THE CASE
A 26-year-old woman presented to the emergency department (ED) with a history of nausea and vomiting for more than 24 hours. The vomiting began when she awoke to breastfeed her 3-month-old infant. She had been unable to eat or drink anything for about 16 hours.
She’d seen her primary care provider earlier in the day. Antiemetics were prescribed, but they did not provide relief. So 10 hours later, when her symptoms worsened, she presented to the ED.
Her medical history was notable for a body mass index of 26. The patient also reported positional back pain, but the review of systems was otherwise negative. The patient indicated that she’d been on a ketogenic diet for about 1 month, but she denied use of supplements.
Upon presentation to the ED, the patient was found to have a metabolic acidosis with a pH of 7.02 and an anion gap of 25. Her glucose level was 132 mg/dL, and she had a positive serum acetone and a beta-hydroxybutyrate level of 75 mg/dL (reference range, 0-2.8 mg/dL). Her salicylate testing was negative, and her lactate level was 1.4 mmol/L (reference range, 0.4-2.0 mmol/L).
THE DIAGNOSIS
This patient, with severe acidosis and an elevated anion gap, received a diagnosis of starvation ketoacidosis—specifically, lactation ketoacidosis. Other causes of elevated anion gap metabolic acidosis were ruled out, including salicylate overdose, lactic acidosis, diabetic ketoacidosis, and other ingestions. The elevated acetone and beta-hydroxybutyrate levels confirmed the diagnosis. The patient was treated with a bolus of 1 L normal saline with 5% dextrose (D5NS) in the ED and admitted.
DISCUSSION
Lactation ketoacidosis is a relatively uncommon condition, but reports have increased with the growing popularity of low-carbohydrate diets. The treatment approach has differed in previous reports in regard to insulin and bicarbonate use.1-9
The use of bicarbonate is controversial in diabetic ketoacidosis and unlikely to be helpful in lactation ketoacidosis, but it is something to consider when the patient’s pH is < 6.9. Insulin use is likely unnecessary for lactation ketoacidosis, as metabolic derangements have been corrected without intervention.
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