Disorders of Fluid

Volume

Because Na is the major osmotically active ion in

the ECF, total body Na content determines ECF
volume. Deficiency or excess of total body Na
content causes ECF volume depletion or
overload. Serum Na concentration does not
necessarily reflect total body Na.
Dietary intake and renal excretion regulate total
body Na content. When total Na content and
ECF volume are low, the kidneys increase Na
conservation. When total Na content and ECF
volume are high, Na excretion (natriuresis)
increases so that volume decreases.
Renal Na excretion can be adjusted widely to
match Na intake. Renal Na excretion requires
delivery of Na to the kidney and so depends on
renal blood flow and GFR. Thus, inadequate Na
excretion may be secondary to decreased renal
blood flow, as in renal disease or heart failure.
The renin-angiotensin-aldosterone axis is the
main regulatory mechanism of renal Na
excretion. In volume-depleted states, GFR and
Na delivery to the distal nephron decrease,
causing release of renin. Renin cleaves
angiotensinogen (renin substrate) to form
angiotensin I. ACE then cleaves angiotensin I to
angiotensin II. Angiotensin II increases Na
retention by decreasing the filtered load of Na
and enhancing proximal tubular Na reabsorption.
Angiotensin II also stimulates the adrenal cortex
to secrete aldosterone, which increases Na
reabsorption via multiple renal mechanisms.
Angiotensin I can also be transformed to
angiotensin III, which stimulates aldosterone
release as much as angiotensin II but has much
less pressor activity. Aldosterone release is also
stimulated by hyperkalemia. Several natriuretic
factors have been identified, including atrial
natriuretic peptide (ANP), brain natriuretic
peptide (BNP), and a C-type natriuretic peptide
(CNP).
ANP, in cardiac atrial tissue, increases in
response to ECF volume overload (eg, heart
failure, renal disease, cirrhosis with ascites) and
primary aldosteronism and in some patients with
essential hypertension. Decreases have
occurred in some patients with nephrotic
syndrome and presumed ECF volume
contraction. High levels increase Na excretion
and increase GFR even if BP is low.
BNP is synthesized mainly in the atria and left
ventricle and has similar triggers and effects to
ANP. BNP assays are available, and high BNP
level is used to diagnose volume overload. CNP,
in contrast to ANP and BNP, is primarily
vasodilatory.
Na depletion requires inadequate Na intake plus
abnormal losses from the skin, GI tract, or kidney
(defective renal Na conservation). Defective
renal Na conservation may be caused by primary
renal disease, adrenal insufficiency, or diuretic
therapy. Na overload requires higher Na intake
than excretion; however, because normal
kidneys can excrete large amounts of Na, Na
overload generally reflects defective renal Na
excretion.
EXTRACELLULAR FLUID VOLUME
CONTRACTION
ECF volume contraction is a decrease in ECF
volume caused by loss of water and total body
Na content. Causes include vomiting, sweating,
diarrhea, burns, diuretic use, and renal failure.
Clinical features include diminished skin turgor,
dry mucous membranes, tachycardia, and
orthostatic hypotension. Diagnosis is clinical.
Treatment involves administration of Na and
water.
A decrease in ECF (ECF volume contraction
[hypovolemia]) is not the same as a decrease in
effective plasma volume. Decreased effective
plasma volume may occur with decreased ECF,
but it may also occur with an increased ECF (eg,
in heart failure, hypoalbuminemia, capillary leak
syndrome).
ECF volume contraction usually involves loss of
Na; Na loss always causes water loss.
Depending on many factors, plasma Na
concentration can be high, low, or normal despite
the decreased total body Na content. Common
causes of ECF volume depletion are listed in
Table 1: Fluid and Electrolyte Metabolism:
Common Causes of Extracellular Fluid Volume
Depletion .
Table 1
Common Causes of
Extracellular Fluid
Volume Depletion
Extrarenal
Bleeding
Dialysis:
Hemodialysis,
peritoneal dialysis
GI: Vomiting,
diarrhea,
nasogastric suction
Skin: Excessive
sweating, burns,
exfoliation
Third-space losses:
Intestinal lumen,
intraperitoneal,
retroperitoneal
Renal/adrenal
Acute renal failure:
Diuretic phase of
recovery
Adrenal disease:
Addison's disease
(glucocorticoid
deficiency),
hypoaldosteronism
Bartter syndrome
Diabetes mellitus
with ketoacidosis
or extreme
glucosuria
 Diuretics
Salt-wasting renal
disease (medullary
cystic disease,
interstitial
nephritis, some
cases of
pyelonephritis and
myeloma)

Symptoms and Signs

ECF volume depletion is suspected in patients
with a history of inadequate fluid intake
(especially in comatose or disoriented patients);
increased fluid losses; diuretic therapy; and renal
or adrenal disease.
In mild (5%) ECF volume depletion, the only sign
may be diminished skin turgor. The patient may
complain of thirst. Dry mucous membranes do
not always correlate with volume depletion,
especially in the elderly or in mouth-breathers.
Oliguria is typical. When ECF volume has
diminished by 5 to 10%, orthostatic tachycardia,
hypotension, or both are generally present,
although orthostatic changes can occur in
patients without ECF volume depletion,
particularly those deconditioned or bedridden.
Skin turgor (best assessed at the upper torso)
may be decreased. If dehydration exceeds 10%,
signs of shock can occur (eg, tachypnea,
tachycardia, hypotension, confusion, poor
capillary refill).
Diagnosis
Diagnosis is usually clinical. If the cause is
obvious and easily correctible (eg, acute
gastroenteritis in an otherwise healthy patient),
laboratory testing is unnecessary; otherwise,
serum electrolytes, BUN, and creatinine are
measured. Plasma osmolality and urine Na,
creatinine, and osmolality are measured if there
is suspicion of clinically meaningful electrolyte
abnormality that is not clear from serum tests
and for patients with cardiac or renal disease.
Invasive monitoring is necessary for patients with
previously unstable heart failure or arrhythmias.
Central venous pressure and pulmonary artery
occlusion pressure are decreased in ECF
volume depletion, but measurement is rarely
required.
During ECF volume depletion, normally
functioning kidneys conserve Na. Thus, the urine
Na concentration is usually < 15 mEq/L; the
fractional excretion of Na (urine Na/serum Na
divided by urine creatinine/serum creatinine) is
usually < 1%; also, urine osmolality is often >
450 mOsm/kg. If metabolic alkalosis is combined
with ECF volume depletion, urine Na
concentration may be high; in this instance, a
urine Cl concentration of < 10 mEq/L more
reliably indicates ECF volume depletion.
Misleadingly high urinary Na (generally > 20
mEq/L) or low urine osmolality can also occur
due to renal Na losses resulting from renal
disease, diuretics, or adrenal insufficiency. ECF
volume depletion frequently increases the BUN
and plasma creatinine levels with the ratio of
BUN to creatinine often > 20:1. Values such as
Hct often increase in volume depletion but are
difficult to interpret unless baseline values are
known.
Treatment
The cause of volume depletion is corrected and
fluids are given to replace existing volume
deficits as well as any ongoing fluid losses and
to provide daily fluid requirements. Mild-to-
moderate volume deficits may be replaced by
increased oral intake of Na and water if the
patient is conscious and is not vomiting severely.
When volume deficits are severe or when oral
hydration is impractical, IV 0.9% saline is given.
Typical IV regimens are presented discussed in
Shock and Fluid Resuscitation: Intravenous Fluid
Resuscitation; oral regimens, discussed in
Dehydration and Fluid Therapy: Oral
Rehydration.
EXTRACELLULAR FLUID VOLUME
EXPANSION
ECF volume expansion is caused by an increase
in total body Na content. It typically occurs in
heart failure, nephrotic syndrome, and cirrhosis.
Clinical features include weight gain, edema,
and orthopnea. Diagnosis is clinical. Treatment
aims to correct volume expansion and its cause.
An increase in total body Na is the key
pathophysiologic event. It increases osmolality,
which triggers compensatory mechanisms that
produce water retention.
Movement of fluid between interstitial and
intravascular spaces depends on Starling's
forces at the capillaries. Increased capillary
hydrostatic pressure, as occurs in heart failure;
decreased plasma oncotic pressure, as occurs in
nephrotic syndrome; or a combination, as occurs
in severe cirrhosis, shifts fluid into the interstitial
space, producing edema. In these conditions,
subsequent intravascular volume depletion
increases renal Na retention, which maintains
fluid overload. Common causes of volume
overload are listed in Table 2: Fluid and
Electrolyte Metabolism: Principal Causes of
Extracellular Fluid Volume Overload .
Table 2
Principal Causes of
Extracellular Fluid
Volume Overload
Renal Na
retention
Cirrhosis
Drugs: Minoxidil
SOME TRADE
NAMES
LONITEN
ROGAINE
Click for Drug
Monograph
, NSAIDs,
estrogens SOME
TRADE NAMES
PREMARIN
Click for Drug
Monograph
, fludrocortisone
SOME TRADE
NAMES
FLORINEF
Click for Drug
Monograph

Heart failure,
including cor
pulmonale
Pregnancy and
premenstrual
edema
Renal disease,
especially nephrotic
syndrome
Decreased
plasma oncotic
pressure
Nephrotic
syndrome
Protein-losing
enteropathy
Reduced albumin
synthesis (liver
disease,
malnutrition)
Increased
capillary
permeability
Acute respiratory
distress syndrome
Angioedema
Burns, trauma
Idiopathic edema
 IL-2 therapy
Sepsis syndrome
Iatrogenic
Administration of
excess Na (eg,
0.9% normal saline
IV)

Symptoms and Signs

Weight gain and weakness may occur before
edema formation. Dyspnea on exertion,
decreased exercise tolerance, tachypnea,
orthopnea, and paroxysmal nocturnal dyspnea
can also occur early when volume overload is
caused by left ventricular dysfunction. Elevated
jugular venous pressure may produce jugular
venous distention.
Early symptoms of edema may include puffy
eyes on rising in the morning and tight shoes at
the end of the day. Edema is often dependent in
heart failure. In ambulatory patients, edema is in
the feet and lower legs; patients at bed rest
develop edema on the buttocks, genitals, and
posterior thighs; women who lie on only one side
may develop edema in the dependent breast.
Edema can be accompanied by myriad findings,
including pulmonary rales, elevated central
venous pressure, an S3 gallop, and an enlarged
heart with pulmonary edema and/or pleural
effusions on chest x-ray. In cirrhosis, edema is
frequently confined to the lower extremities and
accompanied by ascites. Other signs of cirrhosis
include spider angiomas, gynecomastia, palmar
erythema, and testicular atrophy. In nephrotic
syndrome, edema is often diffuse, occasionally
with generalized anasarca, pleural effusions, and
ascites; periorbital edema occurs frequently, but
not invariably.
Diagnosis
Symptoms and signs, including dependent
edema, are usually diagnostic. Physical findings
may suggest a cause. For instance, edema plus
ascites suggests cirrhosis. Rales and S3 suggest
heart failure. Generally, diagnostic testing
includes serum electrolytes, BUN, creatinine,
and any other tests directed at the cause (eg,
chest x-ray for suspected heart failure). Causes
of isolated lower extremity swelling (eg,
lymphedema, venous stasis, venous obstruction,
local trauma) should be excluded.
Treatment
In patients with heart failure, maximizing left
ventricular function (eg, by using inotropic agents
or afterload reduction) can increase Na delivery
to the kidneys and Na excretion. Treatment of
the causes of nephrotic syndrome depends on
the specific renal histopathology.
Loop diuretics, such as furosemide SOME
TRADE NAMES
LASIX
Click for Drug Monograph
, inhibit Na reabsorption in the ascending limb of
the loop of Henle. Thiazide diuretics inhibit Na
reabsorption in the distal tubule. Both loop
diuretics and thiazide diuretics increase
excretion of Na and thus water. K wasting can be
problematic in some patients; K-sparing
diuretics, such as amiloride SOME TRADE
NAMES
MIDAMOR
Click for Drug Monograph
, triamterene SOME TRADE NAMES
DYRENIUM
Click for Drug Monograph
, and spironolactone SOME TRADE NAMES
ALDACTONE
Click for Drug Monograph
, inhibit Na reabsorption in the distal nephron
and collecting duct. When used alone, they
increase Na excretion, but only modestly. Both
triamterene SOME TRADE NAMES
DYRENIUM
Click for Drug Monograph
and amiloride SOME TRADE NAMES
MIDAMOR
Click for Drug Monograph
have been combined with a thiazide to prevent K
wasting.
Many patients respond insufficiently to diuretics;
 common contributing factors include inadequate
treatment of the cause of volume overload,
noncompliance with dietary Na restriction,
hypovolemia, and renal disease. Diuresis can
frequently be achieved by increasing the dose of
a loop diuretic or combining it with a thiazide.
After correction of volume overload,
maintenance of euvolemia may require
restriction of dietary Na unless the underlying
condition can be eliminated. Diets containing 3 to
4 g/day Na are generally adequate, are fairly well
tolerated, and work reasonably well in mild-to-
moderate volume overload diets for heart failure.
Advanced cirrhosis and nephrotic syndrome
often require more severe Na restriction (≤ 1
g/day). K salts are often substituted for Na salts
to make Na restriction tolerable; however, care
should be taken, especially in patients receiving
K-sparing diuretics or ACE inhibitors and in those
with renal disease, because potentially fatal
hyperkalemia can result

Placenta
Previa
 Buy the
Book
PDA
Download

Update Me

E-mail alerts
The Merck
Manual
Minute

Print This
Topic
Email This
Topic

Placenta previa is implantation of the placenta

over or near the internal os of the cervix.
Typically, bright red painless vaginal bleeding
occurs during late pregnancy. Diagnosis is by
transvaginal or abdominal ultrasonography.
Treatment is bed rest for minor vaginal bleeding
before 36 wk gestation or, after 36 wk or in
refractory cases, immediate delivery, usually by
cesarean section.
Placenta previa may be total (covering the
internal os completely), partial (covering part of
the os), or marginal (at the edge of the os), or
the placenta may be low-lying (near the os
without reaching it). Incidence of placenta previa
is 1/200 deliveries. Risk factors include
multiparity, prior cesarean delivery, uterine
abnormalities that inhibit normal implantation
(eg, fibroids), smoking, and multifetal pregnancy.
If placenta previa occurs during early pregnancy,
it usually resolves by 20 wk as the uterus
enlarges.
Symptoms, Signs, and Diagnosis
Symptoms usually first occur in late pregnancy.
Then, sudden, painless vaginal bleeding often
begins; the blood may be bright red, and
bleeding may be heavy, sometimes resulting in
hemorrhagic shock. If placenta previa is present,
pelvic examination may increase bleeding,
sometimes causing sudden, massive bleeding;
thus, if vaginal bleeding occurs after 20 wk,
pelvic examination is contraindicated unless
placenta previa is first ruled out by
ultrasonography. Placenta previa frequently
cannot be distinguished from abruptio placentae
except by ultrasonography. Transvaginal
ultrasonography is an accurate, safe way to
diagnose placenta previa.
 Treatment
Treatment of minor vaginal bleeding before
about 34 wk is hospitalization, bed rest, and
avoidance of sexual intercourse, which can
cause bleeding by initiating contractions or
causing direct trauma. If bleeding stops,
ambulation and usually hospital discharge are
allowed. Delivery is indicated if bleeding is
heavy, uncontrolled, or both or if fetal lungs are
mature, usually at 36 wk. Delivery is almost
always by cesarean section, but vaginal delivery
may be possible for women with a low-lying
placenta if the fetal head effectively compresses
the placenta and labor is already advanced or if
the pregnancy is < 23 wk and rapid delivery is
expected. Hemorrhagic shock is treated (see
Shock and Fluid Resuscitation: Prognosis and
Treatment).

Placenta previa, the implantation of the placenta at least

partially covering the cervix, occurs in about one in 200
pregnancies. There are actually three types of previa.
Complete previa where the cervical os, the mouth of the
uterus, is completely covered. Partial previa where just a
portion of the cervix is covered by the placenta. And the
marginal previa that extends just to the edge of the cervix.
Diagnosing a previa is usually made when there is
painless bleeding during the third trimester. If you are
bleeding it is unwise to do a vaginal exam until an
ultrasound has ruled out a placenta previa. However, there
is a 10% false positive diagnosis rate, usually because of
the bladder being over full. There is also a 7% false
negative rate, typically caused from missing the previa that
is located behind the baby's head.
Other reasons to suspect a previa would sometimes be
premature contractions, abnormal lie (breech, transverse,
etc.), or the uterus measuring larger than you should
according to dates.
During second trimester ultrasounds, done in some places
on a routine basis, will show that there are many more
previas diagnosed at this stage. Typically at 16 weeks the
placenta takes up 25-50% of the surface area. Also the
third trimester brings a growth of this lower uterine
segment, that out flanks the growth of the placenta. For
these reasons, while 5% of pregnancies are diagnosed
with complete previa in second trimester ultrasounds will
see 90% of them resolved by term and while 45% of
pregnancies are diagnosed with marginal previas will see
95% resolved at term. A follow up ultrasound will be done,
and as noted above the vast majority of previas are not
seen.
True placenta previa at term is very serious. Complications
for the baby include:
• Problems for the baby, secondary to acute
blood loss
• Intrauterine growth restriction (IUGR) due to
poor placental perfusion
• Increased incidence of congenital anomalies
Risks for the mother include:
• Life-threatening hemorrhage
• Cesarean delivery

• Increased risk of postpartum hemorrhage

• Increased risk placenta accreta (Placenta

accreta is where the placenta attaches directly
to the uterine muscle.)
Placenta previa, once diagnosed, will usually mean
bed rest for the mother, frequently in the hospital.
Depending on the gestational age steroid shots
may be given to help mature the baby's lungs. If
the bleeding cannot be controlled immediate
cesarean delivery is usually done, regardless of the
length of the pregnancy. Some marginal previas
can be delivered without cesarean surgery, the
other types of placenta previa preclude vaginal
delivery.
There are a few predisposing factors. The following can
increase your risk for placenta previa:
• Advanced maternal age
• Increased parity (number of pregnancies)
• Previous uterine surgery, including cesarean
section (regardless of incision type)
Placenta previa can be a very scary diagnosis for all
involved. The period of time from the diagnosis to the
delivery are often periods of great worry and fear. There
are support groups for bedrested mothers and even some
for mothers with placenta previa. They are available to
help you through this period of time.

ou should drink at least six to eight 8-ounce glasses per

day (48 to 64 fluid ounces) plus one 8-ounce cup for each
hour of light activity. Juices can contribute to your fluid
intake, but keep in mind that they can also provide a lot of
extra calories. Caffeinated beverages, such as coffee,
colas, and teas don't count as part of your fluid intake
because they're diuretics — they make you urinate more
so you actually lose water.

Water plays many vital roles in a healthy pregnancy. Think

of water as your body's transportation system — it carries
nutrients through your blood to the baby. Water also helps
prevent bladder infections, which are common during
pregnancy. If you drink enough water, your urine will stay
diluted, reducing your risk of infection.

Water can also stop constipation and help prevent

hemorrhoids. Although it may seem counterintuitive, the
more water you drink during pregnancy, the less water
your body will retain. Also, drinking enough water prevents
dehydration. This is especially important in the third
trimester when dehydration can actually cause
contractions that can trigger preterm labor.

If you just don't like the taste of water, try adding a wedge
of lemon or lime, or a little juice for additional flavor. If
you're not sure how much water you drink each day, fill a
64-ounce container and try to finish it by the end of the
day.

The next time you see a water fountain, stop for a quick
drink. Every little bit of water helps ensure a healthy
pregnancy.

Benefits of Water
The human body, which is made up of between 55 and 75 percent water (lean people have more
water in their bodies because muscle holds more water than fat), is in need of constant water
replenishment.
Your lungs expel between two and four cups of water each day through
normal breathing - even more on a cold day. If your feet sweat, there
goes another cup of water. If you make half a dozen trips to the bathroom
during the day, that's six cups of water. If you perspire, you expel about
two cups of water (which doesn't include exercise-induced perspiration).
A person would have to lose 10 percent of her body weight in fluids to be
considered dehydrated, but as little as two percent can affect athletic
performance, cause tiredness and dull critical thinking abilities. Adequate
water consumption can help lessen the chance of kidney stones, keep
joints lubricated, prevent and lessen the severity of colds and flu and help
prevent constipation.
Health benefits of water
Water is crucial to your health. It makes up, on average, 60 percent of your body weight. Every
system in your body depends on water.
Lack of water can lead to dehydration, a condition that occurs when you don't have enough water
in your body to carry on normal functions. Even mild dehydration - as little as a 1 percent to 2
percent loss of your body weight - can sap your energy and make you tired. Dehydration poses a
particular health risk for the very young and the very old. Signs and symptoms of dehydration
include:
• Excessive thirst
• Fatigue
 • Headache
• Dry mouth
• Little or no urination
• Muscle weakness
• Dizziness
• Lightheadedness
How much water do you need?
Every day you lose water through sweating - noticeable and unnoticeable - exhaling, urinating
and bowel movements. For your body to function properly, you need to replace this water by
consuming beverages and foods that contain water. So how much water, or more precisely fluid,
do you need?
This isn't an easy question to answer. A healthy adult's daily fluid intake can vary widely. Most
people drink fluid to quench thirst, to supply perceived water needs and "out of habit." At least
three approaches estimate total fluid (water) needs for healthy, sedentary adults living in a
temperate climate.
• Replacement approach. The average urine output for adults is 1.5 liters a day. You lose
close to an additional liter of water a day through breathing, sweating and bowel
movements. Food usually accounts for 20 percent of your fluid intake, so you if you
consume 2 liters of water or other beverages a day (a little more than 8 cups), along with
your normal diet, you can replace the lost fluids.

• Eight 8-ounce glasses of water a day. Another approach to water intake is the "8 x 8
rule" - drink eight 8-ounce glasses of water a day (about 1.9 liters). The rule could also be
stated, "drink eight 8-ounce glasses of fluid a day," as all fluids count toward the daily
total. Though this approach isn't supported by scientific evidence, many people use this
basic rule as a guideline for how much water and other fluids to drink.

• Dietary recommendations. The Institute of Medicine recommends that men consume 3

liters (about 13 cups) of total beverages a day and women consume 2.2 liters (about 9
cups) of total beverages a day. These guidelines are based on national food surveys that
assessed people's average fluid intakes.
You can choose any of these fluid intake approaches to gauge your fluid needs. But your current
total fluid intake is probably OK if you drink enough water to quench your thirst, produce a
colorless or slightly yellow normal amount of urine, and feel well.
Factors that influence water needs
You may need to modify total fluid intake from these recommended amounts depending on
several factors, including how active you are, the climate, your health status, and if you're
pregnant or breast-feeding.
• Exercise. If you exercise or engage in any activity that makes you sweat, you'll need to
drink extra water to compensate for that fluid loss. Drink 2 cups of water two hours
before a long endurance event, for example, a marathon or half-marathon. One to 2 cups
of water is also adequate for shorter bouts of exercise. During the activity, replenish
fluids at regular intervals, and continue drinking water or other fluids after you're
 finished. During intense exercise involving significant sweating, for example, during a
marathon, sodium is lost in sweat, and you may need a sports drink with sodium rather
than just water.

• Environment. You need to drink additional water in hot or humid weather to help lower
your body temperature and to replace what you lose through sweating. You may also need
extra water in cold weather if you sweat while wearing insulated clothing. Heated, indoor
air can cause your skin to lose moisture, increasing your daily fluid requirements. And
altitudes greater than 2,500 meters (8,200 feet) also can affect how much water your body
needs. Higher altitudes may trigger increased urination and more rapid breathing, which
uses up more of your fluid reserves.

• Illnesses or health conditions. Some signs and symptoms of illnesses, such as fever,
vomiting and diarrhea, cause your body to lose extra fluids. To replace lost fluids, drink
more water or oral rehydration solutions (Gatorade, Powerade, CeraLyte, others). When
water loss can't be replaced orally, intravenous water and electrolytes may be necessary.
Increased water intake is nearly always advised in people with urinary tract stones. On
the other hand, you may need to limit the amount of water you drink if you have certain
conditions that impair excretion of water - such as heart failure and some types of kidney,
liver, adrenal and thyroid diseases.

• Pregnant or breast-feeding. Women who are pregnant or breast-feeding need additional

water to stay hydrated and to replenish the fluids lost, especially when nursing. The
Institute of Medicine recommends that pregnant women drink 2.3 liters (nearly 10 cups)
of fluids a day and women who breast-feed consume 3.1 liters (about 13 cups) of fluids a
day.
Beyond the tap: Many sources of water
You don't need to sip from your water bottle all day to satisfy your fluid needs. Your diet,
including the beverages you drink, can provide a large portion of what you need. In an average
adult diet, food provides about 20 percent of total water intake. The remaining 80 percent comes
from beverages of all kinds.
Fruits and vegetables - besides being good sources of vitamins, minerals and fiber - contain lots
of water. For example, oranges are 87 percent water, and cucumbers are 95 percent water. Milk,
juice and other beverages also have large amounts of water. Conversely, dried fruits, nuts, grain
products and baked goods generally contain less water.
Make it count: Meet your water needs through food and beverages
Alcohol - such as beer and wine - and caffeinated beverages - such as coffee, tea or soda - can
contribute to your total fluid intake. But your best beverage is still water. Water is calorie-free,
inexpensive when drawn from a faucet or fountain, and readily available in and out of your
home.
Thirst not always a reliable gauge
If you're healthy and not in any dehydrating conditions, you can generally use your thirst as an
indicator of when to drink water. But thirst isn't always an adequate gauge of your body's need
for fluid replenishment. The older you are, the less you're able to sense that you're thirsty. And
during vigorous exercise, an important amount of your fluid reserves may be lost before you feel
thirsty. So make sure that you're sufficiently hydrated before, during and after exercise.
Increased thirst and increased urination, both in volume and frequency, can be signs and
symptoms of diabetes. With diabetes, excess blood sugar (glucose) in your body draws water
from your tissues, making you feel dehydrated. To quench your thirst, you drink a lot of water
and other beverages and that leads to more frequent urination. If you notice unexplained
increases in your thirst and urination, see your doctor. It may not necessarily mean you have
diabetes. It could be something else. And some people consume large amounts of water and
experience increased urine output not associated with any underlying disease.
Diabetes - Staying safely hydrated
Make a conscious effort to keep yourself hydrated and make water your beverage of choice.
Nearly every healthy adult can consider the following:
• Drink a glass of water with each meal and between each meal.
• Take water breaks instead of coffee or tea breaks.
• Substitute sparkling water for alcoholic drinks at social gatherings.
If you drink water from a bottle, thoroughly clean or replace the bottle often. Every time you
drink, bacteria from your mouth contaminate water in the bottle. If you use a bottle repeatedly,
make sure that the bottle is designed for reuse. To keep it clean, wash your container in hot,
soapy water or run it through a dishwasher before refilling it.
Though uncommon, it's possible to drink too much water. Drinking excessive amounts can
overwhelm your kidneys' ability to get rid of the water. This can lead to hyponatremia, a
condition in which excess water intake dilutes the normal amount of sodium in the blood. People
who are older, who have certain medical conditions such as congestive heart failure and
cirrhosis, or who are taking certain diuretics are at higher risk of hyponatremia.