key: cord-0791584-b96qygv1
authors: Smati, Sarra; Moreau, Pascale Mahot; Bourdiol, Alexandre; Ploteau, Stéphane; Hadjadj, Samy; Cariou, Bertand
title: Euglycaemic ketoacidosis during gestational diabetes with concomitant COVID-19 infection
date: 2020-07-29
journal: Diabetes Metab
DOI: 10.1016/j.diabet.2020.07.008
sha: 55784117f839880c741e2efa57c1f49d31605e74
doc_id: 791584
cord_uid: b96qygv1

nan

Ketoacidosis is a severe acute complication usually arising in patients with type 1 diabetes (T1D) due to insulin deficiency. Although ketoacidosis is uncommon during pregnancy, its consequences can be serious and lead to fetal death.

A 36-year-old woman (gravida 9, para 7) from the Democratic Republic of the Congo was admitted at 32 weeks of gestation to the intensive care unit (ICU) for coronavirus disease 2019 (COVID-19) infection. Her biochemical characteristics on admission are detailed in Table I (Table I) .

Here, in this case report of a patient developing severe euglycaemic ketoacidosis during the third trimester of pregnancy, several risk factors were identified: gestational diabetes; acute starvation due to vomiting; and COVID-19 infection. While it has been well established that diabetes is one of the main comorbidities associated with severe forms of COVID-19, it remains unclear whether COVID-19 increases the risk of diabetic ketoacidosis. One case of inaugural ketoacidosis in T1D precipitated by COVID-19 infection has recently been reported [1] as well as a case series of diabetic ketoacidosis during COVID-19 infection [2] . Moreover, J o u r n a l P r e -p r o o f in a retrospective cohort of 658 patients hospitalized for COVID-19 [3] , 42 (6.4%) presented with ketosis on admission. Of those patients, only 15 (35%) had a history of diabetes.

During pregnancy, the production of certain hormones (prolactin, human placental lactogen, progesterone, cortisol) promotes insulin resistance and increases the risk of ketoacidosis. In addition, as reported here and by others, normal blood glucose levels can also be associated with ketoacidosis. Several mechanisms may contribute to this phenomenon. During pregnancy, glycogenolysis, lipolysis and ketogenesis are all increased during fasting [4] . These physiological changes can lead to accelerated starvation, with the result that diabetic ketoacidosis develops more quickly and at lower levels of blood glucose than in non-pregnant women. Furthermore, several cases of euglycaemic ketoacidosis in pregnant women have been reported. Starvation ketoacidosis is caused by short periods of fasting and may be precipitated by stressful conditions, such as a viral infectious disease [5] .

In conclusion, pregnancy must be considered a high-risk period for euglycaemic ketoacidosis even in non-diabetic women, particularly when associated with other stress factors such as an infectious disease. Ketone testing should be performed systematically in cases of vomiting in the third trimester to quickly establish the correct diagnosis and provide the appropriate treatment. In the context of COVID-19, which can worsen the clinical situation, all diabetologists should be especially aware of the possibility of euglycaemic ketoacidosis.

J o u r n a l P r e -p r o o f 

COVID-19 symptoms masking inaugural ketoacidosis of type 1 diabetes

Protracted ketonaemia in hyperglycaemic emergencies in COVID-19: a retrospective case series

COVID-19 infection may cause ketosis and ketoacidosis

ACCELERATED STARVATION" AND THE SKIPPED BREAKFAST IN LATE NORMAL PREGNANCY

Nondiabetic ketoacidosis in a pregnant woman due to acute starvation with concomitant influenza A (H1N1) and respiratory failure