Diabetic Ketoacidosis Complicating Gestational Diabetes Mellitus

Authors

Camila Alejandra Villavicencio, Department of Medicine, New York Medical College, New York City Health and Hospitals Metropolitan, New York.
Alberto Franco-Akel, Division of Endocrinology, New York Medical College, New York City Health and Hospitals Metropolitan, New York.Follow
Regina Belokovskaya, Division of Endocrinology, New York Medical College, New York City Health and Hospitals Metropolitan, New York.

Author Type(s)

Faculty

DOI

10.1016/j.aace.2022.07.002

Journal Title

AACE Clinical Case Reports

First Page

221

Last Page

223

Document Type

Article

Publication Date

1-1-2022

Department

Medicine

Abstract

BACKGROUND/OBJECTIVE: The prevalence of diabetic ketoacidosis (DKA) in gestational diabetes mellitus (GDM) is very low. We describe a patient with GDM in whom severe DKA with intrauterine fetal demise developed in the setting of nonadherence to therapy. CASE REPORT: A 33-year-old woman, G2P0010, with no preexisting diabetes mellitus (DM) presented at 30 weeks of gestation with acute-onset altered sensorium, nausea, and emesis. GDM was diagnosed at 15 weeks of gestation with a serum glucose level of 266 mg/dL (70-134 mg/dL) after 1-hour 50-gram glucose challenge test. Glycated hemoglobin (HbA1C) was 5.9% (41 mmol/mol) at the time of GMD diagnosis. Insulin was initiated at week 20 of gestation. On presentation, serum glucose level of 920 mg/dL (70-110 mg/dL), pH of 7.02 (7.32-7.43), anion gap level of 38 mmol (5-17 mmol), bicarbonate level of 5.0 mEq/L (22-29 mEq/L), and large serum ketones were found. Ultrasound showed intrauterine fetal demise. She received intravenous fluids and continuous insulin. Following the spontaneous delivery of a nonviable fetus, DKA was resolved. Negative antiglutamic acid decarboxylase, islet cell, and zinc transporter 8 antibodies, C-peptide level of 2.4 ng/dL (1.1-4.4 ng/dL), and HbA1C level of 9% (75 mmol/mol) were found. Inpatient management included basal-bolus and sliding scale insulin therapies. Metformin was added upon discharge 7 days after admission. The HbA1C levels were 5.3% (34 mmol/mol) and 5% (31 mmol/mol) at the 3- and 6-month follow-ups, respectively. Insulin was discontinued. Currently, the patient is on metformin and glucagon-like peptide 1 receptor agonist. DISCUSSION: The development of insulin resistance during pregnancy is driven by multiple factors. Approximately 1% to 2% of pregnant women with impaired glucose tolerance develop DKA; most cases occur in women with type 1 DM. The approximate incidence of DKA in GDM is 0.02%. CONCLUSION: DKA complicating GDM is extremely infrequent, but it cannot be dismissed. Early recognition along with prompt and appropriate medical and obstetrical management is critical.

Recommended Citation

Villavicencio, C. A., Franco-Akel, A., & Belokovskaya, R. (2022). Diabetic Ketoacidosis Complicating Gestational Diabetes Mellitus. AACE Clinical Case Reports, 8 (5), 221-223. https://doi.org/10.1016/j.aace.2022.07.002