Is normalisation of serum potassium and magnesium always necessary in Gitelman Syndrome for a successful obstetric outcome?

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.

Unmasking of Gitelman Syndrome during Pregnancy in an Adolescent with Thyrotoxic Crisis

BACKGROUND

Gitelman syndrome (GS) is an inherited salt-losing renal tubulopathy characterized by hypokalemic metabolic alkalosis with hypomagnesemia and hypocalciuria. Patients can be asymptomatic until late adolescence or adulthood, and hence may be discovered incidentally during presentation with other illnesses. GS has been described in association with thyroid disorders and should be considered in patients with hyperthyroidism and persistent hypokalemia, especially in those with associated hypomagnesemia and hypocalciuria.

CASE SUMMARY

In this report, we describe an 18-year-old female who presented with hyperemesis gravidarum and thyrotoxicosis, and was incidentally found to have GS, confirmed by the sequence analysis of SLC12A3. Conclusions. Thyroid dysfunctions, such as hypothyroidism, thyrotoxicosis, and thyroid nodules, may develop during pregnancy. A structural homology between the beta-human chorionic gonadotropin and thyroid stimulating hormone molecules, as well as their receptors is probably the basis for the transient thyrotoxicosis crisis during pregnancy. Since hyperemesis in pregnancy can also lead to hypokalemia and alkalosis, a high index of suspicion for GS during pregnancy is required for timely diagnosis and management.

Peripartum Management of Gitelman Syndrome for Vaginal Delivery: A Case Report and Review of Literature

We describe the anesthetic management of a spontaneous vaginal delivery at 38 weeks' gestation in a 36-year-old patient with Gitelman syndrome (GS). GS is a rare autosomal recessive renal tubulopathy characterized by hypomagnesemia, hypocalciuria, and secondary aldosteronism, which results in hypokalemia and metabolic alkalosis. To minimize any increase in catecholamine levels and consequent risk of ventricular arrhythmias, a labor epidural analgesia was administered using ropivacaine and fentanyl, along with intravenous magnesium and potassium supplementation. Ropivacaine was substituted for routine bupivacaine to decrease the risk of drug-induced cardiotoxicity. In the event of a cesarean section, the anesthetic plan was to continue with top-up epidural anesthesia and in case of failure, to convert to general anesthesia using propofol and rocuronium for induction. Delivery outcome was successful and uneventful.

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.

[Sectio Caesarea under Gitelman Syndrome]

Gitelman syndrome is a rare inherited renal tubulopathy characterized by hypokalemia, hypomagnesemia and metabolic alcalosis. It is caused by a mutation in the SLC12A3 gene leading to a dysfunction of the thiazide-sensitive sodium chloride cotransporter and the magnesium transporters in the distal convoluted tubules. Only few reports of pregnant woman with Gitelman syndrome exist. Due to many unsolved questions about the impact on pregnancy and the maternal and fetal outcome, the obstetric and anesthesiological management remains a challenge. We discuss the case of a primary cesarean delivery in a 22-year-old woman with a new diagnosed Gitelman syndrome focusing on the anesthesiological approach.

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.

Anaesthesia for emergency caesarean section in a patient with Gitelman syndrome

Gitelman syndrome is a rare autosomal recessive salt-losing disorder of renal tubules, which results in hypokalemic metabolic alkalosis. Associated hypomagnesaemia and hypocalcaemia are also seen. Gitelman syndrome is a variant of renal Bartter's syndrome. Anaesthetic management of these obstetric patients is challenging and requires a careful multidisciplinary approach. Close monitoring of potassium and magnesium levels and their supplementation is required to avoid complications to mother and baby.

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.

The outcome of two pregnancies in a patient with Gitelman syndrome: case report and review of the literature

We report a case of a 30-year-old woman who was first found to have a persistently low serum potassium level at 26 years of age during her first pregnancy. Genetic test of SLC12A3 confirmed Gitelman syndrome. The patient remained asymptomatic and had two deliveries following spontaneous labor. The first neonate died of heart failure due to cardiac abnormalities. The obstetric and neonatal outcome of the second pregnancy was good.

[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.

Hypomagnesaemia and pregnancy

Hypomagnesaemia is common in pregnancy, particularly in developing countries and low-income communities. Despite the frequent therapeutic use of magnesium in pregnancy, and the evidence regarding the association of hypomagnesaemia with adverse pregnancy outcomes in animal studies, it remains unclear whether hypomagnesaemia is associated with complications in human pregnancy. Three case reports of pregnancies complicated by moderate-severe hypomagnesaemia are presented and magnesium physiology in pregnancy is discussed. The evidence as to whether hypomagnesaemia may represent a direct cause, a consequence of other disease processes or an epiphenomenon in adverse pregnancies outcomes is reviewed.

Gitelman syndrome: consensus and guidance from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Gitelman syndrome (GS) is a rare, salt-losing tubulopathy characterized by hypokalemic metabolic alkalosis with hypomagnesemia and hypocalciuria. The disease is recessively inherited, caused by inactivating mutations in the SLC12A3 gene that encodes the thiazide-sensitive sodium-chloride cotransporter (NCC). GS is usually detected during adolescence or adulthood, either fortuitously or in association with mild or nonspecific symptoms or both. The disease is characterized by high phenotypic variability and a significant reduction in the quality of life, and it may be associated with severe manifestations. GS is usually managed by a liberal salt intake together with oral magnesium and potassium supplements. A general problem in rare diseases is the lack of high quality evidence to inform diagnosis, prognosis, and management. We report here on the current state of knowledge related to the diagnostic evaluation, follow-up, management, and treatment of GS; identify knowledge gaps; and propose a research agenda to substantiate a number of issues related to GS. This expert consensus statement aims to establish an initial framework to enable clinical auditing and thus improve quality control of care.

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.

Pregnancy with Gitelman's syndrome

Gitelman's syndrome is a rare genetic disease associated with chronic hypokalaemia, hypomagnesaemia and hypocalciuria. It requires lifelong supplementation with potassium and magnesium. Pregnancy management can be difficult and there are few published reports. Our case adds to the literature and illustrates some of the potential problems.

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.

Activation and enzymatic characterization of recombinant human kallikrein 8

Human kallikrein 8 (hK8), whose gene was originally cloned as the human ortholog of a mouse brain protease, is known to be associated with diseases such as ovarian cancer and Alzheimer's disease. Recombinant human pro-kallikrein 8 was activated with lysyl endopeptidase-conjugated beads. Amino-terminal sequencing of the activated enzyme demonstrated the cleavage of a 9-aa propeptide from the pro-enzyme. The substrate specificity of activated hK8 was characterized using synthetic fluorescent substrates. hK8 showed trypsin-like specificity, as predicted from sequence analysis and enzymatic characterization of the mouse ortholog. All synthetic substrates tested containing either arginine or lysine at P1 position were cleaved by hK8. The highest kcat/Km value of 20x10(3)M-1 s-1 was observed with Boc-Val-Pro-Arg-7-amido-4-methylcoumarin. The activity of hK8 was inhibited by antipain, chymostatin, and leupeptin. The concentration for 50% inhibition by the best inhibitor, antipain, was 0.46 microM. The effect of different metal ions on the enzyme activity was analyzed. Whereas Na+ had no effect on hK8 activity, Ni2+ and Zn2+ decreased the activity and Ca2+, Mg2+, and K+ had a stimulatory effect. Ca2+ was the best activator, with an optimal concentration of approximately 10 microM.

Nausea, Emesis, and Muscle Weakness in a Pregnant Adolescent

BACKGROUND

Gitelman syndrome is a rare autosomal recessive disorder that presents in early adulthood with fatigue, muscle cramps and electrolyte abnormalities.

CASE

A 17-year-old African-American woman presented at 17 weeks of pregnancy with nausea, emesis, profound lower extremity proximal muscle weakness, hypokalemia, and hypomagnesemia. After a thorough evaluation, Gitelman syndrome was diagnosed. The patient was maintained on high levels of potassium and magnesium supplementation throughout the rest of her pregnancy and delivered a healthy infant.

CONCLUSION

In pregnancy, nausea and emesis is most commonly attributed to hyperemesis gravidarum. However, an atypical presentation of these symptoms and/or the coexistence of less common complaints warrant further investigation.

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

Gitelman syndrome (GS) is an autosomal-recessive condition characterized by hypokalaemia, hypomagnesaemia and hypocalciuria. Though it affects women of child-bearing age very little information is available about its impact on maternal and fetal outcome. We describe the course of pregnancy in a patient with GS which was characterized by a sixfold increase in potassium and magnesium requirements with inability to achieve normal levels despite intravenous supplementation. There was no adverse impact on the course of pregnancy or fetal outcome. The case highlights the variability in the phenotypic presentation of GS and recommends frequent monitoring of electrolytes with supplementation guided by clinical requirements without aiming to achieve normal blood levels.