History: A 41-year-old female in her sixth pregnancy at 32nd week of gestation
presented with history of recurrent vomiting for four days. Vomiting had worsened for
48 hours, prompting her to seek medical attention. She was feeling weak and
exhausted. There has been infrequent epigastric pain. She denied any past,
personal, or family medical history and had no surgery in the past. Social history
included occasional alcohol use which was continued during pregnancy.
Physical examination: Patient was afebrile at the time of admission, appeared
dehydrated, and was tachycardic and tachypneic, but relatively low (80-90/60
mmHg). Her skin turgor was poor and her mucosae (e.g. on the lips) appeared dry.
Her pulses were relatively weak. Patient required intubation and mechanical
ventilation for worsening respiratory distress with Kussmaul’s breathing.
Laboratory studies: There was mild leukocytosis and elevated creatinine due to
acute renal failure. Blood tests documented metabolic acidosis and hypokalemia.
Serum glucose level was low and serum acetone was elevated. Urine was positive
for proteins and acetone. Mild transaminitis (elevelation of liver enzymes due to liver
injury) was noted, with normal creatinine kinase (CK) levels. No evidence of infection