MON-553 - Diabetic Ketoalkalosis in Early Pregnancy: A Diagnostic Pitfall in the Setting of Persistent Vomiting

Background:
Diabetic ketoacidosis (DKA) is a serious complication of type 1 diabetes mellitus and may present with atypical biochemical findings, particularly in the presence of mixed acid–base disorders.(1-3) In early pregnancy, vomiting may induce metabolic alkalosis, potentially masking the underlying ketoacidosis and delaying recognition.

Clinical

Case:
A 22-year-old female with type 1 diabetes mellitus since age 10, managed with hybrid closed-loop insulin pump therapy, presented at 12 weeks of gestation with 24 hours of persistent nausea and vomiting. She denied clear triggers and referred appropriate use of her insulin pump and carbohydrate counting. Continuous glucose monitoring demonstrated a time-in-range of 71% using non-pregnant targets.
At evaluation, she was hemodynamically stable, clinically dehydrated, and with recurrent vomiting. Laboratory studies revealed glucose 304 mg/dL, anion gap 21 mEq/L, bicarbonate 14 mmol/L, arterial pH 7.45, potassium 5.2 mEq/L and positive urine ketones.1 These findings meet diagnostic criteria for DKA and a mixed acid–base disorder, specifically diabetic ketoalkalosis, most likely precipitated by persistent vomiting in early pregnancy.(1-3) Management included antiemetic therapy, intravenous fluids, and insulin, with subsequent clinical improvement and resolution of nausea and vomiting.

Conclusion:
Diabetic ketoalkalosis is an underrecognized presentation of DKA in which concurrent metabolic alkalosis, often driven by vomiting, may obscure the underlying high anion gap metabolic acidosis.(2-3) Vomiting leads to loss of gastric hydrochloric acid and volume depletion, promoting metabolic alkalosis through increased bicarbonate retention and activation of the renin–angiotensin–aldosterone system. This may delay diagnosis if clinicians rely primarily on pH rather than the overall metabolic profile. It should be considered in patients with type 1 diabetes who present with hyperglycemia and an elevated anion gap despite a normal or elevated pH. Early recognition and appropriate management are essential to reduce the risk of adverse maternal and fetal outcomes.

References:
1. Umpierrez GE, Korytkowski M, DiGenio A, et al. Hyperglycemic crises in adults with diabetes: a consensus report.Diabetes Care. 2024;47(8):1257–1275.
2. Brill S, et al. Diabetic Ketoalkalosis: A Case Report. Cureus. 2024;16(5):e11166055.
3. Kumar V, Nanavati SM, Komal F, Ortiz LC, Paul N, Kumar M, et al.Ketoalkalosis: Masked Presentation of Diabetic Ketoacidosis With Literature Review. J Endocrinol Metab. 2017;7(6):194–196

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