key: cord-0818010-sfy1089d
authors: Wong, J.M.; Fawcett, E.; Bevan, A.; Tanqueray, T.
title: P.129 Acute starvation ketoacidosis in third trimester with COVID-19
date: 2021-06-09
journal: Int J Obstet Anesth
DOI: 10.1016/j.ijoa.2021.103127
sha: a8ab8f9e377cf9ad0e1785e1a9306a011b1d14e5
doc_id: 818010
cord_uid: sfy1089d

nan

Hospital, Cape Town, South Africa b New Somerset Hospital, Cape Town, South Africa ⇑ Corresponding author.

Introduction: Aortic regurgitation is usually well tolerated in pregnancy. However, the increase in after load due to severe preeclampsia may result in acute cardiac failure. We present a case of a patient with severe aortic regurgitation secondary to an undiagnosed quadricuspid aortic valve (QAV) in pregnancy complicated by severe preeclampsia.

Case Report: A 23-year-old unbooked primigravida was admitted at a tertiary centre at 27 weeks of gestation with shortness of breath, bilateral pleural effusions, elevated blood pressure and proteinuria. Four days after initiating treatment for preeclampsia, she developed pulmonary oedema and required an emergency caesarean section. The anaesthetist, suspicious of an underlying cardiac lesion due to an abnormal cardiac examination, performed a focused transthoracic echocardiogram (TTE) before induction of anaesthesia. This showed moderate to severe aortic regurgitation, an ejection fraction of >60%, no regional wall motion abnormalities, mild tricuspid and mitral regurgitation and large bilateral pleural effusions. General anaesthesia was commenced via modified rapid-sequence induction. An intraoperative point-of-care transoesophageal echocardiogram was performed which demonstrated an abnormal aortic valve with four cusps. Postoperatively, the patient was admitted, extubated, to the maternal high care unit and required further diuresis and continuous positive airway pressure before resolution of both preeclampsia and pulmonary oedema. Subsequent formal TTE confirmed a QAV with thickened valvular cusps and severe aortic regurgitation, mild tricuspid and pulmonary regurgitation, and normal ventricular function. Four months postpartum the patient was asymptomatic with a normal effort tolerance with occasional palpitations.

Discussion: A QAV is a rare congenital heart disease found in only 0.0059-0.0065% of people during TTE examination. 1 QAV predominantly causes aortic regurgitation, which tends to be well tolerated in pregnancy due to the decrease in after load provided by a decreased systemic vascular resistance. 2 It is not unusual for patients with undiagnosed cardiac lesions in lower-to-middle income countries to present in pregnancy to specialised cardiac services for the first time. Preeclampsia is also a common cause of maternal morbidity and mortality in South Africa. 3 The combination of these two pathologies may have significant adverse effects. The large increase in after load resulted in the patient developing pulmonary oedema. Point-of-care TTE was invaluable in the intraoperative management of this patient and contributed to the correct diagnosis and further therapy. 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.

Quadricuspid Aortic Valve: A Comprehensive Review

Pregnancy complicated by valvular heart disease: An update

Maternal death and Caesarean section in South Africa: Results from 2011-2013 saving mothers report of the national committee for confidential enquiries into maternal deaths

The metabolic and immunological characteristics of pregnant women with COVID-19 and their neonates