Jason Mause, MD,
Internal Medicine Resident
ChristianaCare Health Services
Newark, Delaware
Disclosure information not submitted.
Chelsea Hastry, MD
Internal Medicine-Pediatrics Chief Resident
Christiana Care
Newark, Delaware, United States
Disclosure information not submitted.
Christa Fistler, MD
Pulmonary Intensivist
Christiana Care
Newark, Delaware, United States
Disclosure information not submitted.
Title: Euglycemic Diabetic Ketoacidosis in a Pregnant Patient with Symptomatic COVID-19 Infection
Introduction: Euglycemic diabetic ketoacidosis (EDKA) is a life-threatening condition which is uncommon in nonpregnant diabetic individuals, but even more rare in pregnancy. To date, there have been no cases of EDKA in COVID-19 pregnant patients documented in the medical literature.
Description: A 30 year-old female with gestational diabetes presented at 29 weeks estimated gestational age to obstetrics triage with shortness of breathing, vomiting, and decreased oral intake, 5 days after being diagnosed with mild COVID-19. She had not taken her insulin in days. Because she required nasal cannula to maintain an oxygen saturation greater than 95% with significant infiltrates on chest x-ray, she was admitted to the intensive care unit. Dexamethasone was begun to treat fetal lung prematurity and maternal COVID-19 acute hypoxemic respiratory failure. Despite remdesivir, tocilizumab, ceftriaxone, and azithromycin, oxygen requirements escalated over 12 hours to high flow nasal cannula (HFNC). Awake prone positioning with HFNC was attempted but terminated due to fetal distress. Due to a progressive anion gap (AG) metabolic acidosis with euglycemia and an elevated ß-OH level, she was diagnosed with EDKA. Insulin and dextrose infusions were administered until the AG was consistently closed but it reopened 12 hours later in association with worsening hypoxemic respiratory failure. Insulin and dextrose infusions were resumed. Due to recurrent EDKA and progressive hypoxemia, she underwent endotracheal intubation and an emergent cesarean section. Within hours of delivery EDKA resolved, and 7 days later she was successfully extubated.
Conclusion: This is the first report of EDKA in a pregnant patient with COVID-19. It highlights diagnostic and management dilemmas in this specific patient population. Diagnosis of EDKA requires a high index of suspicion because delay can lead to increased maternal-fetal mortality. While indicated in COVID-19, steroids may complicate EDKA. The complex decision to recommend delivery in pregnancy complicated by COVID-19 and EDKA requires close collaboration among a multidisciplinary team and shared decision making with the patient and family. Further research is needed to clarify the COVID-19 hormonal-immunologic connection to improve management in all COVID-19 patients, particularly pregnant women.