Outcome of Pregnancy in a Patient with Gitelman Syndrome: A Case Report

First Diagnosis of Gitelman Syndrome During Pregnancy in an Adolescent Female: A Case Report

Gitelman syndrome (GS) is an inherited somatic recessive disorder characterized by hypokalemic metabolic alkalosis, accompanied by hypocalciuria and hypermagnesuria. It usually presents in late childhood or young adults with muscle weakness, tetany, or convulsions. Limited information is available in the literature regarding the proper management of this syndrome during pregnancy, as well as its effects on both the mother and the child. We herein present the case of a 16-year-old primigravida who was admitted to the emergency department with chief complaints of abdominal pain, weakness, and vomiting for the past three days during the 12th week of gestation. Routine blood investigations revealed hypokalemia and hypomagnesemia, and electrocardiography (ECG) showed ST-segment depressions. Further evaluation was performed due to persistent hypokalemia, and metabolic alkalosis, hypocalciuria, and hyperaldosteronism were found. Hence, a clinical diagnosis of GS took place. The pregnancy progressed smoothly without complications; potassium levels remained consistently below normal, requiring supplementation three times during pregnancy. Pregnant women with GS should be reported due to the rarity of cases, aiming to establish a standardized approach for monitoring and management.

Gitelman's Syndrome in Pregnancy With Adverse Foetal Outcome: A Case Report

Gitelman's syndrome (GS) is a disorder characterized by hypokalaemia, hypomagnesemia, hypocalciuric and metabolic alkalosis. Despite the fact that it affects women of child-bearing age, only limited information is available regarding its impact on maternal and foetal outcome. We present the case of an un-booked and un-investigated 23-year-old primigravida who presented with chief complaints of vomiting and loose stools. The patient also complained of absent foetal movements in the last 12 hours. Investigations revealed hypokalaemia and hypomagnesemia and ultrasound revealed intra-uterine foetal demise. The patient was symptomatically relieved after electrolyte correction. Scarce reports on Gitelman's syndrome in pregnancy have been documented with the majority of cases showing positive outcomes for the foetus. We hereby present a report of a primigravida with Gitelman's syndrome and foetal loss which is considered uncommon.

Gitelman Syndrome in Pregnancy: A Clinical Challenge

PURPOSE

 Disease progress may be affected by pregnancy-related changes, and underlying conditions may also affekt pregnancy outcomes in women with Gitelman syndrome (GS). Case presentation A 35-year-old woman with GS (gravida 2 para 1) was referred to our hospital to start routine antenatal care follow-up at 6 weeks of gestation. At the age of 31, she had been diagnosed with GS after her first uneventful pregnancy. Upon early admission, her serum Mg+level was 0.51 mmol/L and her serum K+level 2.7 mmol/L with normal kidney function tests. She was already taking oral combined potassium citrate and potassium bicarbonate supplementation once a day before pregnancy. At the eighth gestational week, the medication was changed to an oral potassium color sachet of 1.5 gram per day until labor because of the insufficient dosage to maintain optimum potassium levels. She was also taking 365 milligrams of oral magnesium oxide twice a day before and during pregnancy. In the third trimester of the pregnancy, her serum Mg+level was 0.48 mmol/L and serum K+level 2.8 mmol/L. Because of the previous uterine surgery history, she underwent an elective cesarean operation at 39 weeks' gestation under spinal anesthesia and delivered a healthy 3090-gram female infant.

CONCLUSION

 Increased need for potassium and magnesium supplementation should be the critical considerations when managing pregnant patients with GS.

Diagnosis and outpatient management of Gitelman syndrome from the first trimester of pregnancy

A 32-year-old woman presented with an incidental finding of hypokalaemia on routine bloods at 9 weeks of a second pregnancy, on a background of lifelong salt craving. Her previous pregnancy was uncomplicated. She had no previous significant medical or family history. Venous blood gases showed a hypokalaemic, normochloraemic metabolic alkalosis. Urinary potassium was elevated. Escalating doses of oral supplementation of potassium, magnesium, sodium and potassium-sparing diuretics were required through the course of pregnancy, in response to regular electrolyte monitoring. These were later weaned and completely stopped post partum. Delivery was uneventful with no maternal or neonatal complications. Genetic testing performed post partum showed heterogenous mutation of SCL12A3 gene.

Clinical and laboratory features of female Gitelman syndrome and the pregnancy outcomes in a Chinese cohort

AIM

Gitelman syndrome (GS) is a rare inherited salt-losing renal tubulopathy. Data on clinical features and the pregnancy outcome for female GS patients in a large cohort are lacking. The study was aimed to explore the phenotype and pregnant issue for female GS patients.

METHODS

GS cases from the National Rare Diseases Registry System of China (NRSC) were collected, and detailed clinical, laboratory and genetic data were analysed. Articles on pregnancy in GS were also systemically reviewed.

RESULTS

A total of 101 GS patients were included; among them, 42.6% were female and 79.2% showed hypomagnesaemia. A lower proportion of female patients presented before 18 years of age, with less frequently reported polyuria, higher serum potassium and less urine sodium and chloride excretions. There was no gender difference in the sodium-chloride cotransporter (NCC) dysfunction evaluated by hydrochlorothiazide test. Twelve of the 43 female GS patients delivered after disease symptom onset, and their pregnancies were generally uneventful. As a group, pregnant GS patients had lower potassium levels in the first-trimester (P = .002) requiring higher potassium supplementation. After delivery, serum potassium (P = .02) and magnesium (P = .03) increased significantly. Both caesarean section and vaginal delivery were safe.

CONCLUSION

Female GS patients may have a less severe phenotype with generally favourable outcomes of pregnancy. Intensive monitoring and increased potassium supplementation are necessary during pregnancy, especially in the first-trimester.

Gitelman Syndrome Diagnosed in a Woman in the Second Trimester of Pregnancy

Gitelman syndrome is a rare renal tubule disease characterized by hypokalaemia, metabolic alkalosis, hypomagnesaemia, hypocalciuria and normal blood pressure. It shows autosomal recessive inheritance and is usually not diagnosed until late childhood or adulthood. We report the case of 34-year-old woman who at 21 weeks of pregnancy was admitted to the gynaecology department for abdominal pain, muscle cramps and weakness. Routine blood tests showed hypokalaemia (2.32 mEq/l), hypomagnesaemia (1.18 mEq/l), compensated metabolic alkalosis (pH 7.439, bicarbonate 26.1 mmol/l), increased urinary magnesium excretion (140.25 mg/day, normal range 73–122 mg/day) and reduced urinary calcium excretion (49.25 mg/day, normal range 100–250 mg/day). In light of these findings, the patient was diagnosed with Gitelman syndrome and optimum potassium and magnesium levels were maintained with oral supplements.

Gitelman Syndrome: A Rare Cause of Seizure Disorder and a Systematic Review

Gitelman syndrome is one of the few inherited causes of metabolic alkalosis due to salt losing tubulopathy. It is caused by tubular defects at the level of distal convoluted tubules, mimicking a thiazide-like tumor. It usually presents in late childhood or in teenage as nonspecific weakness, fatigability, polyuria, and polydipsia but very rarely with seizures. It is classically associated with hypokalemia, hypomagnesemia, hypocalciuria, hyperreninemia, and hyperaldosteronism. However, less frequently, it can present with normal magnesium levels. It is even rarer to find normomagnesemic patients of GS who develop seizures as the main complication since hypomagnesemia is considered the principal etiology of abnormal foci of seizure-related brain activity in GS cases. Interestingly, patients with GS are oftentimes diagnosed during pregnancy when the classic electrolyte pattern consistent with GS is noticed. Our case presents GS with normal serum magnesium in a patient, with seizures being the main clinical presentation. We also did a comprehensive literature review of 122 reported cases to show the prevalence of normal magnesium in GS cases and an overview of clinical and biochemical variability in GS. We suggest that further studies and in-depth analysis are required to understand the pathophysiology of seizures in GS patients with both normal and low magnesium levels.

[Management of Gitelman syndrome during pregnancy reporting 12 cases]

INTRODUCTION

Gitelman syndrome is a rare hereditary renal tubulopathy, responsable of hypokalemia and hypomagnesaemia-related ionic disorders, which management is poorly codified during pregnancy. We report 12 cases of pregnancies with Gitelman syndrome and we compare our data with those of literature.

MATERIAL AND METHODS

It is a report of 12 pregnancies in 5 patients with Gitelman syndrome between 2002 and 2016. Follow up and outcome of pregnancy, delivery modalities and maternal-fetal prognosis have been collected.

RESULTS

In our serie, maximum kaliemie observed was 3.4mmol/L, with an average potassium, over all pregnancies of 2.3mmol/L. Oral potassium and magnesium supplementation at the end of pregnancy were 8900mg/day and 460mg/day, respectively. There were no serious maternal complications. Two pregnancies were complicated by intrauterine growth retardation in a context of preeclampsia. There is a large disparity in the methods of anesthetic management of these patients. Materno-fetal prognosis at 1 month post-partum is good.

CONCLUSION

Gitelman syndrome is a rare pathology where there is a lack of homogeneity in management of pregnancy. Monitoring of monthly ionogram is necessary. The goal is to obtain stable, non-symptomatic kaliemias, which will never be standardized even in increasing treatment. The most important is to inform and detect situations at risk of decompensation, including vomiting or the use of certain anesthetics. In agreement with literature data, monitoring of fetal growth and the amount of amniotic fluid in the third trimester is still warranted. These pregnancies require the development of a common care in multidisciplinary consultation meeting.

Two cases of successful pregnancy in patients with Gitelman's syndrome

Gitelman's syndrome (GS) is a distal convoluted tubule (DCT) defect clinically characterized by hypokalemic metabolic alkalosis. Pregnancy in women with GS often results in severe hypomagnesemia and hypokalemia. We report two cases of successful pregnancies, after previous fetal loss, in patients with GS managed with aggressive oral and intravenous electrolyte repletion. These cases illustrate increased potassium and magnesium requirements over the course of the pregnancies and are notable due to the high doses of electrolytes required. They also demonstrate the possibility of successful pregnancy outcomes with frequent laboratory monitoring and aggressive titration of electrolyte replacement either orally or intravenously to maintain appropriate serum levels necessary to provide a suitable environment for fetal development.

HELLP syndrome in a pregnant patient with Gitelman syndrome

Gitelman syndrome is characterized by hypokalemia, metabolic alkalosis, hypocalciuria, and hypomagnesemia. The clinical course of Gitelman syndrome in pregnant women remains unclear, but it is thought to be benign. We report here the first Korean case of atypical eclampsia in a 31-year-old who was diagnosed with Gitelman syndrome incidentally during an antenatal screening test. The patient did well during pregnancy despite significant hypokalemia. At 33 weeks' gestation, the patient exhibited eclampsia, hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome, and renal insufficiency without significant hypertension or proteinuria. We explain this unusual clinical course through a review of the relevant literature.

Management of uncommon disorders in pregnancy: Von Hippel-Lindau disease, Gitelman syndrome, and Nutcracker syndrome

Uncommon renal disorders in pregnancy can be challenging to manage given limited evidence in the literature to guide management. We present a series of three uncommon renal disorders in pregnancy: Von Hippel-Lindau disease, Gitelman syndrome, and Nutcracker syndrome. Previously published case reports with differing outcomes offer some guidance to the management of these disorders in pregnancy. In this case series, we address the management of these syndromes during pregnancy and discuss the maternal and fetal outcomes. All three of our patients had good maternal and fetal outcomes, which will contribute to current data on maternal and fetal outcomes in these rare diseases, which is limited.

Hyperemesis Gravidarum in Undiagnosed Gitelman's Syndrome

Introduction. Gitelman's syndrome (GS) is an autosomal recessive inherited defect in the thiazide-sensitive sodium-chloride cotransporter (NCCT) in the renal distal convoluted tubule. Physiologic changes of pregnancy promote renal potassium wasting, but serum potassium levels are kept in the physiologic range by increased levels of progesterone, which resist kaliuresis. In the presence of GS, this compensatory mechanism is easily overwhelmed, resulting in profound hypokalemia. We present a case of an 18-year-old primigravida with undiagnosed GS who presented with hyperemesis gravidarum in her 7th week of pregnancy. This report adds to the limited experience with GS in pregnancy as reported in literature and provides additional information on medical management that leads to successful maternal and fetal outcomes.

Gitelman syndrome during pregnancy – from diagnosis to treatment: a case series and review of the literature

Objective: Gitelman syndrome (GS) is a rare renal disease, originating from a defect in the Na-Cl co-transporter in the distal tubule, which causes hypokalemia, hypomagnesemia, hypocalciuria, metabolic alkalosis and low-normal blood pressure. Mild hypokalemia of pregnancy is physiological. Fatigue, nausea, vomiting, polyuria and low blood pressures are also common complaints associated with a normal pregnancy. Therefore, the diagnosis of an organic renal disorder, i.e., GS, may go undetected, until severe hypokalemia and possible life-threatening cardiac arrhythmias develop. Maternal consequences are obvious. The possibility of fetal pathology remains unclear.

Study design: In this study, we describe nine pregnancies in seven women with a clinical diagnosis of GS. Nearly all women were diagnosed initially during pregnancy. We describe their clinical presentation, serum and urine electrolyte levels during pregnancy and immediately post-partum, their treatment and pregnancy outcome.

Results: Fetal pregnancy outcomes were mostly favorable. While it is likely that women suffering from GS do not require special fetal surveillance, they are at high risk for electrolyte depletion and thus aggravation of GS during pregnancy.

Conclusion: Clinical suspicion of GS should arise in all women presenting with symptomatic hypokalemia. Once the diagnosis is made, adequate supplementation and routine maternal monitoring should ensue.

Outpatient management of Gitelman's syndrome in pregnancy

Gitelman's syndrome is a congenital renal tubular defect which affects the apical membrane of the distal convoluted tubule of the renal system. The syndrome is characterised by hypokalaemia, hypomagnesaemia, metabolic alkalosis and hypocalcuria. There are only a few cases describing the impact of Gitelman's syndrome on pregnancy and the foetus. Although most pregnancies have favourable outcomes, fetal demise has been reported in the third trimester. We report the successful outcome of pregnancy in a patient with Gitelman's syndrome who continued on amiloride in pregnancy to optimise potassium and magnesium levels and review the literature for pregnancy outcomes of this condition.

Gitelman syndrome and pregnancy

Gitelman syndrome (GS) is an autosomal-recessive condition characterized by hypokalemia, hypomagnesemia and hypocalciuria. Very little information is available in the literature to guide the management of pregnant patients with GS. We report a case of a 27-year-old woman with GS who became pregnant and despite persistent hypokalemia and hypomagnesemia during pregnancy and labor, had a successful maternal and fetal outcome.

Syndrome de Gitelman et grossesse: à propos d'un cas et revue de la littérature

Gitelman syndrome (GS) is a tubulopathy characterized by hypokaliemia, hypomagnesiemia, metabolic alkalosis and hypocalciuria. We report a case of a 33-year-old pregnant woman with Gitelman Syndrome. Oral potassium chloride and magnesium citrate were prescribed and the course of the pregnancy was uneventful with vaginal delivery at term. The impact of GS on the physiologic adaptations to pregnancy is not well-known, with few reports to date. Monitoring of serum potassium and magnesium levels with supplementation, amniotic fluid and fetal growth is required to prevent obstetrical and fetal complications in a patient with GS.