A Case of Diabetic Ketoacidosis in Pregnancy

Objective: Diabetes has affected people worldwide across different ethnicity, gender, including the obstetric population. We report a case of a 28 year-old, multi-gravid, which has not been previously, diagnosed with diabetes in her 1st and 2nd pregnancy with no family history of diabetes, but developed severe Diabetic Ketoacidosis (DKA) in her third pregnancy. Case presentation: A 28 year old, Filipino, known diabetic on insulin therapy on her 24th week age of gestation presented with dyspnea and vomiting. On admission, she was received lethargic and hypotensive with a blood pressure of 80/50 mmhg, tachycardic and tachypneic. She had muscle weakness and significant premature uterine contractions. Her random blood glucose was only 357 mg/dl (9.2 mmol/L) but was severely acidotic. Arterial Blood Gas revealed a ph of 7.036, HCO3 of 2.6 mmol/L and PCO2 of 9.5 mmHg, with serum ketones of 4.9 mmol/L and an anion gap of 34 mmol/L. An ultrasound of the abdomen revealed a single live, 24 weeks by fetal biometry with good cardiac and somatic activity, but with sonographic consideration of hydrops fetalis with cardiac enlargement. She was advised to have a complete prenatal diagnostic work up for which she did not comply, and came in with a critical presentation that has lead to maternal and fetal complications. Discussion: Pregnancy is a physiologic state that can lead to a significant change in metabolism. Understanding the biochemical feedback compared to the non-pregnant state is important in the diagnosis of diabetes. A serious but rare metabolic complication is DKA in Pregnancy. Our case is a rare complication of diabetes in pregnancy in the era of approved insulin analogue use. The incidence of DKA in Pregnancy range from 0.5%, the lowest accounted rate in western countries to 8.9% in a study conducted in China. The degree of hyperglycemia in pregnancy complicated by DKA does not present with significant elevation as it may be blunted due to several maternal and fetal adaptive mechanisms. Therefore, it is a diagnostic challenge because the glucose levels are either near normal or not as elevated as the non-pregnant DKA state due to the biochemical feedback. Conclusion: This case illustrates a rare but preventable complication of pregnancy. If diagnosed right away and managed properly, maternal complications can be minimized. Review of hospital records show no similar reported case in the files of Cebu Doctors' University Hospital. Our case illustrates vigilance in diagnosis as it may have long term complications both for the mother and the unborn child.