P.129 Acute starvation ketoacidosis in third trimester with COVID-19

Introduction: Non-diabetic ketoacidosis has been reported in pregnancy and is often associated with emergency caesarean delivery. We present a case of a multiparous woman with profound starvation ketoacidosis in the third trimester. She responded well to treatment and underwent spontaneous vaginal delivery two weeks later.

Case Report: A 39-year-old woman (G11 P9+1) of 36 weeks gestation presented to the emergency department with a 5-day history of fevers, malaise and poor oral intake secondary to nausea and dysphagia. She was tachypnoeic (24 breaths/min) and tachycardic (130 beats/min) with normal oxygen saturations on air. She had no history of gestational diabetes, vomiting, or intentional drug overdose. Her admission venous blood gas was pH 7.19, HCO ₃ 11.4, BE -14.8, lactate 1.5. The calculated anion gap was 19. Serum salicylate, paracetamol and ethanol levels were undetectable. Urinary ketones were ++++. Other blood tests were within normal range apart from a slightly raised ALT (56 U/L) and ALP 199 U/L) but preserved liver synthetic function. Joint medical, obstetric and anaesthetic review deemed starvation ketoacidosis.

She was commenced with IV and oral bicarbonate replacement. This initially improved the pH, however ketones and anion gap were stagnant. Infusion of 10% glucose, alongside potassium replacement then resolved the ketoacidosis and tachycardia. Concurrently she had a positive SARS-CoV-2 with CXR findings. She had a negative CTPA and an unremarkable transthoracic echocardiogram. On Day 3, she developed refeeding syndrome with phosphate 0.36. IV replacement was commenced and dietitian review ensued. Daily CTGs were unremarkable. She was discharged on Day 5, and returned for a spontaneous vaginal delivery two weeks later.

Discussion: It is rare to see a significant acute starvation ketoacidosis in previously healthy young women. It may be seen in pregnancy, particularly in the third trimester, when women develop an increasing insulin resistance and tendency to ketosis. A case series of pregnant women in the third trimester with COVID-19 from Wuhan reported a high proportion (11 of 16) had significant ketonuria.¹ It seems likely that the anorexia associated with COVID-19 can put susceptible patients, like ours, at risk of profound acidosis. Starvation ketoacidosis resolves with intravenous glucose replacement. Treatment may avoid the need for operative delivery whilst the woman is unstable and acidotic. It is also important to monitor and replace potassium, magnesium, phosphate and calcium, as refeeding syndrome can develop after only short periods of starvation.