#4180 HYPERTENSION, HYPOKALEMIA AND PREGNANCY: A CASE OF GELLER SYNDROME
Authors: Sarwal Amara , Abraham Jo 
Published: June 2023

Abstract

Background and Aims
Hypokalemia is not a common laboratory finding in pregnancy, with a recent study revealing a prevalence of less than 1%, nationwide [1]. In a pregnant patient with newfound hypertension and hypokalemia, it is important to consider causes that would affect the Renin-Angiotension-Aldosterone pathway. Although these causes are usually suspected in patients with a triad of hypertension, hypokalemia and metabolic alkalosis, the latter finding may not be present in pregnant patients given metabolic compensation for their respiratory alkalosis of pregnancy.

Method
A 27 year old, 36 week and 5 day pregnant female presented to her OBGYN follow up appointment at the beginning of the year. At that time, she was found to be hypokalemic and was admitted overnight for potassium repletion, consisting of 40 mEq of oral potassium chloride and 40 mEq of intravenous potassium. She was discharged after that with a follow up appointment scheduled the next month. At that clinic visit, her potassium was 2.6 mmol/L and she was admitted for further workup. The patient was also hypertensive, with a blood pressure markedly increased from her baseline value. The patient endorsed having elevated blood pressures during her previous pregnancy with normalization after delivery. She stated that she was followed at a different outpatient clinic at that time, so she did not have all the records, however was told she suffered from pre-eclampsia. During this current admission, patient did note dyspnea, fatigue and generalized weakness. She denied any diarrhea or gastrointestinal distress. Her physical examination was unremarkable. Spot urine potassium was 19 with a serum potassium of 2.8 mmol/L after 40 mEq of potassium supplementation. Aldosterone was &lt;3 ng/dL and renin was 4.8 pg/mL. Urine protein to creatinine ratio was 167 mg/g with normal liver enzymes. Her magnesium level was 1.8 mg/dL. The patient had a vaginal delivery with improvement in blood pressure. No antihypertensive agents were required. During subsequent outpatient visits, her potassium also started to improve and she was eventually weaned off supplementation. Given an unremarkable physical examination along with hypokalemia and hypertension which resolved after delivery, a diagnosis of Geller syndrome was made. Genetic testing was considered but could not be performed.

Results
In Geller syndrome, a gain-of-function mutation allows progesterone to bind and stimulate the mineralocorticoid receptor. Clinically, this presents as a patient who develops hypertension and hypokalemia during states of high circulating progesterone, such as pregnancy. Often these derangements resolve after cessation of high levels of progesterone, such as delivery of fetus, without major intervention.

Conclusion
High clinical suspicion is needed for pregnant patients who present with hypertension and hypokalemia. Reviewing records of past pregnancies can often shed light in this patient population, specifically the resolution of the blood pressure and potassium derangements after delivery of fetus. Newer evaluation techniques, such as genetic testing, can also play an important role with identifying this condition and allowing for counselling prior to subsequent pregnancies. Treatment typically consists of electrolyte supplementation and blood pressure control until birth occurs.