Background
Euglycaemic ketoacidosis (EKA) is an infrequent but serious condition which usually follows a period of starvation, severe vomiting or illness in individuals with or without diabetes. Ketoacidosis is associated with materno-fetal morbidity and mortality necessitating prompt diagnosis and management. Physiological increases in insulin resistance render pregnancy a diabetogenic state with increased susceptibility to ketosis. COVID-19 is associated with worse clinical outcomes in patients with diabetes and is an independent risk factor for ketoacidosis in normoglycaemic individuals.
Case presentations
We describe two cases of SARS-CoV-2 positive pregnant women presenting with normoglycaemic metabolic ketoacidosis. Both cases were associated with maternal and fetal compromise, requiring aggressive fluid and insulin resuscitation and early delivery.
Conclusion
We discuss possible physiology and propose a management strategy for euglycaemic ketoacidosis in pregnancy.
ABSTRACT:Although a direct relationship between numerical-allocation and spatial-attention has been proposed, recent research suggests these processes are not directly coupled. In keeping with this, spatial attention shifts induced either via visual or vestibular motion can modulate numerical allocation in some circumstances but not in others. In addition to shifting spatial attention, visual or vestibular motion-paradigms also (i) elicit compensatory eye-movements which themselves can influence numerical-processing and (ii) alter the perceptual-state of-"self", inducing changes in bodily self-consciousness impacting upon cognitive mechanisms.Thus, the precise mechanism by which motion modulates numerical-allocation remains unknown. We sought to investigate the influence that different perceptual experiences of motion have upon numerical magnitude allocation whilst controlling for both eyemovements and task-related effects. We first used optokinetic visual-motion stimulation (OKS) to elicit the perceptual experience of either "visual world" or "self"-motion during which eye movements were identical. In a second experiment we used a vestibular protocol examining the effects of perceived and subliminal angular rotations in darkness, which also provoked identical eye movements. We observed that during the perceptual experience of "visual-world" motion, rightward OKS biased judgments towards smaller numbers, whereas leftward OKS biased judgments towards larger numbers. During the perceptual experience of "self-motion", judgments were biased towards larger numbers irrespective of the OKS direction. Contrastingly, vestibular motion perception was found not to modulate numerical magnitude allocation, nor was there any differential modulation when comparing "perceived" versus "subliminal" rotations. We provide a novel demonstration that magnitude-allocation can be differentially modulated by the perceptual state of-self during visual-motion.
Mode of delivery and intrapartum analgesia for women with Chiari I malformation pose a challenge to the obstetrician and anaesthetist. Clinicians often advocate caesarean section delivery under general anaesthetic to prevent an uncontrolled rise in intracranial pressure or a fall in cerebrospinal fluid pressure during labour that may result in neurological complications, or rarely, brainstem herniation. This case report discusses a woman with hitherto undiagnosed Chiari I malformation who delivered by CS due to obstetric concerns, but remained asymptomatic throughout the preceding labour and in spite of multiple epidural insertion attempts. We discuss considerations for future pregnancies, and review the literature to challenge the view that women with Chiari I need planned caesarean or must avoid epidural/spinal analgesia; instead presenting evidence to support the safety and suitability of vaginal delivery and neuroaxial block in labouring parturients with this condition.
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