MON-140 A Case of Gestational Starvation Ketoacidosis in a Diabetic Mother Mimicking the Presentation of Acute Coronary Syndrome

Introduction: Hormonal Milieu of pregnancy is known to create a state of “accelerated starvation”, which is exceptionally pathological in a diabetic pregnant patient. Our case presents a diabetic mother with severe chest pain and premature labor in the setting of mixed anion gap metabolic acidosis. Initial diagnosis was diabetic ketoacidosis (DKA), however starvation ketoacidosis (SKA) became more questionable. To our knowledge, this is the first case to report acute coronary syndrome (ACS) as a presentation of SKA with pregnancy. Case Presentation: A 40-year-old woman, gravida 3 para 2 with the diagnosis of Gestational Diabetes at the 9th week of pregnancy, was transferred to our university hospital at 36 weeks of gestation due to concern for ACS. Patient endorsed intense central chest pain with the start of early labor contractions. Three weeks prior, she followed a low carbohydrate and severely calorie deficient diet to reduce her insulin requirements because of the history of fetal macrosomia noted on ultrasound. Cervix was 80% effaced on pelvic examination with blood chemistry remarkable for glucose level of 174 mg/dL, anion gap (AG) of 18 mEq/L and bicarbonate level of 5 mEq/L. Lactic acid level was 0.7 mEq/L, beta-hydroxybutyrate level 5.30 mmol/L and a positive urine dipstick for ketones. Delta ratio was 0.3, explained as combined high AG and normal AG metabolic acidosis. Electrocardiogram showed transient minimal 1mm elevation in the inferior leads with otherwise negative serial Troponin levels. Pulmonary embolism was ruled out by contrast imaging. She was admitted to the Coronary Care Unit and was started on Heparin drip for the initial diagnosis of STEMI. Delivery was accelerated with artificial membrane rupture, after which she was started on insulin and dextrose drips until the closure of the AG. Further cardiac workup was then deferred to outpatient management due to the clinical stability and resolution of chest pain. Discussion: Although similar in physiology and management, both DKA and SKA are 2 distinct entities and a special attention should be paid for both in the state of pregnancy. DKA tends to be more in type 1 diabetes due to absolute insulin deficiency and can be exacerbated by infection, and noncompliance with insulin or diet. SKA however presents with improper diet that is not meeting the high energy demand, creating a “demand more than supply” state. We believe that concomitant use of insulin while being on a low carbohydrate/calorie diet has caused the opposition of lipolysis, the sole remaining source of energy, which has caused more stress hormones production to override that state. This explains the euglycemia as well as the morbid symptoms the patient presented with. Carbohydrate consistent diet in addition to watchful insulin monitoring are advised in diabetic mothers to avoid starvation and its subsequent complications as preterm delivery and severe maternal morbidity.