Endocrine Abstracts

Introduction: We submit a rare presentation of primary hyperparathyroidism in pregnancy posing complex management difficulties.

Case report: A 32-year-old Asian woman presented during third trimester of her pregnancy with symptoms of lethargy, leg pain, and weakness. Routine investigations revealed an elevated calcium level (3.83 mM) and PTH level of 231.1 ng/l. She was treated with i.v. fluids and pamidronate. An ultrasound of her thyroid gland showed a large superior left parathyroid adenoma measuring 1.9 ×1.5 × 4.1 cm. She had a background history of a still birth at 28+6 weeks which was complicated by chickenpox followed by several miscarriages (9) in the first trimester. She was investigated in two different tertiary centres and a possible diagnosis of antiphospholipid syndrome was made due to a borderline positive lupus anticoagulant and anti cardiolipin antibody. She also had a history of severe vitamin D deficiency (level <10 nmol/l) with borderline high calcium (2.64 mM) and very high PTH 386 ng/l 5-yearly previously.She was treated with alpha calcidol and refered to local endocrine team but follow- up was lost because she moved. Owing to this background an urgent caesarean section was performed and healthy baby was delivered at 33 weeks and 4 days. After delivery she was started on cinacalcet to control her calcium levels. Elective para thyroidectomy was performed and now her calcium level and PTH are currently normal. Parathyroid gland biopsy results were in keeping with either adenoma or hyperplasia.

Discussion: Primary hyperparathyroidism during pregnancy poses significant risks to the mother and the foetus. Fortunately, prompt diagnosis and effective management can improve outcomes for both. There is controversy regarding appropriate management of these patients, especially late in gestation. The objective of this case report, therefore, is to review the literature and to propose an evidence-based approach to managing these patients. The prevalence of primary hyperparathyroidism in the general population is 0.15%. In addition to many constitutional symptoms, maternal complications include nephrolithiasis, bone disease, pancreatitis, hyperemesis, muscle weakness, mental status changes, and hypercalcemic crisis. Reported fetal complications include intrauterine growth retardation, low birth weight, preterm delivery, intrauterine fetal demise, postpartum neonatal tetany, and permanent hypoparathyroidism.