Acute starvation ketoacidosis in pregnancy with severe hypertriglyceridemia: A case report

The combination of type 1 diabetes and eating disorder during pregnancy

The problem of eating disorders currently holds a special place in clinical practice. Bulimia nervosa is one of the main forms of eating disorders, characterized by the difficulty in its treatment and a long, recurrent course. Eating disorders are common in patients with type 1 diabetes mellitus (T1D), especially in adolescent girls.

In this article, we present a clinical case of a patient with T1D and bulimia nervosa, which developed before the manifestation of T1D and progressed against its background. The patient is overly concerned with controlling body weight, specifically restricted the intake of carbohydrates, forcibly caused vomiting. During pregnancy fasting ketonuria («low-carb ketone») was repeatedly detected. The minimum weight was 37 kg (BMI 15.2 kg/m2). Particular interest of this case is the course of pregnancy, which ended in the antenatal death. The possible cause could be the restriction on carbohydrate food and prolonged stay in ketosis, that might lead to the development of pregnancy pathology. Additional examination also revealed multiple complications of diabetes and recurrent depressive disorder, which requires conjoint monitoring by an endocrinologist and a psychiatrist.

Combination of T1D and eating disorder in a pregnant patient should be considered as an atypical course of the disease.

Effect of Continuous Subcutaneous Injection of Insulin Analogues in Pregnant Women with Diabetes Mellitus Complicated with Ketoacidosis

OBJECTIVE

To investigate the clinical effect of continuous subcutaneous injection of insulin analogues in pregnant women with diabetes mellitus complicated with ketoacidosis.

METHODS

A total of 92 pregnant patients with diabetes mellitus complicated with ketoacidosis from June 2014 to January 2021 were selected. All patients were randomly divided into an observation group and control group according to the method of random number. The control group received intravenous infusion of insulin, and the observation group received continuous subcutaneous infusion of quick-acting insulin analogues. The clinical effects of the two groups were observed.

RESULTS

The time needed to control blood glucose <13.8 mmol/L, the amount of insulin needed to control blood glucose <13.8 mmol/L, the time needed to correct DKA, and the amount of insulin needed to correct DKA in the observation group were significantly less than those in the control group (P < 0.05). Compared with the control group, the average occurrence times of hypoglycemia, the length of stay, the total amount of insulin in hospital, and the total amount of insulin used during pregnancy in the observation group were significantly less than those in the control group (P < 0.05). The values of SCr, CRP, BUN, arterial blood gas pH, and adiponectin in the two groups were significantly improved as compared with those before treatment, and the improvement in the observation group was significantly better than that in the control group (P < 0.05). After treatment, the fasting blood glucose, 2-hour postprandial blood glucose, carbon dioxide binding capacity, and glycosylated hemoglobin in the experimental group were significantly better than those in the routine group, and the difference was statistically significant (P < 0.05).

CONCLUSION

Continuous subcutaneous injection of insulin analogues is effective in the treatment of diabetic patients with ketoacidosis, which can effectively improve blood glucose, carbon dioxide binding capacity, and glycosylated hemoglobin and accelerate the negative conversion of urinary ketone body. It is worth popularizing to reduce the occurrence of hypoglycemia and the dose of insulin and shorten the time of hospitalization.

The Role of Short-Chain Fatty Acids in Mediating Very Low-Calorie Ketogenic Diet-Infant Gut Microbiota Relationships and Its Therapeutic Potential in Obesity

As the very low-calorie ketogenic diet (VLCKD) gains increased interest as a therapeutic approach for many diseases, little is known about its therapeutic use in childhood obesity. Indeed, the role of VLCKD during pregnancy and lactation in influencing short chain fatty acid (SCFA)-producing bacteria and the potential mechanisms involved in the protective effects on obesity are still unclear. Infants are characterized by a diverse gut microbiota composition with higher abundance of SCFA-producing bacteria. Maternal VLCKD during pregnancy and lactation stimulates the growth of diverse species of SCFA-producing bacteria, which may induce epigenetic changes in infant obese gene expression and modulate adipose tissue inflammation in obesity. Therefore, this review aims to determine the mechanistic role of SCFAs in mediating VLCKD-infant gut microbiota relationships and its protective effects on obesity.

Ketoacidosis in a non-diabetic lactating woman: A case report and literature review

We report the case of a 36-year-old woman who developed non-diabetic ketoacidosis following a low carbohydrate diet in order to lose weight while actively breast feeding her newborn. She was admitted in intensive care unit because of severe metabolic acidosis. She rapidly recovered after refeeding process. Lactation ketoacidosis, a special condition that occurs in non-diabetic breastfeeding women, is rare and life-threatening. This report highlights the importance of nutritional education of lactating women in the post-partum period.

Non-diabetic ketoacidosis: a case series and literature review

The genesis of ketone bodies by organisms is a protective mechanism. This metabolic process helps organisms to survive acute metabolic derangements in times of nutrient deficiency. When prolonged, ketogenesis leads to ketoacidosis, which is a potentially life-threatening metabolic disorder due to the accumulation of keto-acids in the body. The most common cause is diabetic ketoacidosis, though starvation ketoacidosis and alcoholic ketoacidosis are not uncommon. The presentation of all ketoacidotic states is similar—being generally unwell, abdominal pain, rapid and shallow breathing, vomiting and dehydration. Non-diabetic ketoacidotic states are very commonly overlooked due to relative unawareness among the clinicians, leading to misdiagnosis and thereby inappropriate management culminating in added mortality and morbidity. We describe here six cases of alcoholic and starvation ketoacidosis, review the literature currently available and discuss the common pitfalls in managing such cases.

Intrapartum Results on Differing Degrees of Ketonuria in Nulliparous Women with Gestational Diabetes Mellitus during Spontaneous Labor

To compare intrapartum results associated with differing degrees of ketonuria in nulliparous women with gestational diabetes mellitus (GDM), we implemented a retrospective cohort study comparing clinical characteristics among differing degrees of ketonuria and the duration and distribution of ketonuria at different stages of labor. We also analyzed adverse maternal and neonatal outcomes for each group. A total of 570 GDM deliveries were included; of these, 238 had negative ketonuria (41.8%), 180 had moderate ketonuria (31.6%), and 152 had ketosis (26.6%). The proportion of patients with a family history of diabetes significantly increased as the degree of ketonuria increased (P < 0.001). Moreover, a significantly lower level of HOMA-IR (the insulin resistance index) was observed for the Negative group (P < 0.001). The triglyceride (TG) level was significantly higher in the Ketosis group (P < 0.001), and the total cholesterol (TC) levels significantly increased as the degree of ketonuria progressed (P < 0.001). There were also higher maternal blood sugar levels and a significantly higher proportion of oxytocin augmentation in ketonuria cases (P < 0.001). Over three-fourths of patients (75.6%) had a ketonuria duration of ≤2 hours in the Moderate group, 61.2% had a ketonuria duration of between 3 and 4 h in the Ketosis group, and most of the ketonuria cases resolved in the first stage of labor. As the degree of ketonuria progressed, we observed a significantly higher number of cases with fetal heart rate pattern III (FHR pattern III), meconium-stained amniotic fluid III (MSAF III), postpartum hemorrhages, prolonged labor, neonatal hypoglycemia, an umbilical cord arterial pH of <7.2, low Apgar scores, increased neonatal intensive care admissions, augmented forceps-assisted deliveries, and conversions to cesarean sections. The results showed that ketonuria is common during the intrapartum period and that the risk of adverse maternal and neonatal outcomes may increase when complicated with ketonuria.