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New onset post partum DKA in a previously undiagnosed Type 1 Diabetic
Abstract Number: SAT-85
Abstract Type: Case Report/Case Series
Introduction: Diabetic ketoacidosis confers a significant risk of morbidity and mortality in pregnant patients with a history of Type I, Type II, or Gestational diabetes mellitus. It most commonly presents itself as nausea and vomiting, and is often in the setting of lower blood glucose than in the non-pregnant patient. We present a case of DKA in a post-partum patient with no diabetic history.
Case: A 41 y/o G2P1 female at 38w4d with a history of HSV, anemia, anxiety and one previous cesarean delivery presented to the obstetric ED complaining of body aches and chills. She was afebrile with a negative rapid flu. She had an uneventful prenatal course with normal glucose testing. In the ED, fetal monitoring was non-reassuring and she underwent an emergent c section under spinal anesthesia. A vigorous male infant was delivered and the procedure was completed uneventfully. In the PACU, the patient was hypotensive (BP: 80s/50s), but asymptomatic. She was treated with fluids and phenylephrine boluses. She complained of shortness of breath and blurry vision a few hours after arriving to the postpartum unit, but stated that her vision changes started about a week ago. Two hours later, after ambulating, she complained of worsening dyspnea and chest pain. Her vitals revealed RR: 36 and BP: 137/64. The differential at this time included pre-eclampsia, anxiety, and PE. One hour later, the patient was found to be obtunded and tachycardic to the 120s, BP: 173/83. A fingerstick was performed due to her worsening mental status and was > 700. She was transferred to the ICU where she was treated for DKA of unclear etiology (pancreatitis vs. sepsis vs. new onset type I DM). Her C-peptide was low (0.1) and Hgb A1C was found to be 6.1%, providing a diagnosis of new onset Type I DM. She remained in the hospital for 8 days post c-section, due to difficulty in blood glucose control.
Discussion: The incidence of diabetic ketoacidosis in pregnancy has been estimated at 1-2% of parturients and has decreased in the last decade, most likely due to increased prenatal counseling and tight glucose control in diabetic patients. It may be for this reason that a significant amount of patients that experience DKA have no previous history of diabetes either prior to or during pregnancy. These parturients, as exemplified by our current case report, may exhibit vague symptoms of hyperglycemia. However, with no heightened suspicion for abnormal glucose tolerance, blood glucose testing is often not initially performed, causing the clinical picture to deteriorate. It is therefore imperative to remember DKA in one’s differential diagnosis especially in parturients without previous history of diabetes.
Dalfra MG. Ketoacidosis in diabetic pregnancy. J Matern Fetal Neonal Med. 2016.
De Veciana M. Diabetes ketoacidosis in pregnancy. Semin Perinatol. 2013.
Parker JA. Diabetic ketoacidosis in pregnancy. Obstet Gynecol Clin North Am. 2007.