Co-existence of starvation ketoacidosis and hyperthyroidism in early pregnancy: a case report
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CASE REPORT
Co‑existence of starvation ketoacidosis and hyperthyroidism in early pregnancy: a case report Djordje Marina1 · Elisabeth R. Mathiesen1,2 · Marianne Klose1 · Berit Woetmann Pedersen2,3 · Lene Ringholm1,2 Received: 11 May 2020 / Accepted: 17 June 2020 © Springer-Verlag Italia S.r.l., part of Springer Nature 2020
Introduction Ketoacidosis is a potentially life-threatening complication of diabetes characterised by hyperglycaemia, metabolic acidosis and increased ketone body concentration caused by an absolute or relative lack of insulin [1]. During pregnancy, the onset of diabetic ketoacidosis can occur at normal or only slightly elevated glucose levels, and ketoacidosis progresses more rapidly than in non-pregnant women with type 1 diabetes [1]. Ketoacidosis can result in intrauterine death, with a fetal mortality of up to 35% [2]. Diabetes is often, but not always, diagnosed before onset of ketoacidosis and other etiologies of ketoacidosis as starvation ketoacidosis may be considered [2]. Hyperemesis gravidarum is a condition with extreme and persistent nausea and vomiting in early pregnancy that may lead to insufficient food and fluid intake and starvation ketosis [3]. Further, signs of hyperthyroidism with elevated thyroid hormones and suppressed thyroid stimulating hormone (TSH) are often concomitantly present in women with hyperemesis gravidarum [3]. The co-existence of ketoacidosis and hyperthyroidism was first described in 1957 [4]. Hyperthyroidism is associated with increased metabolism, lipolysis, blood glucose levels and insulin resistance which may further trigger the development of ketogenesis and ketoacidosis in susceptible individuals [4]. This article belongs to the topical collection Pregnancy and Diabetes, managed by Antonio Secchi and Marina Scavini. * Djordje Marina [email protected] 1
Department of Endocrinology PE7562, Rigshospitalet, Blegdamsvej 9 DK‑2100 Copenhagen, Denmark
2
Center for Pregnant Women with Diabetes, Rigshospitalet, Blegdamsvej 9, DK‑2100 Copenhagen, Denmark
3
Department of Obstretics, Rigshospitalet, Blegdamsvej 9, DK‑2100 Copenhagen, Denmark
Conditions where increased carbohydrate requirement exceeding the carbohydrate intake leads to ketosis have been described in both healthy women in late pregnancy [2] and during lactation [5], but to our knowledge not in healthy women in early pregnancy. We report a case of a woman without known diabetes who presented with signs and symptoms of ketoacidosis and gestational hyperthyroidism in combination with hyperemesis gravidarum in early pregnancy.
Case report A 30-year-old otherwise healthy woman presented with nausea for two weeks and frequent vomiting the last two days. She had been unable to eat for 4–5 days and had an unintended 5 kg weight loss within the last weeks (BMI 19.2 kg/m2). She described fatigue and slightly decreased consciousness. She reported no intake of alcohol, ketogenic diet or history with eating disorder. The patient had experienced symptoms of hyperemesis gravidarum in tw
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