolic Acidosis In Pregnancy

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 >>

Diabetic Ketoacidosis In Pregnancy

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 >>

Is Low Carb And Keto Safe During Pregnancy?

Is Low Carb And Keto Safe During Pregnancy?

When Carolina Cartier discovered she was pregnant with twins this past March, she never questioned whether she would continue eating a ketogenic diet. The 31-year-old Seattle area woman had been plagued by metabolic issues literally all her life: precocious puberty at age 3; polycystic ovarian syndrome (PCOS) by age 14; weight gain of 320 lbs (145 kg) on her 6 foot (183 cm) frame and pre-diabetes by her 20s. Her PCOS caused her ovaries to be enlarged and covered in cysts. She was told she was infertile and likely never able to have children. In August 2014, aged 28, her health was so poor that she went on medical disability from her job as a financial analyst. That first month off, however, she discovered and adopted the ketogenic diet. Between summer 2014 and February 2017, she lost 120 lbs (54 kg), experienced her first ever natural menstrual period that gradually established into a regular 28-day cycle; her blood sugar normalized and her ovaries reduced to 3.5 cm (< 1.5 inches) size. Her long-standing depression lifted. While she lost two early pregnancies at the start of 2016, likely because of poor egg quality, she knew she was getting healthier every day. Her positive pregnancy test in March 2017 was a happy surprise, as was the news soon after that she was carrying healthy twins. Except for a bout of extreme nausea and sea sickness for a week on a low-carb cruise early in this pregnancy, she has adhered to the ketogenic diet now through to 20 weeks of pregnancy and counting. She plans to continue this way of eating for the rest of her life. She feels great and looks wonderful; the twins in utero are thriving. “My life is transformed. Why would I even consider abandoning this way of eating when all of my positive health changes, and my pregnancy, I owe to this d Continue reading >>

Life Threatening Starvation Ketoacidosis In Pregnancy

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: A Cause Of Severe Anion Gap Metabolic Acidosis In Pregnancy

Starvation Ketoacidosis: A Cause Of Severe Anion Gap Metabolic Acidosis In Pregnancy

Abstract 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. Discover the world's research 14+ million members 100+ million publications 700k+ research projects Join for free Starvation Ketoacidosis: A Cause of Severe Anion Gap Metabolic Nupur Sinha, Sindhaghatta Venkatram, and Gilda Diaz-Fuentes Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center and Albert Einstein College of Medicine, Correspondence should be addressed to Nupur Sinha; [email protected] Received  February ; Revised  May ; Accepted  May ; Published Continue reading >>

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