Extreme maternal metabolic acidosis leading to fetal distress and emergency caesarean section (original) (raw)
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Starvation Ketoacidosis: A Cause of Severe Anion Gap Metabolic Acidosis in Pregnancy
Case Reports in Critical Care, 2014
Pregnancy is a diabetogenic state characterized by relative insulin resistance, enhanced lipolysis, elevated free fatty acids and increased ketogenesis. In this setting, short period of starvation can precipitate ketoacidosis. This sequence of events is recognized as “accelerated starvation.” Metabolic acidosis during pregnancy may have adverse impact on fetal neural development including impaired intelligence and fetal demise. Short periods of starvation during pregnancy may present as severe anion gap metabolic acidosis (AGMA). We present a 41-year-old female in her 32nd week of pregnancy, admitted with severe AGMA with pH 7.16, anion gap 31, and bicarbonate of 5 mg/dL with normal lactate levels. She was intubated and accepted to medical intensive care unit. Urine and serum acetone were positive. Evaluation for all causes of AGMA was negative. The diagnosis of starvation ketoacidosis was established in absence of other causes of AGMA. Intravenous fluids, dextrose, thiamine, and fo...
A 31-year-old pregnant woman (32 + 3 weeks) was admitted with extreme tachypnea. She had a previous history of congenital muscular dystrophy (Ullrich's disease) and isolated glucosuria. The patient had reduced food intake during the last 24 hours prior to admission and vomited twice. Serum glucose level was normal (112 mg/dL), while urinalysis revealed glucosuria 4+ and ketonuria 4+. ABG revealed pH 7.06, PCO 2 9 mm Hg, and bicarbonate 2 mmol/L. Anion gap was 28 mmol/L. Tachypnea was a compensatory mechanism for a severe nonlactic metabolic acidosis. The diagnosis of starvation ketoacidosis was established. The patient received supplemental dextrose 10% intravenously and sodium bicarbonate. As fetal heart monitoring was pathological, an emergency caesarean section was performed. Umbilical cord venous pH was 7.01, with PCO 2 34 mm Hg and bicarbonate 8 mmol/L. Starvation ketoacidosis is a rare metabolic disorder that may occur mainly in the third trimester of pregnancy. Muscular dystrophy and renal glucosuria were precipitating factors.
A case of severe metabolic acidosis during pregnancy
Clinical Case Reports, 2019
Key Clinical MessageRenal tubular acidosis (RTA) is a disorder that impairs renal acid‐base regulation leading to normal anion gap metabolic acidosis. It is rare to encounter this entity during pregnancy. Pregnancy can worsen renal tubular acidosis (RTA) due to the physiological changes that happen during pregnancy. Teamwork including nephrologist and obstetrician is very important to identify and properly manage pregnant women with RTA to ensure smooth pregnancy and prevent complications.
European Journal of Obstetrics & Gynecology and Reproductive Biology, 2019
Introduction: Isovaleric or organic academia is a rare, but potentially serious metabolic disorder, incidence around 1 in 250,000 children. Autosomal recessive disease resulted from deficiency of the enzyme isovalryl CoA dehydrogenase which is responsible of break dawn of amino acids especially leucine leads to accumulation of organic acids (acidosis). It can lead to maternal morbidity and mortality. Clinical description: Twenty-three years primigravida, had follow up in Women Hospital, HMC, Qatar. She is a known case of IVA since childhood. Was managed by the metabolic team and followed in fetal-maternal unit. At 29 weeks ultrasound showed cerebral ventriculomegaly that was further suggested by another US and MRI, possible diagnosis is neuro-metabolic disorder (Zellweger Syndrome). On 23rd August, the metabolic team issued a letter of the protocol for management during labor and in case of emergency. Patient came in labor at 39 weeks, was reviewed by labor room and anaesthesia team. The protocol of management was implemented, delivered vaginally without complications. Outcome baby male, 3.4 kg, vigorous, normal Apgar, was admitted to neonatal intensive care unit, baby was evaluated, found to be normal apart from hypoplastic right kidney, last seen at the age of 6 weeks, weight 4.4 kg, well. Objective: Outline the management of IVA in pregnancy and labor, to increase awareness about such rare genetic disorders. Methods: Case report. Discussion and conclusions: Discussion: The wide spread availability of genetic services in some communities with high rate of consanguinity has resulted in early diagnosis of cases of rare genetic disorders. In addition to high quality health services resulted in their survival into adulthood, though cases seen in pregnancy remain rare. The reported cases in pregnancy are very few. A 2011 review of 176 cases found that diagnoses made early in life (within a few days of birth) were associated with more severe disease and a mortality of 33%. Children diagnosed later, and who had milder symptoms, showed a lower mortality rate of ∼3%. Conclusion: Successful maternal outcome in cases of metabolic disorder, that may incur serious morbidities depends on early diagnosis, high quality services, efficient multidisciplinary involvement.
Can Obstetric Risk Factors Predict Fetal Acidaemia at Birth? A Retrospective Case-Control Study
Journal of Pregnancy, 2018
Background. Despite major advances in perinatal medicine, intrapartum asphyxia remains a leading and potentially preventable cause of perinatal mortality and long-term morbidity. The umbilical cord pH is considered an essential criteria for the diagnosis of acute intrapartum hypoxic events. The purpose of this study was to evaluate whether obstetric risk factors are associated with fetal acidaemia at delivery. Methodology. In a case-control study, 294 women with term singleton pregnancies complicated by an umbilical artery cord pH < 7.20 at birth were individually matched by controls with umbilical artery cord pH > 7.20. Groups were compared for differences in maternal, obstetric, and fetal characteristics using logistic regression models presented as odds ratio (OR) with 95% confidence intervals (CI). Results. The study showed pregestational diabetes (PGDM) [OR: 5.31, 95% CI: 1.15- 24.58, P = 0.018], urinary tract infection (UTI) [OR: 3.21, 95% CI: 1.61- 6.43, P < 0.001], ...
Current base deficit is not a relevant marker of neonatal metabolic acidosis
American Journal of Obstetrics and Gynecology, 2017
A similar case can be made for increasingly aggressive vaginal birth after cesareans and prolonging the first and second stages of labor, not due to a lack of training, but because studies have shown that these procedures are inherently more dangerous than CD. 5 Besides the medicallegal problems that the obstetrician is almost surely to face when complications arise, there is the psychological toll that follows from being involved in a case that resulted in a patient's injury whether or not there was any negligence on the obstetrician's part. And therein lies the rub. The eternal conflict exists between the people sitting behind desks, dictating what practicing physicians should do without regard to the effect it will have on their patients, their practices, their lives, and their livelihoods, and the obstetrician who is responsible for the well being of two patients in every clinical encounter. Obstetricians must resist the pressure to depart from accepted safe procedures for the minefield of unproven practices, at the behest of administrators who have no evidence of their safety, for their patients' sake as well as their own.
Fatal Foetal Outcome from Diabetic Ketoacidosis in Pregnancy
Anaesthesia and Intensive Care, 1995
Pregnancy is recognised as a state of accelerated starvation with ketosis being regularly seen in normal pregnancy after overnight fasting'. Ketoacidosis with profound reduction in pH is rare but has been described previously in association with diabetes mellitus in pregnancy2-5. Our patient was a young woman pregnant with her second child with no previous history of diabetes, who presented with a profound metabolic acidosis and had an intra-uterine death during the course of her admission. CASE HISTORY A twenty-year-old female presented to medical casualty with a four-day history of malaise, dry cough, nausea, vomiting and anorexia. She also complained of dyspnoea on the day of admission. There was no history of diabetes mellitus. Systematic enquiry revealed an eight-month history of amenorrhoea and a three-day episode of fever two weeks prior to admission. The patient had one previous pregnancy two years prior to admission, complicated by pregnancy-induced hypertension and early neonatal death at term. On this admission the patient denied ingestion of herbal toxins, illicit drugs or any other medication. A drug screen was not performed in view of the negative history. On examination the patient was distressed with a respiratory rate of 40/min. Bilateral basal crackles were heard in the chest. The heart rate was 110 per minute with a blood pressure (BP) 130/80 mmHg and normal heart sounds. She was not clinically dehydrated. Abdominal examination revealed a gravid uterus °EEA. (S.A.
Neonatal metabolic acidosis at birth: In search of a reliable marker
Gynécologie Obstétrique & Fertilité, 2016
Objective.-A newborn may present acidemia on the umbilical artery blood which can result from respiratory acidosis or metabolic acidosis or be of mixed origin. Currently, in the absence of a satisfactory definition, the challenge is to determine the most accurate marker for metabolic acidosis, which can be deleterious for the neonate. Methods.-We reviewed the methodological and physiological aspects of the perinatal literature to search for the best marker of NMA. Results.-Base deficit and pH have been criticized as the standard criteria to predict outcome. The proposed threshold of pathogenicity is not based on convincing studies. The algorithms of various blood gas analyzers differ and do not take into account the specific neonatal acid-base profile. Conclusion.-Birth-related neonatal eucapnic pH is described as the most pertinent marker of NMA at birth. The various means of calculating this value and the level below which it seems to play a possible pathogenic role are presented.
Identification of neonatal near miss by systematic screening for metabolic acidosis at birth
Facts, views & vision in ObGyn, 2011
To evaluate the relevance of systematic screening for neonatal metabolic acidosis at birth as part of perinatal audit. For every baby, born in Ziekenhuis Oost Limburg, Genk Belgium between 1/1/2010 and 31/12/2010, cord blood was analysed to diagnose metabolic acidosis, defined as arterial or venous pH ≤ 7.05 or 7.17 respectively, in association with base excess of ≤ -10 mmol/L. Three observers identified indicators for suboptimal peripartal care with likely contribution to metabolic acidosis. In a multidisciplinary consensus meeting, these indicators were classified into 5 categories : (a) fetal monitoring error (b) labour management error, (c) instrumental vaginal delivery for fetal distress within 2 h of second stage, (d) non-obstetric medical complications, (e) preterm births or accidental cases at term. In a total of 2117 neonates, there were 11 intra-uterine, 1 intrapartum and 3 early neonatal deaths, bringing early perinatal mortality rate at 7.1‰. Metabolic acidosis was ident...