Laura Alban, PA
Critical Care PA
Saint Barnabas Medical Center, United States
Disclosure information not submitted.
Nirav Mistry, MD
MD
Saint Barnabas Medical Center, United States
Disclosure information not submitted.
Title: Euglycemic DKA in a Pregnant Patient: An Uncommon Presentation of a Common ICU Admission
Introduction: Euglycemic Diabetic Ketoacidosis (EDKA) is an uncommon presentation of Diabetic Ketoacidosis (DKA). The most common cause of EDKA is the SGLT2 class of anti-hyperglycemic medications with incidence of EDKA increasing as SGLT2s have become more popular. Certain states of physiologic stress such as pregnancy have also been documented as precipitating EDKA.
Case: A 39-year-old female (G2P1) with past medical history of DMII and preeclampsia, currently pregnant at 32 weeks 3 days gestation, presented to the ED upon suggestion by her obstetrician for evaluation of preeclampsia. Patient's DMII had previously been managed with empagliflozin but was switched to metformin and insulin during pregnancy. On presentation to the ED, patient's blood pressure was mildly elevated and she had complaints of HA and scotomata. Patient was diagnosed with preeclampsia and treated with high dose magnesium and labetalol. Labs were grossly normal on admission, however, over the first day of hospitalization serial chemistries showed abrupt drop in bicarbonate (22 to 7 mmol/L) and a rise in anion gap (12 to 23). Lactic acid was negative, serum blood glucose was 170, and ABG showed a metabolic acidosis with pH of 7.27. Other organic causes of high anion gap metabolic acidosis were ruled out. Urinalysis displayed ketones and beta hydroxybutyrate was elevated at 68 mg/dL confirming diagnosis of EDKA.
Patient was admitted to ICU and maintained on insulin and D5W drips. Over the next few days, patient's EDKA resolved with improvement in serum bicarbonate and closure of anion gap.
Discussion: EDKA is an uncommon manifestation of DKA and remains an underappreciated diagnosis especially during pregnancy. The risk of DKA is nearly 200% higher in the pregnant versus non-pregnant population with an incidence of 0.2%. Within this population, it is most common in those with poorly controlled DMI. EDKA represents a subsection of this population. DKA in pregnancy is associated with fetal and developmental risk factors. Because of this and the unique physiologic conditions associated with both pregnancy and EDKA, there must be increased awareness of EDKA in this patient population. Early recognition and prompt diagnosis are needed to ensure proper management and multi-disciplinary treatment between critical care and obstetrics.