PSUN240 A Case of Euglycemic DKA in Pregnancy

BACKGROUND: Euglycemic diabetic ketoacidosis (EKDA) is a rare diagnosis of exclusion occurring in a state of decreased hepatic production of glucose due to fasting state or enhanced urinary excretion of glucose. Pregnancy predisposes a woman to a state of accelerated starvation, where even short periods of fasting can lead to increased lipolysis and subsequent ketosis. DKA can develop quickly at lower serum glucose concentrations when triggers such as stress, pump malfunction, infection are present. EDKA is particularly important to recognize and treat in pregnant patients, as this increases risk of fetal demise. Diagnostic criteria of EKDA are elevated beta-hydroxybutyrate in serum or urine, decreased serum bicarbonate, glucose > 200 mg/dL, anion gap metabolic acidosis.Clinical case:26-year-old female G1P2 at 29-weeks’ gestation, with a medical history of type 1 diabetes mellitus on insulin pump, hypothyroidism, prior pregnancy complicated by pre-eclampsia presented as a transfer from an outside hospital after a low-impact motor vehicular accident. Patient was transferred with concern for DKA. At the time of presentation patient had been using her insulin pump per home settings, was NPO for at least 24 hours due to nausea and mild abdominal pain. BP was 140/77 mmHg, HR 114 beats/min, 97.6F, RR 16 with SpO2 99% on RA. Patient was alert and oriented, not in acute distress. Labs were notable for beta-hydroxybutyrate of 3.3 mmol/L, lactate 1.0 mmol/L, HbA1c 7.3%, TSH 3.16 mIU/L, Na 136 mmol/L, K 4 mmol/L, Cl 105 mmol/L, serum bicarbonate 18 mmol/L, glucose 97 mg/dL, creatinine 0.49 mg/dL, eGFR >90 mL/min/1.73m(2), anion gap of 13 mmol/L. Patient was found to be in euglycemic DKA and was started on IV insulin with fluid resuscitation per protocol. Endocrinology was consulted as labs demonstrated worsening, with Na 135 mmol/L, serum bicarbonate 17 mmol/L, glucose 166 mg/dL. At this point patient had just started tolerating PO intake, no fetal distress was observed. We recommended continuation of treatment for a total of 24 hours, with subsequent normalization of labs and resolution of nausea. Patient was transitioned to home insulin pump with recommendation to snack frequently between meals and was discharged home with outpatient follow up. Upon follow up, patient did not experience recurrence of DKA but had been induced at 33 weeks due to pre-eclampsia, successfully giving birth to a live baby girl with Apgar scores of 5/6. CONCLUSIONS: EDKA is a rare but easily missed diagnosis that is important to treat particularly in a pregnant patient, as risks of fetal demise are high. Serum or urine ketones should be checked in any hospitalized diabetic patient regardless of symptoms or other laboratory indicators. Triggers of EKDA in a state of pregnancy can include brief periods of fasting, infection, stress, and dehydration. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.