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Dietary Advice to Support Glycaemic Control and Weight Management in Women with Type 1 Diabetes during Pregnancy and Breastfeeding. Nutrients 2022; 14:nu14224867. [PMID: 36432552 PMCID: PMC9692490 DOI: 10.3390/nu14224867] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/06/2022] [Accepted: 11/07/2022] [Indexed: 11/19/2022] Open
Abstract
In women with type 1 diabetes, the risk of adverse pregnancy outcomes, including congenital anomalies, preeclampsia, preterm delivery, foetal overgrowth and perinatal death is 2-4-fold increased compared to the background population. This review provides the present evidence supporting recommendations for the diet during pregnancy and breastfeeding in women with type 1 diabetes. The amount of carbohydrate consumed in a meal is the main dietary factor affecting the postprandial glucose response. Excessive gestational weight gain is emerging as another important risk factor for foetal overgrowth. Dietary advice to promote optimized glycaemic control and appropriate gestational weight gain is therefore important for normal foetal growth and pregnancy outcome. Dietary management should include advice to secure sufficient intake of micro- and macronutrients with a focus on limiting postprandial glucose excursions, preventing hypoglycaemia and promoting appropriate gestational weight gain and weight loss after delivery. Irrespective of pre-pregnancy BMI, a total daily intake of a minimum of 175 g of carbohydrate, mainly from low-glycaemic-index sources such as bread, whole grain, fruits, rice, potatoes, dairy products and pasta, is recommended during pregnancy. These food items are often available at a lower cost than ultra-processed foods, so this dietary advice is likely to be feasible also in women with low socioeconomic status. Individual counselling aiming at consistent timing of three main meals and 2-4 snacks daily, with focus on carbohydrate amount with pragmatic carbohydrate counting, is probably of value to prevent both hypoglycaemia and hyperglycaemia. The recommended gestational weight gain is dependent on maternal pre-pregnancy BMI and is lower when BMI is above 25 kg/m2. Daily folic acid supplementation should be initiated before conception and taken during the first 12 gestational weeks to minimize the risk of foetal malformations. Women with type 1 diabetes are encouraged to breastfeed. A total daily intake of a minimum of 210 g of carbohydrate is recommended in the breastfeeding period for all women irrespective of pre-pregnancy BMI to maintain acceptable glycaemic control while avoiding ketoacidosis and hypoglycaemia. During breastfeeding insulin requirements are reported approximately 20% lower than before pregnancy. Women should be encouraged to avoid weight retention after pregnancy in order to reduce the risk of overweight and obesity later in life. In conclusion, pregnant women with type 1 diabetes are recommended to follow the general dietary recommendations for pregnant and breastfeeding women with special emphasis on using carbohydrate counting to secure sufficient intake of carbohydrates and to avoid excessive gestational weight gain and weight retention after pregnancy.
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Kachaner A, Rives-Lange C, Radu A, Czernichow S, Ranque B, Pouchot J, Lafont E. Ketoacidosis in a non-diabetic lactating woman: A case report and literature review. Eur J Clin Nutr 2021; 76:775-777. [PMID: 34675399 DOI: 10.1038/s41430-021-01013-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 09/15/2021] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Alexandra Kachaner
- Université de Paris, Paris, France.,Service de médecine interne, Hôpital Européen Georges-Pompidou, Paris, France
| | - Claire Rives-Lange
- Université de Paris, Paris, France.,Service de nutrition, Hôpital Européen Georges-Pompidou, Paris, France
| | - Alina Radu
- Université de Paris, Paris, France.,Service de nutrition, Hôpital Européen Georges-Pompidou, Paris, France
| | - Sebastien Czernichow
- Université de Paris, Paris, France.,Service de nutrition, Hôpital Européen Georges-Pompidou, Paris, France
| | - Brigitte Ranque
- Université de Paris, Paris, France.,Service de médecine interne, Hôpital Européen Georges-Pompidou, Paris, France
| | - Jacques Pouchot
- Université de Paris, Paris, France.,Service de médecine interne, Hôpital Européen Georges-Pompidou, Paris, France
| | - Emmanuel Lafont
- Université de Paris, Paris, France. .,Service de médecine interne, Hôpital Européen Georges-Pompidou, Paris, France.
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3
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Marzban S, Arbee M, Vorajee N, Richards GA. Non-diabetic ketoacidosis associated with a low carbohydrate, high fat diet in a postpartum lactating female. Oxf Med Case Reports 2020; 2020:omz026. [PMID: 32793371 PMCID: PMC7416821 DOI: 10.1093/omcr/omz026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 01/21/2019] [Accepted: 03/02/2019] [Indexed: 12/18/2022] Open
Abstract
A 31-year old non-diabetic woman presented to our hospital with symptoms of dehydration, drowsiness, fatigue, shortness of breath and vomiting present for two consecutive days prior to admission. She had started a low carbohydrate, high fat (LCHF) diet to induce weight loss while breastfeeding her 4-month-old child 2 weeks prior to admission. The patient was found to have a severely high anion gap metabolic acidosis. It was determined to be due to ketoacidosis, which was as a result of carbohydrate restriction in the presence of increased metabolic demands related with the synthesis and secretion of milk. She denied alcohol use or ingestion of any drugs prior to admission. The patient underwent dialysis and received insulin, 5% dextrose water alongside a well-balanced diet with adequate calories. All abnormal laboratory results normalized and follow-up visits were done. Lactating women are at risk of developing ketoacidosis due to high metabolic demands of the body to produce milk. LCHF diets may exacerbate the body's demand to meet its milk production requirement and result in ketoacidosis. Health professionals need to be aware of the complications of LCHF diet in this population to prevent mortality associated with this condition.
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Affiliation(s)
- Saba Marzban
- Clinical Pharmacy, Netcare Christiaan Barnard Memorial Hospital, Cape Town, South Africa
| | - Mohamed Arbee
- Clinical Haematology, Netcare Garden City Hospital, Johannesburg, Gauteng, South Africa
| | - Naseema Vorajee
- Division of Pathology, National Institute for Occupational Health, National Health Laboratory Services, Johannesburg, Gauteng, South Africa
| | - Guy A Richards
- Division of Critical Care Charlotte Maxeke Hospital and University of the Witwatersrand, Faculty of Health Sciences
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Castellanos L, Tuffaha M, Koren D, Levitsky LL. Management of Diabetic Ketoacidosis in Children and Adolescents with Type 1 Diabetes Mellitus. Paediatr Drugs 2020; 22:357-367. [PMID: 32449138 DOI: 10.1007/s40272-020-00397-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Diabetic ketoacidosis (DKA) is the end result of insulin deficiency in type 1 diabetes mellitus (T1D). Loss of insulin production leads to profound catabolism with increased gluconeogenesis, glycogenolysis, lipolysis, and muscle proteolysis causing hyperglycemia and osmotic diuresis. High levels of counter-regulatory hormones lead to enhanced ketogenesis and the release of 'ketone bodies' into the circulation, which dissociate to release hydrogen ions and cause an overwhelming acidosis. Dehydration, hyperglycemia, and ketoacidosis are the hallmarks of this condition. Treatment is effective repletion of insulin, fluids and electrolytes. Newer approaches to early diagnosis, treatment, and prevention may diminish the risk of DKA and its childhood complications including cerebral edema. However, the potential for some technical and pharmacologic advances in the management of T1D to increase DKA events must be recognized.
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Affiliation(s)
- Luz Castellanos
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA
| | - Marwa Tuffaha
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA
| | - Dorit Koren
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA
| | - Lynne L Levitsky
- Division of Pediatric Endocrinology and Pediatric Diabetes Center, Massachusetts General Hospital, 175 Cambridge Street, 5th Floor, Boston, MA, 02114, USA.
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Ringholm L, Stougaard EB, Nørgaard SK, Damm P, Mathiesen ER. Diabetes Management During Breastfeeding in Women with Type 1 Diabetes. Curr Diab Rep 2020; 20:34. [PMID: 32562097 DOI: 10.1007/s11892-020-01315-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW To provide an update on glycemic management of type 1 diabetes during breastfeeding with focus on diet and insulin treatment to prevent hypoglycemia, ketoacidosis, and weight retention. Recommendations for insulin pump settings are given. RECENT FINDINGS Women with type 1 diabetes are encouraged to breastfeed. Hypoglycemia is a concern in the breastfeeding period among women with type 1 diabetes, and ketoacidosis may also occur. The usual goals for glucose values for persons with diabetes also apply during breastfeeding. The recommended minimum daily carbohydrate intake is 210 g during breastfeeding, and this may contribute to prevention of hypoglycemia and ketoacidosis while aiming for gradual weight loss. Insulin requirements are 21% lower during breastfeeding than before pregnancy. Diabetes management in breastfeeding women with type 1 diabetes includes the same goals for glucose values as in other persons with diabetes, sufficient carbohydrate intake, and adequate reduction in insulin dose.
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Affiliation(s)
- Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
- Steno Diabetes Center Copenhagen, Niels Steensens Vej 2, DK-2820, Gentofte, Denmark.
| | | | - Sidse Kjærhus Nørgaard
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
- Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Lactation Ketoacidosis: A Systematic Review of Case Reports. ACTA ACUST UNITED AC 2020; 56:medicina56060299. [PMID: 32560535 PMCID: PMC7353886 DOI: 10.3390/medicina56060299] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 12/29/2022]
Abstract
Background and Objective: Lactation ketoacidosis is a rare cause of high anion gap metabolic acidosis affecting breastfeeding mothers. We aim to review and analyze all cases of lactation ketoacidosis reported. Materials and Methods: A systematic search of PubMed/MEDLINE and Cumulative Index to Nursing and Allied Health Literature (CINAHL), identifying relevant case reports published from 1 January 1970 to 31 December 2019. We extracted the following data: the first author, country, year of publication, age of the mother, age of the child, weight/body mass index (BMI) of the mother, precipitating factors, presenting symptoms, biochemical results, treatment, breastfeeding, and time from presentation to the resolution of ketoacidosis. Results: Sixteen case reports and 1 case series reporting 18 cases of lactation ketoacidosis were found. Presenting symptoms were nausea (72%, 13/18), vomiting (67%, 12/18), malaise (56%, 10/18), abdominal pain (44%, 8/18), dyspnea (33%, 6/18), headache (22%, 4/18), and palpitation (11%, 2/18). Dieting and physical exercise to lose weight were reported in 76% (14/18). The treatments included IV dextrose, sodium bicarbonate, insulin, rehydration, monitoring and replacement of electrolytes, and resumption of a balanced diet. The prognoses were good, with no mortalities. Conclusions: lactation ketoacidosis should be suspected in unwell breastfeeding women with high anion gap metabolic acidosis, after excluding other causes.
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Al Alawi AM, Al Amri U, Falhammar H. Lactation Ketoacidosis: A case series. Sultan Qaboos Univ Med J 2019; 19:e359-e363. [PMID: 31897320 PMCID: PMC6930031 DOI: 10.18295/squmj.2019.19.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 09/23/2019] [Accepted: 10/24/2019] [Indexed: 11/25/2022] Open
Abstract
Lactation ketoacidosis is an extremely rare type of high anion gap metabolic acidosis. We report two lactating women who were diagnosed with lactation ketoacidosis. The first patient presented to the Emergency Department at Royal Darwin Hospital, Darwin, Australia, in 2018 with lethargy, nausea and abdominal pain after she commenced a new diet regimen based on three meals of protein per day and free of glucose, gluten and dairy products. The second patient presented to the Emergency Department at Sultan Qaboos University Hospital, Muscat, Oman, in 2018 with headache, severe malaise, epigastric pain and worsening of gastroesophageal symptoms. Blood investigation results showed that both patients had high anion gap metabolic acidosis, ketosis and hypoglycaemia. The patients responded well to intravenous dextrose and resumption of a balanced diet. Both patients were able to continue breastfeeding and remained well on follow-up.
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Affiliation(s)
| | - Usama Al Amri
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
| | - Henrik Falhammar
- Division of Medicine, Royal Darwin Hospital, Darwin, Australia.,Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden.,Menzies School of Health Research, Darwin, Australia
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Ketogenic Diet-Induced Severe Ketoacidosis in a Lactating Woman: A Case Report and Review of the Literature. Case Rep Nephrol 2019; 2019:1214208. [PMID: 31360561 PMCID: PMC6644245 DOI: 10.1155/2019/1214208] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/25/2019] [Accepted: 05/20/2019] [Indexed: 12/16/2022] Open
Abstract
The ketogenic diet (KD) is a high-fat, adequate-protein, and low-carbohydrate diet that leads to nutritional ketosis and weight loss. It is known to induce ketosis but is not an established cause of clinically significant ketoacidosis. Lactation ketoacidosis is well established in bovine literature but remains a rare phenomenon in humans. Here we present a life-threatening case of severe ketoacidosis in a nondiabetic lactating mother on a strict ketogenic diet. We review the available case reports of lactation ketoacidosis in humans and the mechanisms thereof. Although ketogenic diet has been shown to be safe in nonpregnant individuals, the safety of this diet in lactating mothers is not known. Health professionals and mothers should be made aware of the potential risk associated with a strict ketogenic diet when combined with lactation. Prompt diagnosis and immediate treatment cannot be overemphasized. To our knowledge, this is the first reported case of life-threatening lactation ketoacidosis associated with ketogenic diet while consuming an adequate number of calories per day.
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Seckold R, Fisher E, de Bock M, King BR, Smart CE. The ups and downs of low-carbohydrate diets in the management of Type 1 diabetes: a review of clinical outcomes. Diabet Med 2019; 36:326-334. [PMID: 30362180 DOI: 10.1111/dme.13845] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2018] [Indexed: 12/14/2022]
Abstract
Dietary management has been a mainstay of care in Type 1 diabetes since before the discovery of insulin when severe carbohydrate restriction was advocated. The use of insulin facilitated re-introduction of carbohydrate into the diet. Current management guidelines focus on a healthy and varied diet with consideration of glycaemic load, protein and fat. As a result of frustration with glycaemic outcomes, low-carbohydrate diets have seen a resurgence in popularity. To date, low-carbohydrate diets have not been well studied in the management of Type 1 diabetes. Studies looking at glycaemic outcomes from low-carbohydrate diets have largely been cross-sectional, without validated dietary data and with a lack of control groups. The participants have been highly motivated self-selected individuals who follow intensive insulin management practices, including frequent blood glucose monitoring and additional insulin corrections with tight glycaemic targets. These confounders limit the ability to determine the extent of the impact of dietary carbohydrate restriction on glycaemic outcomes. Carbohydrate-containing foods including grains, fruit and milk are important sources of nutrients. Hence, low-carbohydrate diets require attention to vitamin and energy intake to avoid micronutrient deficiencies and growth issues. Adherence to restricted diets is challenging and can have an impact on social normalcy. In individuals with Type 1 diabetes, adverse health risks such as diabetic ketoacidosis, hypoglycaemia, dyslipidaemia and glycogen depletion remain clinical concerns. In the present paper, we review studies published to date and provide clinical recommendations for ongoing monitoring and support for individuals who choose to adopt a low-carbohydrate diet. Strategies to optimize postprandial glycaemia without carbohydrate restriction are presented.
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Affiliation(s)
- R Seckold
- Department of Paediatric Diabetes and Endocrinology, John Hunter Children's Hospital, Newcastle, NSW
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
| | - E Fisher
- Department of Paediatric Diabetes and Endocrinology, John Hunter Children's Hospital, Newcastle, NSW
| | - M de Bock
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - B R King
- Department of Paediatric Diabetes and Endocrinology, John Hunter Children's Hospital, Newcastle, NSW
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
| | - C E Smart
- Department of Paediatric Diabetes and Endocrinology, John Hunter Children's Hospital, Newcastle, NSW
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, Australia
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Abstract
BACKGROUND Metabolic acidosis refers to any process that increases the hydrogen ions in the body and reduces the bicarbonate concentration. Metabolic acidosis is subdivided based on presence of anion gap (AG), and AG metabolic acidosis is most often due to ketoacidosis, lactic acidosis, renal failure, or toxic ingestions. AG metabolic acidosis is frequently encountered in the clinical practice. Rarely, the underlying cause of the AG metabolic acidosis is considered a diagnostic dilemma as the established algorithm allows the physicians to identify the etiology. CASE PRESENTATION A fifty-three-year-old Black woman with well-controlled human immunodeficiency virus (HIV), hypertension, and asthma presented with recurrent episodes of severe anion gap metabolic acidosis. The patient's AG metabolic acidosis always corrected with the administration of intravenous normal saline. Laboratory studies were always negative for common causes of acidosis. CONCLUSION Nucleoside reverse transcriptase inhibitors-associated lactic acidosis has been reported in the literature. The shift to anaerobic mitochondrial metabolism induced by the HIV medications used in this patient could be explain the recurrent severe metabolic acidosis.
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Al Alawi AM, Falhammar H. Lactation ketoacidosis: case presentation and literature review. BMJ Case Rep 2018; 2018:bcr-2017-223494. [PMID: 29848523 DOI: 10.1136/bcr-2017-223494] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 35-year-old woman presented to the emergency department with a 2 days history of malaise and headache. She was breastfeeding her 5-month old infant and had recently started an altered diet based on reducing carbohydrate amount. Moreover, she had also started exercising 2 weeks prior to her illness. Initial blood tests revealed high anion gap metabolic acidosis and hypoglycaemia (pH 7.13 (normal 7.30-7.40), bicarbonate 9.4 mmol/L (normal 21.0-28.0), anion gap 22.6 mmol/L (normal 8-12), glucose 2.9 mmol/L (normal fasting 3.9-5.8) and ketones 6.4 mmol/L (normal <0.6)). The patient was treated with intravenous dextrose and showed complete resolution of ketoacidosis and hypoglycaemia within 48 hours. She was discharged home and remained well with a balanced diet. After excluding all other the causes of hypoglycaemia and ketoacidosis, the diagnosis of lactation ketoacidosis was made and it was considered triggered by altered diet, exercise and skipping meals. All 11 cases of lactation ketoacidosis which has previously been published are reviewed as well.
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Affiliation(s)
- Abdullah M Al Alawi
- Royal Darwin Hospital, Casuarina, Australian Capital Territory, Australia.,Department of Medicine, Sultan Qaboos University, A'Seeb, Muscat, Oman
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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