Euglycemic Diabetic Ketoacidosis in a Patient With Gestational Diabetes Mellitus and COVID-19 Infection

Introduction: Diabetic ketoacidosis (DKA) is a life-threatening medical emergency requiring urgent treatment. Euglycemic DKA may occur in patients with both type 1 and type 2 Diabetes Mellitus (DM), as well as pregnancy. The absence of marked hyperglycemia can result in delayed diagnosis and treatment, resulting in potential adverse outcomes. Diabetes is a major comorbidity associated with severe hospital course and high fatality rate among patients with COVID-19 infection. We report our experience in a patient with gestational diabetes mellitus who developed euglycemic DKA and COVID-19 infection in her third trimester of pregnancy. Clinical Case: A 30-year-old lady at 29weeks gestation presented with two-day history of vomiting, diarrhea and abdominal pain. She reported good fetal movements. She had been diagnosed with Gestational Diabetes Mellitus (GDM) at 20 weeks gestational age, receiving treatment with multiple daily injections of insulin. 5 days earlier, she had tested positive for COVID-19 infection. She was asymptomatic; testing was performed as she had been in contact with a confirmed case. On examination she was afebrile and vitally stable, but dehydrated. Her initial laboratory investigations showed ketonemia with normal glucose level and normal anion gap. She was treated as a case of starvation ketosis and dehydration, with intravenous fluids and electrolyte replacement. However, 3 days later, the patient complained of worsening nausea and vomiting with dry cough and she developed hypotension. Chest X-ray showed bilateral mid and lower zone pulmonary infiltrates. She was treated as COVID-19 pneumonia, received 2 units of COVID-19 convalescent plasma and broad-spectrum intravenous antibiotics. Repeated investigations showed worsening ketosis with high anion gap metabolic acidosis, consistent with a diagnosis of euglycemic DKA. Insulin infusion was initiated, isotonic saline with electrolyte replacement was also continued. She symptomatically improved over the next two days, with resolution of ketonemia and acidosis. The patient was discharged and she was well at her outpatient follow up visit. She underwent emergency Cesarean Section at 37 weeks gestational age, due to non-reassuring electronic fetal monitoring. She delivered a healthy female infant weighing 2445grams. Conclusion: Pregnancy is a high-risk period for DKA particularly when associated with other stressors that were identified in our patient – GDM, restricted calorie intake and COVID-19 infection. Diabetes is a risk factor for developing severe forms of COVID-19 and on the other hand, COVID-19 infection is associated with poor glycemic control and higher risk of hyperglycemic emergencies including ketoacidosis in diabetic patients. Prompt recognition of euglycemic DKA is critical in pregnancy, as this condition is associated with high fetal mortality rates.