A Case of Nondiabetic Ketoacidosis in Third Term Twin Pregnancy

Context: We report on a case of nondiabetic ketoacidosis due to mild starvation in a third term twin pregnancy. Objective: The aim was to present a case report and review of the literature in nondiabetic ketoacidosis in pregnancy, including precipitating factors and underlying pathophysiology. Design: The case report includes collation of earlier data and literature review. Setting: The patient was admitted to the obstetrics ward of a large general hospital and, after cesarean section, was transferred to the intensive care unit. Patient: We present the case of a 26-yr-old obese patient with a 35-wk twin pregnancy. Intervention: We provided appropriate management with fluid infusion after cesarean delivery. Results: The patient and her two daughters survived, and no disabilities were foreseen. Alcohol, methanol, and lactic acid levels were normal. No signs of renal disease or diabetes were present. Pathological examination revealed no abnormalities of the placentae. Toxicological tests revealed a salicylate level of less than 5 mg/liter, an acetaminophen level of less than 1 mg/liter, and an acetone level of 300 mg/liter (reference, 5-20 mg/liter). Conclusions: We present a case of third term twin pregnancy with high anion gap metabolic acidosis due to (mild) starvation. Starvation, obesity, third term twin pregnancy, and perhaps a gastroenteritis were the ultimate provoking factors. In the light of the erroneous suspicion of sepsis and initial fluid therapy lacking glucose, one wonders whether, under a different fluid regime, cesarean section could have been avoided. Severe ketoacidosis in the pregnant woman is associated with impaired neurodevelopment. It therefore demands early recognition and immediate intervention. (J Clin Endocrinol Metab 97: 3021-3024, 2012)