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Starvation Ketosis In Pregnancy Treatment

Case Of Nondiabetic Ketoacidosis In Third Term Twin Pregnancy | The Journal Of Clinical Endocrinology & Metabolism | Oxford Academic

Case Of Nondiabetic Ketoacidosis In Third Term Twin Pregnancy | The Journal Of Clinical Endocrinology & Metabolism | Oxford Academic

We provided appropriate management with fluid infusion after cesarean delivery. The patient and her two daughters survived, and no disabilities were foreseen. Alcohol, methanol, and lactic acid levels were normal. No signs of renal disease or diabetes were present. Pathological examination revealed no abnormalities of the placentae. Toxicological tests revealed a salicylate level of less than 5 mg/liter, an acetaminophen level of less than 1 mg/liter, and an acetone level of 300 mg/liter (reference, 520 mg/liter). We present a case of third term twin pregnancy with high anion gap metabolic acidosis due to (mild) starvation. Starvation, obesity, third term twin pregnancy, and perhaps a gastroenteritis were the ultimate provoking factors. In the light of the erroneous suspicion of sepsis and initial fluid therapy lacking glucose, one wonders whether, under a different fluid regime, cesarean section could have been avoided. Severe ketoacidosis in the pregnant woman is associated with impaired neurodevelopment. It therefore demands early recognition and immediate intervention. A 26-yr-old patient was admitted to our hospital complaining of rapid progressive dyspnea and abdominal discomfort. She was pregnant with dichorial, diamniotic twins for 35 wk and 4 d. Medical history showed that she was heterozygous for hemochromatosis. Two years before, she had given birth to a healthy girl of 3925 g by cesarean section, and 1 yr before, she had had a spontaneous abortion. Her preadmission outpatient surveillance revealed slightly elevated blood pressure varying from 132158 mm Hg systolic and 7995 mm Hg diastolic. Glucose and glycosylated hemoglobin were tested at 24 wk and were normal at 4.6 mmol/liter and 5.4% (36 mmol/mol), respectively. Urine analysis at the outpatient obstetri Continue reading >>

Ketoacidosis In Diabetic Pregnancy

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 >>

What Are Ketones?

What Are Ketones?

Ketones are an acid remaining when the body burns its own fat. When the body has insufficient insulin (or cannot use sufficient insulin), it cannot get glucose (sugar) from the blood into the body's cells to use as energy and will instead begin to burn fat stores. When the body is burning too much fat, it may cause ketones to become present as by product shown in your urine. Burning fat instead of glucose can lead to a condition called ketosis. It can make you feel poorly, with lack of energy. If you have healthy or low BMI it can also be dangerous as you may also lose too much weight. Testing for ketones Your urine is usually tested for ketones during your diabetes clinic appointments. You may also be tested for ketones if you have been taken into hospital with high blood sugar levels. Ketones are detected by testing the urine with a dip stick. They are measured on a scale with 0 being lowest and 4++ being the highest. The test sticks can be purchased from a pharmacy or online and in some cases you may be prescribed test strips for home testing for if you get blood sugar levels over a certain level. Your diabetes midwife will usually complete ketone tests when you attend clinic appointments, so it is not necessary to purchase dip sticks for home use unless you're advised to by a medical professional. Blood ketones can also be tested and are much more accurate than the urine dip sticks. Type 1 diabetics may be given ketone blood testing monitors. Why are ketones common in ladies diagnosed with gestational diabetes? Ketones can be detected when you have not eaten for a long period of time and may be found in samples taken in the morning due to fasting overnight. It is common for mothers with gestational diabetes to develop ketones due to limiting too many carbohydrates f 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 >>

A Rare Cause Of Metabolic Acidosis: Ketoacidosis In A Non-diabetic Lactating Woman

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 >>

Accelerated Starvation In Pregnancy: Implications For Dietary Treatment Of Obesity And Gestational Diabetes Mellitus

Accelerated Starvation In Pregnancy: Implications For Dietary Treatment Of Obesity And Gestational Diabetes Mellitus

The biological significance of ketonemia of brief duration and moderate proportions during pregnancy remains uncertain. Thus, controversy persists about whether caloric restriction for obese women during pregnancy, particularly when the obesity is complicated by gestational diabetes mellitus (GDM), constitutes appropriate therapy. We have demonstrated, in a rigorously controlled setting using a Clinical Research Center, that all of the features of ‘accelerated starvation’ become manifest after 14 h and before 18 h of dietary deprivation. Women with GDM exhibit the same capacity for early ‘accelerated starvation’ as in normal pregnancy; thus, their insulin deficiency and insulin resistance do not appear to be sufficient to render them increasedly at risk for uncontrolled catabolism. Some cautious exploration of the use of hypocaloric diets as a therapeutic approach to the metabolic disturbances of GDM may be justified. © 1987 S. Karger AG, Basel Continue reading >>

Euglycemic Diabetic Ketoacidosis In Pregnancy

Euglycemic Diabetic Ketoacidosis In Pregnancy

1 Department of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia 2 Department of Medicine, King Faisal Specialist Hospital, Riyadh, Saudi Arabia Click here for correspondence address and email Diabetic ketoacidosis (DKA) can be a catastrophic event during pregnancy, complicating almost nine percent of diabetics in pregnancy. It induces both maternal and fetal mortality. Ketosis has been implicated in fetal distress and causes adverse neurological outcome. DKA with a relatively low blood sugar levels is called euglycemic DKA, which is a rare entity and reported usually in type I diabetic patients. A 37-year-old Saudi female patient known to have type II diabetes developed euglycemic [blood glucose level 4.3 mmol/L (78 mg/dl)] DKA while in her fifth pregnancy. She responded to intravenous dextrose and insulin with gradual improvement. Euglycemic DKA should be considered in type II diabetics during pregnancy and treated promptly. Keywords: Euglycemia, Diabetes mellitus, Ketoacidosis Diabetic ketoacidosis (DKA) is a state characterized by hyperglycemia (glucose >250 mg/dl), acidosis (pH <7.35), low serum bicarbonate, high anion gap and positive serum and urinary ketones. [1],[2],[3],[4] DKA is the result of an absolute or relative deficiency of insulin and increase in the level of counter regulatory hormones. The pathophysiology of DKA is based on the inability of cells to take up and utilize glucose and an increased degree of lipolysis and proteolysis, the end-result being volume depletion and a high anion metabolic acidosis. Burge et al, in their study noted that a fast of short duration (32 hours) predisposes type I diabetic subjects to an accelerated development of ketoacidosis during insulin deficiency with normal serum glucose levels. [5] They proposed 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 >>

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 >>

Acute Starvation In Pregnancy: A Cause Of Severe Metabolic Acidosis

Acute Starvation In Pregnancy: A Cause Of Severe Metabolic Acidosis

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. Do you want to read the rest of this article? ... Among the 10 reported nondiabetic starvation ketoacidosis cases, [1][2][3][4][5][6][7]only 3 patients [5][6][7]experienced reversal of severe acidosis after being treated with a 5% or 10% dextrose infusion [6,7] or a fixed-dose insulin regimen, [5] and most patients required emergency delivery. [1][2][3][4]Those 3 cases focused on the Wei et al. Medicine (2016) 95:26 www.md-journal.com ... 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 >>

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 >>

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 >>

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 >>

Diabetic Ketoacidosis: Evaluation And Treatment

Diabetic Ketoacidosis: Evaluation And Treatment

Diabetic ketoacidosis is characterized by a serum glucose level greater than 250 mg per dL, a pH less than 7.3, a serum bicarbonate level less than 18 mEq per L, an elevated serum ketone level, and dehydration. Insulin deficiency is the main precipitating factor. Diabetic ketoacidosis can occur in persons of all ages, with 14 percent of cases occurring in persons older than 70 years, 23 percent in persons 51 to 70 years of age, 27 percent in persons 30 to 50 years of age, and 36 percent in persons younger than 30 years. The case fatality rate is 1 to 5 percent. About one-third of all cases are in persons without a history of diabetes mellitus. Common symptoms include polyuria with polydipsia (98 percent), weight loss (81 percent), fatigue (62 percent), dyspnea (57 percent), vomiting (46 percent), preceding febrile illness (40 percent), abdominal pain (32 percent), and polyphagia (23 percent). Measurement of A1C, blood urea nitrogen, creatinine, serum glucose, electrolytes, pH, and serum ketones; complete blood count; urinalysis; electrocardiography; and calculation of anion gap and osmolar gap can differentiate diabetic ketoacidosis from hyperosmolar hyperglycemic state, gastroenteritis, starvation ketosis, and other metabolic syndromes, and can assist in diagnosing comorbid conditions. Appropriate treatment includes administering intravenous fluids and insulin, and monitoring glucose and electrolyte levels. Cerebral edema is a rare but severe complication that occurs predominantly in children. Physicians should recognize the signs of diabetic ketoacidosis for prompt diagnosis, and identify early symptoms to prevent it. Patient education should include information on how to adjust insulin during times of illness and how to monitor glucose and ketone levels, as well as i Continue reading >>

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