New Insights into the Diagnosis and Management of Pregnancy-Related Diabetes Insipidus

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Diabetes insipidus in pregnancy (diabetes insipidus gravidarum, gestational diabetes insipidus or pregnancy-related diabetes insipidus) is considered to be a rare disease complicating up to 1 in 25000-30000 pregnancies; however, emerging evidence suggests that often the disease is under-diagnosed (Aleksandrov et al., 2010). As stated by the Italian E. Momigliano, in 1929, in his first monograph on 31 cases of pregnancy-related diabetes insipidus (Momigliano, 1929), the disease may occur in an apparently healthy woman, during any stage of pregnancy, usually in the latter half, or may aggravate during pregnancy when previously diagnosed. As a paradox, the disorder may disappear days to weeks after delivery, or may alleviate, or remain unaltered (Bleakley, 1938). Moreover, aggravated recurrence of the disorder in successive pregnancies is recognized (Blotner & Kunkel, 1942). Interest towards pregnancy-related diabetes insipidus revived about 20-30 years ago, once it became apparent that this clinical condition is closely associated with liver disease, HELLP syndrome and the wide spectrum of preeclampsia, all with potentially serious consequences on the maternal course of gestation and fetal health and development. The aim of the present book chapter is to review the body water homeostasis during pregnancy as well as to insist on clinical conditions associated with the occurrence of diabetes insipidus in pregnancy and the early postpartum period. Not only true gestational diabetes insipidus will be addressed but, notably, maternal hypothalamic-pituitary diseases associated with diabetes insipidus presenting high incidence during pregnancy and the postpartum period will be detailed. It is the author’s hope that at the end of the chapter, the reader will find answers to hot questions on the intimate mechanisms facilitating gestational diabetes insipidus, the need to screen or not for alterations in water metabolism in pregnant women at risk, the challenges in differential diagnosis of arginin-vasopressin (AVP) disturbances in a pregnant women and the associated clinical conditions including preeclampsia, acute fatty liver and HELLP (Hemolysis-Elevated Liver enzymes-Low Platelets) syndrome. In addition, etiological considerations on AVP deficiency or defective hormone action in the fetus and neonate will be made.