A Case of Euglycemic Diabetic Ketoacidosis in Pregnancy Complicated with Gestational Diabetes Mellitus

Introduction: Euglycemic Diabetic Ketoacidosis (EDKA) is an uncommon condition that complicates one percent of all pregnant patients with DKA. This condition is challenging to identify and often undiagnosed. EDKA is critical in pregnancy and needs prompt diagnosis and treatment since fetal demise can be as high as 35% without appropriate management.

Case Report: A 28-year-old gravida 3 para 2002 at 36 weeks and 3 days gestation was admitted for sepsis secondary to bilateral inner thigh cellulitis. She had presented to the emergency room one week ago with cellulitis, where imaging was performed to rule out deep vein thrombosis and deep spread of infection and sent home with antibiotics. Her prenatal history was significant for obesity with a body mass index of 46 kg/m² and insulin-dependent gestational diabetes mellitus diagnosed at 26 weeks by a 50-g glucose challenge test of 244 mg/dL. Her first trimester hemoglobin A1c was 5.5%. Her finger sticks were well controlled on glargine 40 units in the night; however, the last estimated fetal weight was 97th percentile. The patient was started on intravenous antibiotics cefazolin and clindamycin immediately, and sepsis was resolved. Although the patient remained euglycemic and asymptomatic, trending laboratories revealed an elevated anion gap of 17 Mmol/L, β hydroxybutyrate 5.01 Mmol/L, and a lactic acid of 1.5 Mmol/L. The patient was diagnosed with EDKA and transferred to Medical Intensive Care Unit for management with insulin drip and electrolyte replacement. Following the resolution of DKA, the patient underwent a primary cesarean delivery for macrosomia at 37 weeks. Baby girl of 4,920 g and APGAR of 9, 9 was born and managed in NICU for hypoglycemia. Postoperatively, the cellulitis improved, and she was discharged home on post-operative day four with antibiotics for seven more days.

Conclusion: DKA is challenging to identify in asymptomatic patients with normal or low values of glucose. Though the literature has reports on EDKA in mothers with type 1 and 2 pre-gestational diabetes, this case report demonstrates that EDKA can develop in patients with well controlled GDMA2. Obesity and systemic infection are reported risk factors. Thus, to reduce maternal and fetal morbidity, we recommend evaluating for ketonemia and acidosis in obese pregnant women with diabetes and infection, even in the setting of normal glucose values.

Publication History

Article published online:
17 September 2021