SUN-535 Recurrent Euglycemic DKA in Pregnancy, A Rare Phenomenon

Abstract Disclosure: P.J. Bhatt: None. A.R. Crawford: None. Euglycemic Diabetic Ketoacidosis (DKA) is commonly associated with SGLT-2 inhibitors, but is rare in pregnancy, only accounting for 17.6-30% of the 1-3% of DKA cases seen in in pregnant patients [1-3]. Maternal and fetal comorbidities are extremely high in patients with euglycemic DKA with up to 35% cases resulting in fetal death. In the mother, they are associated with increased rates of cardiac complications, acute renal failure, blood loss requiring transfusions, critical care procedures and other adverse maternal/fetal outcomes [4-6]. A 23-year-old female 36 weeks pregnant with a history of type I diabetes on an insulin pump (most recent hemoglobin A1c 7.8%) and recent COVID-19 infection 1 week prior presented with nausea, leg cramps, BP 152/88, beta-hydroxybutyrate (BHB) 0.67mmol/L [0-0.3], and was admitted for gestational hypertension observation. On presentation, she did not have acidosis, elevated anion gap, or hyperglycemia. Mildly elevated BHB was attributed to starvation ketosis. After being discharged home, she ate a grilled cheese sandwich and vomited 7 times. She developed worsening leg cramps and abdominal pain, and presented back to the ED the next morning. On arrival, labs showed blood glucose (BG) 144mg/dL, BHB 4.08mmol/L, anion gap 18 [<12], HCO3- 16mmol/L, lactate 2.0mmol/L [0.5-2.2], and VBG pH7.35/pCO2 31mmHg/ HCO3- 16.7mmol/L consistent with euglycemic DKA triggered by poor PO intake and recent viral infection. She was treated with IV fluids and insulin drip after which her symptoms resolved, VBG pH was 7.42, anion gap closed, HCO3- improved to 19mmol/L, and was transitioned back on her insulin pump. The next day, she was asymptomatic but labs showed an elevated anion gap 17, HCO3- of 16mmol/L, VBG with pH 7.36/ CO2 28mmHg/ HCO3- 15.7mmol/L, BHB 2.89mmol/L, BG 128mg/dL and she was again treated with IV fluids and insulin drip with resolution of her gap, BHB and HCO3- levels. She was continued on this regimen until early induction of labor with vacuum assistance and was successfully transitioned to an insulin pump after delivering a healthy female infant without complications. In pregnancy, insulin resistance from human placental lactogen, placental insulinase, cortisol, and progesterone, accelerated starvation from increased glucose consumption, and respiratory alkalosis with bicarbonate renal loss create a ketosis prone state. An increased metabolic rate and GFR further predispose women to ketosis at lower blood glucose levels, and can delay diagnosis and treatment, increasing the risk for adverse events [2,3,6-9]. Vomiting, inadequate calorie intake and infections in pregnancy are frequent precipitants. Moreover, studies have shown DKA in pregnancy is more common and severe in patients with type I diabetes mellitus as seen in our patient who had recurrent episodes [1,4, 9]. Prompt recognition and treatment are crucial to prevent maternal and fetal complications. Presentation: Sunday, July 13, 2025