Euglycaemic ketoacidosis in pregnant women with COVID-19: two case reports

Pikovsky, Margaret; Tan, Min Yi; Ahmed, Amanda; Sykes, Lynne; Agha-Jaffar, Rochan; Yu, Christina

doi:10.1186/s12884-021-03928-w

Cited by 16 publications

(22 citation statements)

References 31 publications

(32 reference statements)

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“…Among the included studies, 11 reported DKA and COVID-19 in children [ 8 , 11 , 22 , 30 , 34 , 44 , 45 , 56 , 61 , 66 , 72 ], 56 reported DKA and COVID-19 in adults [ 9 , 10 , 12 – 21 , 23 , 25 – 29 , 31 – 33 , 35 – 43 , 46 – 55 , 57 – 60 , 62 – 65 , 67 – 71 , 73 – 75 ], and only 1 study reported DKA and COVID-19 in both children and adults [ 24 ]. There were 54 case report [ 8 – 12 , 14 , 16 , 17 , 19 – 23 , 25 – 27 , 29 – 42 , 44 – 51 , 53 – 58 , 60 , 61 , 64 , 66 , 67 , 69 , 71 , 72 , 74 , 75 ], 10 case series [ 13 , 15 , 28 , 43 , 58 , 59 , 62 , 63 , 70 , 73 ...…”

Section: Resultsmentioning

confidence: 99%

“…The median random blood glucose level, HbA1c, pH, bicarbonate, and anion gap in all included patients at presentation were 507 mg/dl [IQR 399–638 mg/dl], 11.4% [IQR 9.9–13.5%], 7.16 [IQR 7.00–7.22], 10 mmol/l [IQR 6.9–13 mmol/l], and 24.5 mEq/l [18–29.2 mEq/l]; respectively. Five patients had blood glucose < 250 mg/dl at presentation (euglycemic DKA) [ 16 , 53 , 65 , 71 ]; one was on SGLT2 inhibitor medication [ 16 ] while seven patients had gestational diabetes mellitus [ 53 , 65 , 70 ].…”

Section: Resultsmentioning

confidence: 99%

“…The current meta-analysis is more comprehensive and included a total of 68 studies [ 8 – 75 ] including a total of 639 patients; whose details on final treatment outcome were available; in comparison to smaller sample size in previous meta-analyses [sample size: n = 45 and n = 21, respectively] [ 90 , 91 ]. The inclusion of 48 recently published studies [ 8 – 14 , 16 , 21 , 23 – 26 , 28 , 30 , 32 – 35 , 40 , 42 – 46 , 48 , 50 , 51 , 53 , 54 , 56 – 59 , 61 – 64 , 66 – 75 ] contributed to the refinement on evidence of the demographic, biochemical, and clinical characteristics; in addition to final therapy outcome in COVID-19 patients with DKA.…”

Section: Discussionmentioning

confidence: 99%

“…In our study, out of the 639 DKA patients infected with SARS-CoV-2, there was (n = 75, 11.7%) newly diagnosed diabetes mellitus cases at admission. Of these 75 cases, 22 had HbA1c > 9.0% (ranging from 9.5% to 17.4%) [ 8 , 9 , 11 , 12 , 20 , 22 , 33 – 35 , 39 , 40 , 44 , 45 , 53 , 56 , 67 , 69 ] and three of which had a BMI > 30 [ 44 , 69 ], suggesting these patients had undiagnosed diabetes mellitus and improbable was caused by SARS-CoV-2 infection. DKA in COVID-19 patients was the least to occur in newly diagnosed diabetes cases probably as a result of increased diabetes screening and early recognition, DKA now occurs more frequently in persons with established diabetes rather than at the time of the initial diagnosis [ 100 ].…”

Section: Discussionmentioning

confidence: 99%

“…Out of the 11 (1.7%) DKA cases infected with COVID-19 who were taking SGLT2 inhibitors, two patient [18.2%] were diagnosed with SGLT2-associated euglycemic DKA [blood glucose < 250 mg/dl at presentation] [ 16 , 48 ]; in addition to seven patients who had gestational diabetes mellitus [ 53 , 65 , 70 ]. Euglycemic DKA is a rare life-threatening complication associated with the use of SGLT2 inhibitors in patients with type 2 diabetes that may be unnoticed, particularly in COVID-19 pandemic, due to the absence of significant hyperglycaemia, delaying its treatment [ 16 ].…”

Section: Discussionmentioning

confidence: 99%

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Diabetic ketoacidosis in patients with SARS-CoV-2: a systematic review and meta-analysis

Alhumaid

Mutair

Alawi

et al. 2021

Diabetol Metab Syndr

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Background One possible reason for increased mortality due to SARS-CoV-2 in patients with diabetes is from the complication of diabetic ketoacidosis (DKA). Objectives To re-evaluate the association of SARS-CoV-2 and development of DKA and analyse the demographic and biochemical parameters and the clinical outcomes in COVID-19 patients with DKA. Design A systematic review and meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was followed. Methods Electronic databases (Proquest, Medline, Embase, Pubmed, CINAHL, Wiley online library, Scopus and Nature) were searched from 1 December 2019 to 30 June 2021 in the English language using the following keywords alone or in combination: COVID-19 OR SARS-CoV-2 AND diabetic ketoacidosis OR DKA OR ketosis OR ketonemia OR hyperglycaemic emergency OR hyperglycaemic crisis. We included studies in adults and children of all ages in all healthcare settings. Binary logistic regression model was used to explore the effect of various demographic and biochemical parameters variables on patient’s final treatment outcome (survival or death). Results Of the 484 papers that were identified, 68 articles were included in the systematic review and meta-analysis (54 case report, 10 case series, and 4 cohort studies). Studies involving 639 DKA patients with confirmed SARS-CoV-2 [46 (7.2%) were children and 334 (52.3%) were adults] were analyzed. The median or mean patient age ranged from < 1 years to 66 years across studies. Most of the patients (n = 309, 48.3%) had pre-existing type 2 diabetes mellitus. The majority of the patients were male (n = 373, 58.4%) and belonged to Hispanic (n = 156, 24.4%) and black (n = 98, 15.3%) ethnicity. The median random blood glucose level, HbA1c, pH, bicarbonate, and anion gap in all included patients at presentation were 507 mg/dl [IQR 399–638 mg/dl], 11.4% [IQR 9.9–13.5%], 7.16 [IQR 7.00–7.22], 10 mmol/l [IQR 6.9–13 mmol/l], and 24.5 mEq/l [18–29.2 mEq/l]; respectively. Mortality rate was [63/243, 25.9%], with a majority of death in patients of Hispanic ethnicity (n = 17, 27%; p = 0.001). The odd ratios of death were significantly high in patients with pre-existing diabetes mellitus type 2 [OR 5.24, 95% CI 2.07–15.19; p = 0.001], old age (≥ 60 years) [OR 3.29, 95% CI 1.38–7.91; p = 0.007], and male gender [OR 2.61, 95% CI 1.37–5.17; p = 0.004] compared to those who survived. Conclusion DKA is not uncommon in SARS-CoV-2 patients with diabetes mellitus and results in a mortality rate of 25.9%. Mortality key determinants in DKA patients with SARS-CoV-2 infection are individuals with pre-existing diabetes mellitus type 2, older age [≥ 60 years old], male gender, BMI ≥ 30, blood glucose level > 1000 mg/dl, and anion gap ≥ 30 mEq/l.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 3 more Smart Citations

Diabetic ketoacidosis in patients with SARS-CoV-2: a systematic review and meta-analysis

Alhumaid

Mutair

Alawi

et al. 2021

Diabetol Metab Syndr

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Euglycemic diabetic ketoacidosis and COVID‐19 management in a term pregnant patient; a case report

Mohammadzade

Khodabakhshi

Amiri

et al. 2022

Clinical Case Reports

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Diabetic acidosis with severe fetal hypoxia in pregnancy: Narrative review and case study

Mam‐Lam‐Fouck,

Cheloufi,

Rigouzzo

et al. 2024

Intl J Gynecology & Obste

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Diabetic ketoacidosis (DKA) in pregnancy could be a disastrous event with increased maternal and perinatal morbidity and mortality. DKA can occur with a normal blood glucose level, known as euglycemic DKA. It particularly affects pregnant women with type I diabetes. Here, we report the case of a 28 year‐old primigravid patient, with a diagnosis of type 1 diabetes for 8 years. This patient consulted our department at 29 weeks of gestation with a previous history of headaches, vomiting and diarrhea for 9 h. Blood glucose level was 8.8 mmol/L with a ketone test positive (>15 mg/dL). Blood test showed high anion gap (17.9 mmol/L) with low serum bicarbonate rate (21 mmol/L). Systemic examination and fetal heart rate (FHR) was reassuring. The patient was subsequently discharged. She returned to the clinic 19 h later with further symptoms of nausea, polyuria‐polydipsia, asthenia and a weight loss of 4 kg since the day before. Blood sugar was 14.3 mmol/L and a ketone test was strongly positive. Cardiotocography showed fetal tachycardia and repeated late decelerations. A diagnosis of DKA was made and emergency cesarean was performed for fetal distress. At delivery, pH was acidosis (pH: 7.02, lactates: 6.2). The patient was successfully treated with intravenous hydration and insulin. Neonatal evolution was favorable. Pregnant women with type I diabetes can develop euglycemic DKA. Early recognition and prompt treatment could help prevent severe maternal and fetal adverse outcomes. DKA in pregnant women can induce fetal acidosis with abnormal FHR. In this situation, a cesarean can be performed to improve neonatal outcome even inducing a premature delivery. Prolonged pregnancy can lead to irreversible neonatal brain abnormalities.

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Euglycaemic ketoacidosis in pregnant women with COVID-19: two case reports

Cited by 16 publications

References 31 publications

Diabetic ketoacidosis in patients with SARS-CoV-2: a systematic review and meta-analysis

Diabetic ketoacidosis in patients with SARS-CoV-2: a systematic review and meta-analysis

Euglycemic diabetic ketoacidosis and COVID‐19 management in a term pregnant patient; a case report

Diabetic acidosis with severe fetal hypoxia in pregnancy: Narrative review and case study

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