Introduction: Gitelman syndrome (GS) is a rare autosomal recessive tubulopathy characterized by hypokalemia, hypomagnesemia, metabolic alkalosis and hypocalciuria, usually treated with electrolyte replacements, nonsteroidal anti-inflammatories or aldosterone antagonists. Pregnancy imposes the need for more intensive control of the disease, but has a good prognosis for the mother and neonate
Case summary : 25 year old, primiparity, with GS on regular potassium (4.8 gm/ day) and magnesium (1.5 gm /day) replacement and low dose spironolactone( 12.5 mg /day), presented at first trimester with multiple episodes of hyperemesis gravidarum, weakness and leg cramps associated with severe hypokalemia and hypomagnesemia ( Seum potassium 2.2 mmol/L, Serum magnesium 0.5 mmol/L),although on high dose oral potassium and magnesium replacement.
She had to be treated with repeated intravenous electrolyte replacements on multiple occasions along with prednisolone and antiemetics. As spironolactone was stopped, her oral replacement doses of potassium (9.6gm/day) and magnesium (2.25gm/day) needed to be increased subsequently through her pregnancy. Her baby had mild intrauterine growth restriction. She underwent vaginal delivery at 36 weeks' gestation with birth weight of 1995gm.
Conclusion: Hyperemesis gravidarum and discontinuation of aldosterone antagonists leads to higher risk of symptomatic hypokalemia/hypomagnesemia in patients with GS during pregnancy. Pré-pregnancy planning with higher doses of electrolyte replacement, counselling on aldosterone antagonists or potassium sparing diuretics and optimal control of hyperemesis is crucial to avoid symptomatic episodes. Aldosterone antagonists such as spironolactone, amiloride and eplerenone have been used successfully in pregnant women with GS.