Areia, AL

Marta, E

Moura, P

Name not available

Insulin dependent diabetes mellitus presenting as diabetic ketoacidosis during pregnancy

Repositório Institucional dos Hospitais da Universidade de Coimbra

143Acta Obstet Ginecol Port 2008;2(3):143-145Caso Clínico/Case ReportABStRACtType 1 diabetes mellitus seldom presents in the form of diabetic ketoacidosis during pregnancy. We report a case of a 20-year-old woman, presenting at 32 weeks gestation with hyperglycemia, heavy glycosuria and ketonuria. The unstable maternal condition together with a non-reassuring fetal status and unfavorable cervix led to the performance of a cesarean section. One year of follow-up con-firmed the diagnosis of type 1 diabetes mellitus. Obstetricians should be aware that pregnant women presenting with hyperglycemic symptoms need appropriate evaluation in order to rule out type1 diabetes mellitus. If this diagnosis is made, imme-diate treatment is required to prevent the high maternal and fetal morbidity associated with diabetic ketoacidosis. Key words: Type 1 Diabetes; Pregnancy; KetoacidosisIntRoduCtIonIf a diagnosis of diabetes is made in pregnancy, it is gestational diabetes. In this condition there is insulin resistance and insulin is insufficient to maintain a nor-mal glucose value but usually it is enough to prevent ketoacidosis episodes.Diabetic ketoacidosis as a form of appearance of type 1 diabetes in pregnancy is very rare. We report one such case.Insulin dependent diabetes mellitus presenting as diabetic ketoacidosis during pregnancyDiabetes Mellitus insulinodependente que se manifesta como cetoacidose diabética durante a gravidezAna Luísa Areia*,  Elvira Marta**, Paulo Moura***Maternidade Daniel de Matos, Hospitais da Universidade de Coimbra* Interna Complementar de Ginecologia / Obstetrícia ** Assistente hospitalar Graduada de Obstetrícia *** Professor Auxiliar de Obstetrícia da Faculdade de Medicina da univer-sidade de Coimbra. Director de Serviço de Obstetrícia da Maternidade Daniel de Matos.CASEA 20-year-old Caucasian European woman was ad-mitted in our department at 32 weeks gestation with preterm labour; she reported diminished fetal move-ments for the past 24 hours.There was neither past nor family history of diabe-tes mellitus or risk factor for developing gestational diabetes mellitus (GDM). She had been diagnosed with Crohn’s disease six years previously, but she had needed no medication during pregnancy.Previous antenatal progress in our hospital was un-remarkable with a normal 50 g glucose challenge test carried out at the 28th week. At the most recent check-up, 15 days before admission, glycosuria was absent. 144On admission she was hyperventilating and ke-totic. her pulse was 80 beats/minute and her supine blood pressure was 120/80 mmhg. heavy glycosuria and ketonuria were present. Random plasma glucose revealed a value of 618 mg/dl, with other biochemical parameters normal.Further history revealed that she had been hav-ing increased thirst and polyuria during the previous month, whose significance she failed to appreciate. The non-stress-test was non-reassuring and dem-onstrated regular contractions. ultrasound scan showed a fetus without malformations, with abdomi-nal circumference above the 90th percentile (LGA baby) and a normal biophysical profile.Tocolytic and corticoid therapy were initiated and intravenous insulin infusion was started. Re-hydrata-tion and electrolyte supplementation were adminis-tered.Despite continuous intravenous insulin infu-sion, plasma glucose values remained between 494 and 569 mg/dl. Twenty four hours after admission, a non-stress test revealed null variability and fetal ul-trasound found oedema of subcutaneous tissue and absence of fetal respiratory movements. umbilical artery doppler was still normal.Combining the severity of the mother’s condition with the non-reassuring fetal well-being and the un-favorable cervical score, a cesarean section was per-formed. A healthy 2410 g female infant was born who had no hypoglycemia episodes.Supplementary investigation revealed that serum insulin was zero; islet cells antibodies (ICA) were undetectable at that time, with positive values for an-tibodies to glutamate decarboxylase (anti-GAD) and IA2 antibodies. Glycosylated hemoglobin (hbA1c) was 10 %.In the puerperium, she continued with insulin ther-apy. Complementary results at that time revealed ICA positivity. And so on day three, a regimen of insulin treatment was started with the diagnosis of new onset insulin dependent diabetes mellitus.The patient is monitored in our institution, with good glycemic control under intensive insulin ther-apy (intermediate and ultra-fast insulin) 12 months after that ketoacidosis episode.CoMMEntThe literature reports some cases of type 1 diabetes mellitus (DM) developing during pregnancy, but those with ketoacidosis are scarce.Diabetes first appearing during pregnancy is clas-sified as gestational DM, a self-limiting disorder that usually terminates when pregnancy ends1. But type 1 DM commonly presents as a new diagnosis during the teenage years2.Diabetic ketoacidosis (DKA) in pregnancy, al-though rare, is a possible complication in both wom-en with GDM and pregnant women with preexisting DM1.Newly-developing type 1 DM first presenting in pregnancy as DKA has only been reported in the lit-erature eight times (reported in 15 cases). DKA is associated with high fetal morbimortal-ity (up to 90%), probably due to low placental blood flow during maternal hypovolemia2.It is known that pregnancy is a state of immuno-suppression (3). Type 1 DM can be seen as an organ specific autoimmune phenomena that rarely presents as DKA during pregnancy because of that immuno-suppressor effect. But DKA episodes could occur in the 3rd trimester owing to the loss of that effect in late pregnancy3.The genesis of rapid-onset islet-cell failure and resultant diabetes remains a controversial topic. Re-search suggests that the genesis may be related to recent viral infection and that susceptibility to the diabetogenic effects of a virus may be genetic. Cer-tain viral strains seem to have a special tropism for beta cells. Furthermore, toxins such as lead have been implicated in rapid-onset diabetes4. Our case had no history of either.Our patient showed normal progress at her ante-natal visits, but the elevated hbA1c concentration at presentation suggests that she was hyperglycemic for a few months before presenting with DKA. So, even though some authors argue that the 50g glucose challenge test can prevent DKA episodes1, our case was not an example. The pregnant woman exhibited symptoms of diabetes and hyperglycemia one month before presenting with DKA although she had a nega-Areia AL,  Marta E, Moura P145Acta Obstet Ginecol Port 2008;2(3):143-145tive test for diabetes. Once she developed symptoms of hyperglycemia, the time lapse to ketoacidosis was brief. She was proven to have type 1 DM and has re-mained insulin dependent since then.Pregnancy can predispose a patient to ketoacidosis in several ways. In the fasting state, the increased use of glucose by both the fetus and maternal units can lead to conversion to a catabolic metabolism. More-over, the production of diabetogenic hormones (hu-man placental lactogen, prolactin and cortisol) during pregnancy predisposes to DKA4. During pregnancy, conditions such as infection, β-sympathomimetic therapy and labour can increase endogenous cate-cholamine release, thereby contributing to the onset of DKA4.Some authors argue that ICA are predictors of type1 DM and that the stress of the third trimester of pregnancy could make the insulin deficiency mani-fest itself earlier than if the woman had not become pregnant2. Other authors consider that, besides being a diabetogenic condition itself, pregnancy may be an environmental factor that precipitates type 1 DM in susceptible patients5. Moreover, the presence of GAD when type 1 DM is diagnosed suggests a more rapid progression towards rapid islet β cell destruction5.Our experience should alert obstetricians to the fact that when a pregnant woman presents with hy-perglycemic symptoms, type1 DM should be ruled out and immediately treated to prevent the high ma-ternal and fetal morbidity associated with DKA. REfEREnCES1.    Robertson G, Wheatley T, Robinson RE. Ketoacidosis in pregnancy: an unusual presentation of diabetes mellitus. Case reports. Br J Obstet Gynaecol 1986; 93(10):1088-90.2.   Sills IN, Rapaport R. New-onset IDDM presenting with diabetic ketoacidosis in a pregnant adolescent. Diabetes Care 1994; 17(8):904-5. 3.     Ko GT, Chow CC, Li CY, Yeung VT, Cockram CS. Insulin-dependent diabetes mellitus presenting as diabetic ketoacidosis in pregnancy. Aust N z J Obstet Gynaecol 1995;35(3):321-2. 4.     O’Shaughnessy MJ, Beingesser KR, Khieu Wu. Diabetic ketoacidosis in pregnancy with a recent normal screening test. West J Med 1999; 170(2):115-8. 5.     Quatraro A, Consoli G, Magno M, Ceriello A, Giuliano D. Pregnancy as environmental factor precipitating IDDM. Diabetes Care 1989; 12(6):438-40. 

Insulin dependent diabetes mellitus presenting as diabetic ketoacidosis during pregnancy

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Repositório Institucional dos Hospitais da Universidade de Coimbra