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Starvation Ketoacidosis Presenting as Hypocapnia during Emergency Cesarean Section
Abstract Number: T-59
Abstract Type: Case Report/Case Series
Introduction: Starvation ketoacidosis is a rare metabolic derangement that has been primarily reported in the third trimester of pregnancy. Patients often present with poor calorific intake due to nausea and vomiting. Maternal acidosis can be severe, requiring critical care admission and possible emergency cesarean section for fetal distress.
Case Report: We describe a case of a 29 year-old, G6P0503 female at 25 weeks gestational age and no prenatal care who underwent emergency cesarean section under general anesthesia for fetal distress. She reported a one-month history of daily nausea and vomiting with no food intake during the preceding two days. Upon initiation of positive pressure ventilation, patient was noted to have marked hypocapnia measured by capnography (EtCO2: 8), despite satisfactory endotracheal tube placement and hemodynamic status. ABG revealed pH: 7.039, bicarbonate 6 mmol/L, PCO2 25.1 mmHg, base excess -22.7 mmol/L, and an anion gap of 23. The patient was also noted to have acute renal failure. She was treated with sodium bicarbonate and fluid resuscitation intraoperatively pending further evaluation of her acid-base disturbance. B-hydroxybuterate serum concentration was elevated beyond 9 mmol/L while urinalysis revealed ketonuria (80 mg/dL) in the absence of glucosuria. Serum hemoglobin A1C and glucose concentrations were within normal limits. Evaluation for other causes of anion gap metabolic acidosis was unremarkable. A male newborn weighing 836 grams with APGAR scores 2 and 7 was delivered and transferred to the neonatal ICU. With improved oral intake, the patient’s serum bicarbonate and renal function normalized on postoperative day 2.
Discussion: Poor calorific intake and insulin resistance due to placental hormones, particularly in the third trimester, result in compensatory upregulation of catabolic pathways promoting protein and fatty acid degradation. Anion gap metabolic acidosis results from increased hepatic ketogenesis to provide substrate for central nervous system metabolism during starvation. Providing adequate calorific intake is fundamental to limiting and reversing this process.
References: Frise, CJ. et al. (2013) Eur J Obstet Gynecol Reprod Biol 167(1):1-7
Scholte, JB. et al. (2012) J Clin Endocrinol Metabol 97(9): 3021-4