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Carbohydrate and lipid metabolism in pregnancy: normal compared with gestational diabetes mellitus. Ingested K+ is absorbed rapidly and enters the portal circulation, where it stimulates insulin secretion. An increase in extracellular potassium concentration also stimulates aldosterone secretion (via angiotensin II), and aldosterone increases K+ excretion. Potassium homeostasis is maintained by the balance of potassium excretion and potassium cellular shifts.
This applies to certain high-risk patient populations with cardiac disease, such as ischemic or scarred myocardium, left ventricular hypertrophy, congestive heart failure, or myocardial infarction).
Hypokalemia is found in about 20% of hospitalized patients, but it occurs in less than 1% of otherwise healthy adults. Hypokalemia can result from transcellular shifts (from extracellular into intracellular spaces), or when potassium losses are increased; these losses can be from renal or nonrenal causes (Box 1). When hypokalemia is reported, the initial step is to ascertain whether it is associated with clinical symptoms or arrhythmias that would require prompt intervention.
In a person with normal renal function and average potassium intake, FEK is approximately 10%.
The usefulness of the FEK and TTKG is limited by their variability with diet and chronic kidney disease.
Cause of hypokalemia should be addressed (remove drug, change diet, stop gastric drainage).
All other situations except for renal tubular acidosis: replace with oral potassium bicarbonate, citrate, acetate, or gluconate. More than 80% of hyperkalemic episodes are caused by impaired potassium excretion from renal insufficiency.1 Usually, another event that prevents or overcomes the renal adaptation precipitates the hyperkalemia. Patients with hyperkalemia are usually asymptomatic, although some patients may present with generalized muscle weakness, and cardiac conduction may be impaired.
The initial step with reported hyperkalemia is to ascertain whether it is associated with clinical symptoms or arrhythmias that would require prompt intervention. The urine potassium concentration, FEK, and TTKG can also be used to help distinguish between renal and nonrenal causes of hyperkalemia.
Ascertain whether it is associated with clinical manifestations, such as arrythmias, which require immediate treatment. A careful history and a physical examination should be done, especially looking for evidence of catecholamine surge, hypertension, vomiting or diarrhea, and medication use.
Ascertain whether it is associated with clinical symptoms, such as changes on the ECG, which require immediate attention. Careful history and physical examination should be done, looking specifically for chronic kidney disease, medications, dietary, or clinical situations associated with transcellular shifts, such as hyperglycemia. Batlle DC, Arruda JA, Kurtzman NA: Hyperkalemic distal renal tubular acidosis associated with obstructive uropathy. Elisaf M, Siamopoulos KC: Fractional excretion of potassium in normal subjects and in patients with hypokalaemia. Ethier JH, Kamel KS, Magner PO, et al: The transtubular potassium concentration in patients with hypokalemia and hyperkalemia. West ML, Marsden PA, Richardson RM, Zettle RM, Halperin ML: New clinical approach to evaluate disorders of potassium excretion.
West ML, Marsden PA, Richardson RM, et al: New clinical approach to evaluate disorders of potassium excretion.
Pregnant women without known diabetes mellitus should be screened for GDM after 24 weeks of gestation.
Increased secretion of placental hormones leads to increasing insulin resistance, especially throughout the third trimester.
Antenatal testing in women who have GDM that is well controlled without medications is not beneficial,40 because the risk of stillbirth is not increased in this population.41 Antenatal testing is commonly performed in women who require medication for GDM, although data supporting this practice are limited to older observational studies.
Clinicians should prepare to manage shoulder dystocia at the time of delivery and exercise caution when considering an operative vaginal delivery.Women with GDM rarely need oral agents or insulin immediately after delivery.


About 90% of total body potassium is intracellular and 10% is in extracellular fluid, of which less than 1% is composed of plasma. Insulin increases Na+,K+-ATPase activity and facilitates potassium entry into cells, thereby averting hyperkalemia.
In the steady state, K+ excretion matches intake, and approximately 90% is excreted by the kidneys and 10% in the stool. Transcellular shifts can occur in pathologic conditions associated with a catecholamine surge, such as chest pain syndromes, or mediated by acid-base disturbances. Manifestations of hypokalemia include generalized muscle weakness, ileus, and cardiac arrhythmias. In the absence of compelling indications for immediate therapy, a careful history and physical examination should be performed. Hypokalemic patients with a lower FEK would suggest extrarenal loss of K+, whereas hypokalemia from renal losses would be associated with an elevated FEK.
The numerator is an estimate of the luminal potassium concentration, and the osmolality ratio is used to correct for the increase in UK caused by water extraction. Mortality data caused by hyperkalemia are unavailable for the general population but accounted for 1.9% of patients with end-stage renal disease in the United States in 1993.
The earliest electrocardiographic changes are tenting of T waves, followed by widening of the QRS complex, atrioventricular conduction block, ventricular fibrillation, and then asystole. If no compelling indication for immediate therapy exists, a careful history and physical examination should be performed, with particular emphasis on medication, diet, and chronic kidney disease. Intravenous calcium is required for rapid reversal of conduction abnormalities that are present. Treatment of GDM results in a statistically significant decrease in the incidence of preeclampsia, shoulder dystocia, and macrosomia. Preventive Services Task Force updated its 2008 statement to recommend that asymptomatic pregnant women be screened for GDM after 24 weeks of gestation (B recommendation). Although women with elevated glucose levels on the 75-g test have an increased risk of adverse pregnancy outcomes,17 no trials have demonstrated that treatment of GDM in these women improves outcomes.
Renal K+ excretion is mediated by aldosterone and sodium (Na+) delivery (glomerular filtration rate [GFR]) in principal cells of the collecting ducts.3 K+ is freely filtered by the glomerulus, and almost all the filtered K+ is reabsorbed in the proximal tubule and loop of Henle (Fig. In patients with ischemic or scarred myocardium, left ventricular hypertrophy, congestive heart failure, or myocardial infarction, hypokalemia is associated with an increased incidence of ventricular ectopy, ventricular tachycardia, and ventricular fibrillation. Important clinical clues such as medication, vomiting, and hypertension should be specifically sought. Moreover, in patients with chronic kidney disease (lower GFR), adaptive responses increase K+ excretion, with resultant increases in FEK and TTKG. Pseudohyperkalemia can occur with thrombocytosis, hemolysis, and extremely high white cell counts.
Impaired K+ excretion or impaired potassium entry into cells accounts for all other causes of hyperkalemia. The serum potassium concentrations are poorly correlated to the electrocardiographic and conduction abnormalities. An exception to this is hyperkalemia caused by digoxin toxicity because acute hypercalcemia can potentiate the toxic effects of digoxin. Most clinicians in the United States use a two-step approach, first administering a 50-g non-fasting oral glucose challenge test at 24 to 28 weeks, followed by a 100-g fasting test for women who have a positive screening result.13A  Alternatively, clinicians may use a one-step approach and administer only a 75-g two-hour fasting oral glucose tolerance test. Some physicians obtain serial ultrasonography (separated by at least four weeks) to monitor fetal growth in patients with GDM.
Factitious or spurious hypokalemia, which can occur in patients with leukemia or elevated white cell counts because K+ is taken up by these metabolically active cells in the test tube, should be ruled out. Therefore, the normal values will vary, making the interpretation of significance difficult.
In these cases, lysis of the cells in the test tube releases potassium into the serum and increases potassium concentrations.
Acute therapy is also directed at rapidly moving potassium into cells with intravenous dextrose and insulin.


If glucose levels remain above target values, pharmacologic therapy with metformin, glyburide, or insulin should begin.
Less intensive glucose monitoring is appropriate for women with GDM that is well controlled with diet and exercise.1,2LIFESTYLE CHANGESInitial treatment for GDM involves diet and activity modification. One regulates K+ excretion, or external balance through the kidneys and intestines, and the second regulates K+ shifts, or internal balance between intracellular and extracellular fluid compartments. This absorption in the proximal part of the nephron passively follows that of Na+ and water, whereas reabsorption in the thick ascending limb of the loop of Henle is mediated by the Na+,K+,2Cl- carrier (NKCC2) in the luminal membrane. If true hypokalemia is present, then determine whether it was caused by a transcellular shift or a decrease in total body potassium.
Repeated fist clenching with a tourniquet can also release K+ from muscle cells and increase potassium concentrations factitiously. A plasma K+ determination, instead of serum determination, is sometimes necessary in addition, spurious hyperkalemia will not be associated with abnormalities on the electrocardiogram (ECG).
Women with GDM should receive individualized nutrition counseling from a registered dietitian, which commonly includes a recommendation to limit carbohydrate intake to 33% to 40% of calories.2 No high-quality data exist on the optimal diet for women with GDM. Hypokalemia from transcellular shift is managed by treating the underlying condition or removing the offending agent. In hyperkalemic patients, a value greater than 10 suggests normal aldosterone action and an extrarenal cause of hyperkalemia. If hyperkalemia is indeed present, then determine whether it occurred with a transcellular shift or reduction in potassium excretion, or in the setting of preserved renal function.
Longer term therapy for hyperkalemia without conduction abnormalities should be directed toward minimizing intake and increasing excretion of potassium. Induction of labor should not occur before 39 weeks in women with GDM, unless glycemic control is poor or another indication for delivery is present. This search included meta-analyses, randomized controlled trials, clinical trials, and reviews. 1) in the cortical and outer medullary collecting tubule, and the papillary (or inner medullary) collecting duct via luminal potassium channels (ROMK). Magnesium depletion reduces the intracellular potassium concentration and causes renal potassium wasting; it appears to be caused by an impairment of cell membrane Na+, K+-ATPase (Box 2). Unless otherwise indicated, scheduled cesarean delivery should be considered only in women with an estimated fetal weight greater than 4,500 g.
Maternal obesity, excess gestational weight gain, and GDM are independent and additive risk factors for macrosomia. Also searched were the Agency for Healthcare Research and Quality evidence reports, the U.S. Secretion in these segments varies according to physiologic requirements, and is responsible for most of the urinary potassium excretion. Urine potassium, chloride, creatinine, and serum aldosterone levels are determined to distinguish the causes of extrarenal and renal losses of K+ so that the primary condition can be treated, in addition to replacement therapy (see Fig.
Preventive Services Task Force, the Cochrane database, DynaMed, and Essential Evidence Plus. Secretion in the distal segments is also balanced by K+ reabsorption through the intercalated cells (see Fig. These patients should be screened six to 12 weeks postpartum for persistently abnormal glucose metabolism, and should undergo screening for diabetes every three years thereafter. Although insulin has historically been the standard therapy for women with uncontrolled GDM, oral medications are now appropriate first-line therapies as well.2 Options for oral medications include metformin (Glucophage) and glyburide. This process is mediated by an active H+,K+-ATPase pump in the luminal membrane and results in both proton secretion and K+ reabsorption. Metformin and glyburide cross the placenta but have not been associated with birth defects or short-term adverse neonatal outcomes.2,31,32 However, data on long-term metabolic effects on children with in utero exposure are limited.



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