E022

Navigating Starvation Ketosis in Expectant Mothers with Gestational Diabetes Mellitus.

O Velicu, F Hussein, B Bhatt, A Uddaraju, A Unipan, E Phillips, H Hussain, S Godwin,

G Mlawa.

Barking, Havering and Redbridge University Hospitals NHS Trust.

Abstract

Introduction

Starvation ketosis occurs when available glucose stores are inadequate to meet metabolic demands, resulting in a compensatory breakdown of free fatty acids into ketone bodies. In pregnancy, this metabolic complication is uncommon but potentially life-threatening, and a history of gestational diabetes (GDM) can markedly accelerate its development. Prompt recognition and treatment of this condition is vital to prevent adverse maternal and foetal outcomes.

Case report

We present a case of a 30-year-old female that was 29 weeks pregnant with history of GDM managed by diet alone. She presented with a 6 day history of persistent vomiting and abdominal pain, on a background of previous appendectomy four years ago. Upon investigation, blood ketones were elevated without accompanying acidosis. The urinalysis revealed 4+ ketones, and blood ketones 1.6 mmol/L despite normo-glycaemia.

Initial management comprised of IV thiamine followed by IV dextrose and further imaging in view of her surgical history. MRI results displayed a small bowel obstruction secondary to postoperative adhesions. Despite conservative management, vomiting persisted and decision to operate was initiated, managed with sliding scale prior and during surgery. Adhesiolysis was successfully performed, freeing the obstructed small bowel. Post-operatively, the patient had resumed oral intake, with ketone levels decreasing to 0.1 mmol/L.

Discussion

This case highlights the importance of considering starvation ketosis in pregnant women with GDM, presenting with persistent vomiting, even in the absence of ketosis. Management in such cases can be multifactorial, involving both medical and surgical care. In such cases, administration of intravenous thiamine prior to dextrose is essential to prevent lactic acidosis and Wernicke’s encephalopathy. Prompt recognition and management of starvation ketosis is vital to ensuring positive maternal and foetal outcomes, preventing metabolic decompensation and impaired foetal development. The lack of local trust policy in managing starvation ketosis in pregnancy highlights the requirement of increased awareness into this under-recognised but potentially serious complication.

Conclusion

This case underscores the need for prompt recognition and early multidisciplinary involvement in cases of starvation ketosis, to enable optimal outcomes for maternal and foetal health.