QJM: An International Journal of Medicine, 2019, 123–124
doi: 10.1093/qjmed/hcy252
CASE REPORT
Gestational diabetes insipidus
P.L. Chong1, J. Pisharam2, A. Abdullah3 and V.H. Chong
From the 1Division of Diabetes and Endocrinology, Department of Internal Medicine, 2Department of Renal
Services, 3Department of Obstetrics and Gynaecology and 4Division of Gastroenterology and Hepatology,
Department of Internal Medicine, RIPAS Hospital, Bandar Seri Begawan BA1710, Brunei Darussalam
Address correspondence to Dr P. L. Chong, Division of Diabetes and Endocrinology, Department of Medicine, RIPAS Hospital, Bandar Seri Begawan BA1710,
Brunei Darussalam. email: lina.chong@moh.gov.bn
Learning points for clinicians
• Liver disease during pregnancy may precipitate gesta-
tional diabetes insipidus (GDI) and evaluation of liver
function is necessary in patients who develop GDI.
• Desmopressin is the treatment of choice and is safe in
pregnancy.
• Clinician awareness, prompt diagnosis and treatment
should minimize the risk of maternal morbidity and
mortality.
Case
A 25-year-old housewife presented with reduced foetal move-
ments at 28 weeks of her fourth pregnancy (G4P2). She had diet-
controlled gestational diabetes mellitus and was not on any
medications. Although foetal heartbeat was detected, a foetal
ultrasound revealed an anomalous baby with a three-chamber
heart and features of hydrops fetalis. She was counselled
regarding the likelihood of intrauterine foetal death.
Her initial admission was complicated by vomiting, gastritis,
hypokalaemia and hyperglycaemia. On day 6 of admission, she
developed osmotic symptoms and significant hypernatraemia
(serum Naþ 164 mmol/l). The following day, despite intravenous
fluids, she remained clinically dehydrated with a sinus tachy-
cardia (107 beats/min), BP 104/74 mmHg, and 24-h urine output
of 5400 ml. Serum Naþ was 170 mmol/l, serum osmolality
342 mmol/kg (normal range [NR]: 275–305 mosmol/kg), urine
osmolality 55 mmol/kg (50–1200 mosmol/kg) and urine specific
gravity 1.010. Renal function was normal.
Liver function test was deranged (Table 1) with negative viral
screen. Liver ultrasonography was unremarkable. Other results
include negative autoimmune screen, proteinuria (protein:
Received: 22 October 2018; Revised (in revised form): 24 October 2018
C The Author(s) 2018. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved.
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Case report
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4
creatinine ratio 282; NR 0–45 mg/mmol), raised uric acid
(588; NR: 150-350lmol/l), leucocytosis (white cell count 20.9; NR:
3.8–11.8  109g/l), microcytic anaemia (Haemoglobin 9.8;
NR: 10.9–14.3g/dl and mean corpuscular volume 69.3; NR:
75.5–95.3fl), normal platelet count (430; NR: 150–450  109).
Haemolysis was considered unlikely with mild lactate dehydro-
genase (578; NR: 125–220 U/l) and haptoglobulin (0.09; NR: 0.35–
2.50g/l) abnormalities.
On Day 8 of admission, foetal heartbeat became undetectable.
Intranasal desmopressin (DDAVP) 10 mcg was administered for
suspected gestational diabetes insipidus. A water deprivation
test was not performed in view of the risk of further dehydration.
After one dose of desmopressin, her urine output slowed down
to 20–50 ml/h and hypernatraemia improved (Figure 1).
She developed spontaneous contractions the next day and
delivered a dismorphic female foetus without signs of life.
Blood sampling was undertaken unsuccessfully for karyotype
analysis. A pituitary magnetic resonance imaging was unre-
markable with normal posterior pituitary and stalk. Her electro-
lytes and liver function test normalized and no further polyuria
was reported. She had an uneventful recovery postnatally and
has remained well on follow-up 2 years later without any symp-
toms of liver dysfunction or features of diabetes insipidus.
Discussion
Diabetes insipidus (DI) is defined as an inability to concentrate
urine with polyuria (urine output > 3 l/day) and polydipsia.1
Gestational diabetes insipidus (GDI) is a rare complication of
pregnancy affecting 2–4 per 100 000 pregnancies. It tends to
occur at the end of the second trimester or during the third
trimester. GDI is usually transient with spontaneous resolution
4–6 weeks after delivery. Excessive vasopressinase activity has
been implicated in the pathophysiology of GDI. Vasopressinase
is produced by placental trophoblasts from the seventh week of
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Table 1. Trend of liver function test during admission

Day 7 Day 8 Day 9a Day 10 Day 12 Day 17 Day 18 Ref range

ALT 170 167 106 57 35 25 15 1–54 U/l

ALP 174 185 205 209 214 109 102 40–150 U/l
GGT 365 410 372 332 324 94 57 9–36 U/l
Bilirubin 47.2 56.3 70.7 47.2 14.9 10.4 9.5 3.4–20.5 umol/l
Albumin 19 18 16 16 17 26 34 35–50 g/l

a
Spontaneous delivery.
ALT, alanine aminotransferase; ALP, alkaline phosphatase; GGT, gamma-glutamyl transferase.

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Figure 1. Trend of serum Naþ (mmol/L).

gestation and degrades vasopressin. As trophoblast mass
increases during pregnancy, vasopressinase levels reach
1000-fold peaking in the third trimester. Its activity remains high
during labour and delivery, then decreases by 25% per day to
becoming undetectable between two and four weeks postpartum.2,3
As vasopressinase is metabolized by the liver, any hepatic
dysfunction may lead to increased degradation of vasopressin
resulting in diabetes insipidus. The cause of hepatic dysfunction
in our patient is unknown but we believed she had acute fatty
liver of pregnancy (AFLP). This is supported by clinical features
fulfilling the Swansea diagnostic criteria for AFLP, its appearance
during the third trimester and resolution after delivery.4,5
Our case illustrates poor foetal outcome in a patient with
liver dysfunction and GDI. Although intrauterine foetal death
(IUFD) was expected in an anomalous foetus, the underlying se-
quence of events is unknown. AFLP is associated with foetal
mortality5 and having GDI may have accelerated foetal demise.
IUFD was previously reported in a twin pregnancy in which the
mother developed GDI secondary to hepatic dysfunction from
haemolysis, elevated liver enzymes, low platelet syndrome.6
Conflict of interest: None declared.
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