Multidisciplinary Management and Anesthesia Considerations for Diabetic Ketoacidosis With Hypertriglyceridemic Acute Pancreatitis in Pregnancy: A Case Report

Abstract

Patient: Female, 28-year-old

Final Diagnosis: Acute pancreatitis • diabetic ketoacidosis

Symptoms: Abdominal pain

Clinical Procedure: —

Specialty: Critical Care Medicine • Metabolic Disorders and Diabetics • Obstetrics and Gynecology

Objective: Unusual clinical course

Background

Pregnancy complicated by diabetic ketoacidosis (DKA) and hypertriglyceridemic acute pancreatitis (HTG-AP) is a grave and life-threatening emergency for both the expectant mother and the fetus. Physiological insulin resistance and dyslipidemia during pregnancy exacerbate these conditions, creating a vicious cycle of metabolic derangements and systemic inflammation. Multidisciplinary collaboration is critical for prompt diagnosis and tailored management to improve maternal-fetal outcomes.

Case Report

We present a case of a 28-year-old pregnant woman with a history of gestational diabetes mellitus who developed DKA and HTG-AP at 32 weeks 4 days of gestation, necessitating an emergency cesarean section. A multidisciplinary team implemented a joint management protocol for DKA and HTG-AP, including rapid fluid resuscitation, insulin infusion for glycemic control, electrolyte correction, and emergency cesarean section. Anesthesia management comprised general anesthesia with endotracheal intubation combined with transversus abdominis plane block, along with dynamic monitoring of acid-base homeostasis through serial intraoperative arterial blood gas analyses (n=5). The neonate exhibited significant improvement in Apgar scores following resuscitation, while the mother was transferred to the ICU postoperatively and achieved full recovery after 8 days of comprehensive treatment.

Conclusions

This case shows that DKA and HTG-AP during pregnancy constitute critical conditions requiring multidisciplinary collaboration to enable rapid diagnosis, personalized interventions, and precise anesthesia management, all of which are pivotal determinants of improved prognosis.

Introduction

Diabetic ketoacidosis (DKA) and hypertriglyceridemic acute pancreatitis (HTG-AP) during pregnancy are critical, life-threatening conditions that endanger maternal and fetal safety [1,2]. Their complex and intertwined pathophysiological mechanisms can rapidly progress to multi-organ dysfunction, leading to fetal distress, preterm birth, and even perinatal mortality [3]. When coexisting, metabolic acidosis, insulin resistance, and systemic inflammatory response syndrome (SIRS) form a vicious cycle, exacerbating hemodynamic instability and placental hypoperfusion, thereby posing formidable challenges in clinical management [4]. Currently, standardized protocols for optimizing the care of such cases are lacking, necessitating multidisciplinary collaboration (involving obstetrics, endocrinology, anesthesiology, critical care, and neonatology) to develop individualized intervention strategies. Moreover, anesthesia management must balance maternal hemodynamic stability with fetal safety, where dynamic blood gas monitoring and judicious application of regional nerve block techniques are pivotal for optimizing maternal and neonatal outcomes. This article presents a critical case of a 32-week+4-day gestation patient with concurrent DKA and HLP, exploring the practical experience of multidisciplinary rapid diagnosis, precision interventions, and anesthesia management to provide insights for clinical practice.

Case Report

The patient was a 28-year-old woman with a BMI of 34.9 kg/m², at 32 weeks 4 days of gestation, admitted to the Department of Gastroenterology due to persistent epigastric pain lasting 24 hours. She had a history of gestational diabetes mellitus 4 years earlier, but her blood glucose levels had been well controlled during her hospitalization at that time.

However, she had not undergone prenatal testing before this admission, so we do not know her recent glycemic and blood pressure control. On admission, her body temperature was 37.5°C, heart rate was 158 beats per minute, and blood pressure was 166/91 mmHg. Blood tests were conducted, showing: pH 7.073,blood glucose 333 mg/dl, β-hydroxybutyrate (β-HB) >4.5 mmol/L, amylase 212 U/L, lipase 985 U/L, hemoglobin (Hb)153g/L, total leukocyte count 20 800/μL, sodium 126.1mmol/L, triglycerides 14.88 mmol/L, activated partial thromboplastin time (APTT) 35, prothrombin time, and international normalized ratio (PT/INR) 0.95. Her epigastric pain progressively worsened, accompanied by nausea, vomiting, chest tightness, and dyspnea. Fetal heart rate and uterine contraction monitoring demonstrated fetal tachycardia and recurrent late decelerations. After multidisciplinary consultation with the departments of Endocrinology, Obstetrics, and Critical Care Medicine, she was diagnosed with DKA and suspected HTG-AP according to the examination results. The medical team immediately initiated treatment for DKA and HTG-AP, including intravenous fluids, insulin therapy, and electrolyte replacement. After obtaining informed patient consent, we decided to perform emergency cesarean section due to fetal distress.

The anesthesiologist performed a rapid preoperative assessment of the patient. A bedside echocardiogram revealed normal cardiac function, and the patient’s family denied that she had any previous cardiopulmonary disorders. Given the urgency of the procedure, the potential inability of the patient to cooperate with positioning, and the need for postoperative ICU respiratory support, general anesthesia was chosen. The goals of anesthesia management were to maintain intraoperative electrolyte and acid-base balance, hemodynamic stability, and timely management of potential arrhythmias.

At this time, pH was 6.890 and the blood glucose was 365.8 mg/dl, so insulin therapy was continued while a sodium bicarbonate injection was administered. Upon arrival in the operating room, she underwent immediate vital signs monitoring, revealing blood pressure 100/57 mmHg and heart rate 160 bpm. She had impaired consciousness and respiratory distress. Fingertip oxygen saturation was only 85–88%. Nursing staff established 2 peripheral i.v. lines via 18-gauge indwelling needles, while the anesthesiologist performed radial artery cannulation for invasive blood pressure monitoring and prepared the autologous blood recovery. The neonatologist was present for neonatal assessment and resuscitation readiness.

Inhaled sevoflurane was administered alongside rapid sequence induction (RSI) with intravenous esketamine, propofol, and rocuronium, followed by tracheal intubation. The neonate was delivered smoothly within 2 minutes of anesthesia induction. After delivery, intravenous sufentanil was administered and a remifentanil infusion was initiated. The baby girl, weighing 3350 g, exhibited no hypoglycemia and decreased breath sounds bilaterally. The neonate’s 1-minute Apgar score was 6, prompting airway suctioning, positive-pressure ventilation, and thermal management under neonatologist guidance. The neonate’s condition improved, with a 5-minute Apgar score of 9. Arterial blood gas (ABG) analysis revealed no significant abnormalities, and the neonate was subsequently transferred to the neonatal intensive care unit (NICU) for ongoing observation. Intraoperatively, 300 mL of chylous fluid was recovered from the autologous blood salvage tank. This was suspected to be secondary to acute hyperlipidemic pancreatitis.

A total of 5 arterial blood gas analyses were performed during the operation to guide the adjustment of sodium bicarbonate infusion rate and ventilator parameters. Fluid resuscitation and insulin therapy were continued in conjunction with potassium supplementation. After completion of surgery, to reduce postoperative pain, a bilateral transversus abdominis plane (TAP) block was performed under ultrasound guidance. The patient’s endotracheal tube was not removed, and she was transferred to the ICU for continued care and management. Acute pancreatitis was confirmed by abdominal computed tomography (CT), and the mother was treated with fluid infusion, insulin and lipid-lowering. On postoperative day 1, after clinical evaluation, the endotracheal tube was removed. Subsequently, parenteral nutrition was stopped and replaced with enteral nutrition on postoperative day 3. The mother’s laboratory test results on day 8 were triglycerides 5.67 mmol/L, blood glucose 134.1 mg/dL, β-HB 0.52 mmol/L, lipase 298 U/L, amylase 165 U/L. Both mother and neonate were discharged in stable condition, and were reexamined at 7 days and 1 month after discharge, respectively, with all parameters within normal limits.

Discussion

DKA and HTG-AP are severe complications during pregnancy. Although rare, they can lead to critical maternal and fetal outcomes [1,2,4]. During pregnancy, physiological insulin resistance and dyslipidemia significantly increase the risk of DKA, while hypertriglyceridemia (serum triglycerides >11.3 mmol/L or >1000 mg/dL) has emerged as an important trigger for AP in pregnancy [5]. These conditions may form a vicious cycle of metabolic dysfunction and organ injury, in which excessive lipolysis in DKA exacerbates hypertriglyceridemia, while inflammatory cascades triggered by pancreatitis further aggravate insulin resistance and β-cell dysfunction [3]. Patients presenting with the triad of DKA, hypertriglyceridemia, and AP have significantly higher mortality rates and increased incidence of complications compared to those with other comorbidities [6]. Early recognition and prompt intervention based on laboratory and clinical findings are crucial for saving lives. Therefore, proactive prevention of DKA and HTG-AP is essential in pregnancy. This involves regular blood glucose monitoring, completing oral glucose tolerance tests (OGTT), and maintaining appropriate physical activity.

Currently, there are no detailed treatment guidelines for DKA during pregnancy complicated by HTG-AP. Notably, HTG-AP and DKA share common emergency management strategies, including fluid resuscitation, insulin therapy, triglyceride control, and electrolyte repletion. Aggressive intravenous fluid resuscitation is the critical first step in managing patients with HTG-AP complicated by DKA. The initial priority is to administer isotonic saline (0.9% NaCl) to restore intravascular volume and correct sodium deficits. This is often followed by a balanced crystalloid solution (eg, lactated Ringer’s solution) to help address the underlying metabolic acidosis and electrolyte imbalances. Continuous intravenous insulin infusion is essential to suppress ketogenesis, correct hyperglycemia, and lower triglyceride levels by inhibiting lipolysis. In severe cases presenting with complications such as oliguria, anuria, or refractory acidosis, continuous renal replacement therapy (CRRT) may be indicated. For HTG-AP, lipid emulsion should be avoided during parenteral nutrition support due to high triglyceride levels [7,8]. However, comprehensive management requires multidisciplinary collaboration due to the complexity of care.

DKA may potentially complicate the diagnosis, treatment, and clinical outcomes of HTG-AP [9]. Especially in pregnancy, abdominal pain manifested by HTG-AP can be easily masked, so physicians should be vigilant. Preoperative thorough evaluation guides meticulous anesthesia planning and sets intraoperative goals. Serial arterial blood gas analyses are critical for maintaining electrolyte and acid-base balance, and glycemic control, particularly in DKA patients. Typically, for cesarean section, neuraxial anesthesia is the first choice. With this method, the patient remains conscious, and it exerts no marked adverse effects on the fetus. Nevertheless, in the present case, given the emergency situation and the patient’s respiratory distress, general anesthesia with rapid sequence induction using esketamine, propofol, and rocuronium was performed. These agents have rapid onset without significant impacts on maternal hemodynamics or neonatal Apgar scores. Considering the potential risks of DKA and AP to both mother and fetus, the mother and neonate were transferred postoperatively to the ICU and NICU, respectively, for continued monitoring of glucose and biochemical parameters, and for specialized care.

Conclusions

Although the incidence of DKA complicated by HTG-AP in pregnancy is low, this condition carries significant risks for maternal and fetal outcomes. Consequently, prompt medical intervention combined with emergency cesarean section is often necessary. Detailed therapeutic protocols and anesthesia-surgical planning are needed for pregnant patients with DKA and AP.