Balancing Benefits and Risks of Indomethacin in the Management of Antenatal Bartter Syndrome: A Case Report

Abstract

BackgroundBartter syndrome, a very rare inherited renal tubular disorder, characterized by urinary salt wastage, hypokalemia, polyuria, and metabolic alkalosis, may manifest antenatally as severe isolated polyhydramnios. Indomethacin is known to reduce salt wastage and subsequent polyhydramnios during pregnancy; however, it reduces the Ductus Arteriosus diameter among other potential complications, such as inhibition of gastrointestinal perfusion and increasing the risk of renal toxicity.CaseA 36-year-old multigravida presented with severe isolated polyhydramnios at 30 weeks of gestation. Based on a history of a previous pregnancy affected with Bartter syndrome, indomethacin was initiated. Amniotic fluid volume and Ductus Arteriosus diameter were monitored. As evidence lacks on optimal dose and duration of indomethacin, multiple-dose adjustments were made to reduce the amniotic fluid volume while maintaining normal Ductus Arteriosus diameter. Progressive polyhydramnios led to Cesarean section at 34+ weeks of gestation resulting in a healthy fetus diagnosed with Bartter syndrome in the early neonatal period.ConclusionWe share our experience in the adjustment of the dose and duration of Indomethacin therapy in the treatment of severe polyhydramnios associated with antenatal Bartter syndrome. Amniotic fluid index, Ductus Arteriosus diameter, and umbilical artery doppler work together as key indicators to guide the success and safety of the therapy.

Bartter Syndrome Presenting as Arginine-Vasopressin Resistance: A Report of 2 Cases

“…Prenatal genetic diagnosis is the recommended step, with calculation of the “Bartter index” (total protein multiplied by alpha-fetoprotein; measurements on the amniotic fluid) as an alternative [ 9 ]. Treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and serial amniocentesis have been used with satisfactory success in case reports [ 10 , 11 ], although risks of therapy – especially with NSAIDs – should be carefully monitored, preferably in a multidisciplinary setting [ 9 ]. In addition, uncovering a genetic etiology allows genetic counseling and reproductive assisted techniques to parents that desire further healthy pregnancies, as shown in our first case.…”