Endocrine Abstracts

Primary hyperparathyroidism in pregnancy can be associated with serious complications. Maternal complications include, increased risk of pre-eclampsia/eclampsia, miscarriage, arrythmia during labour/delivery, and still/premature birth. Neonatal complications include risk of permanent hypoparathyroidism, tetany, seizures, hypotonia, low birth, weight and respiratory distress. Early part of second trimesters is the best time to operate, as risks of surgery and anaesthesia are minimal, foetal parathyroids are formed during second and third trimester and hypercalcemia in third trimester may lead to hypertension/pre-eclampsia. We present a case of primary hyperparathyroidism presenting during pregnancy as hyperemesis.

A 22-year-old primiparous lady with poorly controlled type 2 diabetes, hypertension, morbid obesity (BMI 39.4) was admitted at 12 weeks gestation with intractable vomiting. She had similar admissions earlier in this pregnancy with ‘hyperemesis’. She was found to have a biochemical picture of primary hyperparathyroidism, with raised calcium of 3.16 mmol/l and elevated PTH of 17.9 pmol/l. TSH was normal (1.62 mU/l). Ultrasound of parathyroid revealed a 9.5 mm well defined soft tissue nodule in the right side, raising a probability of parathyroid adenoma. During second trimester, she underwent an open exploration of the neck and removal of a single slightly large parathyroid gland from her right neck. Although the parathyroid hormone levels dropped initially, it plateaued at ~ 11 pmol/l. Six days later, she underwent re-exploration and removal of left parathyroid gland which was retro-tracheal in position. Intra-operative parathyroid hormone estimations showed a satisfactory drop in PTH level to 1.1 pmol/l. Intra-operative frozen section confirmed an adenoma. Post-operatively, she was established on α-calcidol. She delivered a healthy baby at term.

This case highlights the importance of checking calcium in pregnant women presenting with intractable vomiting. Intra-operative PTH measurements could be useful during difficult operations. Timely multidisciplinary approach in the management of such a patient is crucial for best maternal and foetal outcomes.