Title - Severe Ketoacidosis during Lactation – the Dangers of a Low Carbohydrate Diet

Presentation Number: MON 293
Date of Presentation: April 3rd, 2017

Vidya murty Aluri*1 and Joseph Stephen Dillon2
1University of Iowa Hospitals and Clinics, Iowa City, IA, 2University of Iowa Hospital and Clinics, Iowa City, IA

Abstract

Introduction – Ketosis during lactation is a well-known phenomenon in lactating cattle and is well described in veterinary literature [1]. We present a case of severe metabolic acidosis secondary to ketosis in a non-diabetic woman, precipitated by lactation and a low carbohydrate diet.

Case – A 34 year old Caucasian female who was 6 weeks post partum with her 5th child was admitted to our institute from her primary care physician’s office with hyperventilation. She had been actively pumping 60-70 ounces of breast milk per day. She had started a low carbohydrate diet 2 weeks post partum with less than 40-50 gm per day, in an effort to lose weight.

She presented to her primary care physician with fatigue and was sent to the emergency room as her respiratory rate was >40 /minute. Her labs on presentation showed severe metabolic acidosis with a PH of 7.06, anion gap of 35 ,bicarbonate of 4 and a beta hydroxybutyrate of 12.3 mEq/l (0-0.3). She did not have a history of diabetes mellitus and did not use medications like metformin or salicylates. Her urine drug screen, blood alcohol levels were normal and work up for infection was negative. Other laboratory studies obtained during her hospitalization included an A1c of 4.7% (4.8-6%), TSH of 2.05 mIU/ml (0.27 – 4.2) free T4 of 0.94 ng/dl (0.8 – 1.8), normal liver enzymes, renal functions, lactate of 1.5 and cortisol on presentation of 39.4 mcg/dl

The patient was started on intravenous dextrose and a diet with 60 to 80 grams of carbohydrate per meal. Over the next 24 – 48 hours, the patient’s tachypnea improved and her blood gases started to normalize. She was discharged on day 3 of her hospitalization after she met with the dieticians and had established a meal plan while she continued to breast feed her baby.

Discussion – Under normal circumstances glycolysis generates pyruvate, which enters the citric acid cycle to generate ATP. In starvation where there is low glucose availability, there is deficiency of pyruvate entering the citric acid cycle due to depletion of glycogen stores. Other sources of energy like acetyl CoA from beta-oxidation of fatty acids are generated which can result in the formation of beta-hydroxybutyrate, acetoacetate, and acetone. [2] Lactating women are at a risk for a similar situation due to the requirements of milk production exceeding the energy intake.

There are no specific nutritional recommendations for lactating women. There are some previous case reports where ketosis was precipitated in women who were lactating and had either adopted a low carbohydrate diet or were in a fasting state due to another medical condition. [3,4] This case underscores the importance of educating lactating women to adopt a well-balanced dietary plan to compensate for their increased metabolic demands.

 

Nothing to Disclose: VMA, JSD