Background: Lactation ketoacidosis is an infrequent but clinically significant cause of high anion gap metabolic acidosis.1,2 We describe a case of severe ketoacidosis in a non-diabetic lactating woman.
Case: A 20-year-old 12 weeks postpartum woman who was breastfeeding her child presented with 2 days of nausea, vomiting and was unable to tolerate any oral intake. Since delivery, she had been having irregular small meals with an overall low daily calorie intake. Her pregnancy and medical history were unremarkable, and she was not on any regular medications. She had mild epigastric tenderness with a soft abdomen. Investigations revealed severe non-diabetic ketoacidosis: pH, 7.13; pCO2, 25mmHg; bicarbonate, 8mmol/L; point-of-care ketone, 5.7mmol/L; glucose, 4.4mmol/L; and with an elevated anion gap of 25mmol/L. Lactate was normal and history did not reveal alcohol or toxin ingestion. Full blood count, lipase, liver enzymes and electrolytes were unremarkable. Acidosis, ketosis and symptoms rapidly resolved with the administration of intravenous dextrose. A diagnosis of lactation ketoacidosis was made. The patient was discharged with dietary advice to ensure sufficient energy intake while breastfeeding.
Discussion: While fasting under ordinary circumstances produces mild acidosis at maximum, it can be dangerous during lactation. The increased energy requirements of lactation cause enhanced gluconeogenesis, decreased insulin secretion, lipolysis and can subsequently induce ketogenesis. The metabolic demands of breastfeeding coupled with carbohydrate deficiency put lactating women at risk of ketoacidosis.3,4 There have been only a few reported cases of lactation ketoacidosis.2,4 Most commonly reported precipitating factors include fasting in the context of an acute illness and low-carbohydrate diets. Energy replacement and rehydration resulted in complete symptomatic and biochemical resolution in all cases.1,2
Conclusion: Awareness of this potential cause of ketoacidosis is vital for early recognition and appropriate management. Glucose administration is the mainstay of treatment. Education regarding the nutrition requirements during breastfeeding is essential.1,2