Case series of COVID-19 infection in pregnancy complicated by ketoacidosis and symptomatic breathlessness

Abstract

Background The differential diagnosis of acute shortness of breath in a pregnant woman with COVID-19 is broad. Pregnancy is a ketosis-prone state, which can result in metabolic acidosis and tachypnoea. Methods We describe four pregnant women with COVID-19 and breathlessness where ketoacidosis was found to contribute to symptomatic tachypnoea. Results One patient did not have associated COVID-19 pneumonitis, but presented with severe tachypnoea and metabolic acidosis; three women had pneumonitis and metabolic acidosis. Corrective treatment for the metabolic abnormalities resulted in resolution of the ketoacidosis in all cases. No women had coexistent diabetes. Conclusion This is the first series of COVID-19 in pregnancy complicated by ketoacidosis and symptomatic tachypnoea. Ketoacidosis associated with COVID-19 is an important cause of tachypnoea requiring specific treatment, which should not be overlooked. Potential mechanisms for this are discussed with a framework for interpretation of blood gas results during pregnancy.

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

“…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 ...…”

“…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 ].…”

“…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 ].…”

Considerations for women with COVID-19 admitted to hospital

“…Ketoacidosis has been reported in the setting of COVID-19 infection in non-pregnant individuals, and more recently noticed and reported in pregnant women with COVID-19. 13 , 14 Irrespective of Covid infection, pregnant women are more at risk of significant ketosis, particularly in the third trimester, which is usually the result of relatively short periods of reduced oral intake. Importantly, the blood glucose may be low or normal so ketones should be checked even in the absence of hyperglycaemia, if there are any concerns about the woman becoming unwell, but this is of particular importance if tachypnoea or metabolic acidosis develops.…”

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

“…Pregnant women are at higher risk for developing ketosis, and concomitant infections may lower the metabolic threshold at which ketoacidosis happen. 2 …”