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Salicylate poisoning following topical administration of methylsalicylate

follow up. We present a case of ketoacidosis in pregnancy in the setting of mild hyperglycaemia and following a 7 day history of minimal oral intake due to ongoing nausea and vomiting secondary to acute pancreatitis. Ketoacidosis in non-pregnant subjects may occur in the setting of diabetes mellitus, alcohol excess, starvation, drug toxicity, sepsis and inborn errors of metabolism. Three subjects have been reported as manifesting ketoacidosis at the time of presentation with acute pancreatitis in the absence of any other pathogenic factors. Ketoacidosis following starvation has been described in pregnant women with normal glucose tolerance, gestational and pregestational diabetes mellitus. Blood glucose levels in the first two scenarios tend to be much lower than with diabetic ketoacidosis in non-pregnant women, and have been labelled euglycaemic ketoacidosis. Late pregnancy has been described as accelerated starvation because of a lower threshold for ketosis. Late pregnancy is a state of chronic respiratory alkalosis and this reduces the buffering capacity of the kidneys. Insulin resistance is increased in pregnancy due to the effects of progesterone, cortisol, and placental production of human placental lactogen and glucagon. This results in increased lipolysis and elevated levels of free fatty acids and enhanced ketogenesis. Thus, starvation in pregnancy, particularly in the third trimester, results in susceptibility to ketoacidosis. Frise et al. reviewed 11 cases of starvation ketoacidosis in pregnancy. The duration of starvation ranged from less than 24 h to a week. Nine of the cases described were not known to have glucose intolerance. Two cases of ketoacidosis in women with GDM occurred with euglycaemia. Based on the presence or absence of diabetes mellitus, ketoacidosis during pregnancy has been variably labelled as euglycaemic or starvation ketoacidosis. These two entities appear to be part of the same process with similar underlying pathophysiological mechanisms. Severe ketoacidosis might be associated with adverse fetal outcome, including intrauterine death. In conclusion, the risk of ketoacidosis in late pregnancy is high even after brief periods of starvation. It is important to test pregnant women in the third trimester who present to the ED with vomiting or following starvation for ketonemia as this can develop after as short a period as 16 h after starvation. Early recognition and management of this condition might prevent prolonged hospital stay and avoid caesarean section and adverse fetal outcomes.