Endocrine Abstracts

Primary hyperparathyroidism (PHPT) is rare in pregnancy, with an incidence of 1%. It is associated with maternal, fetal, and neonatal complications. Treatment options include both medical and surgical approaches. Parathyroidectomy is the definitive and preferred treatment, especially when serum calcium level is higher than 10.8 mg/dl and with a prior history of pregnancy loss. Herein, we present two cases of gestational primary hyperparathyroidism with different treatments.

Case one

A 40-year-old lady G5P3023 at 30 weeks of gestation who presented with epigastric. Initial workup revealed serum lipase of 1256 u/l and serum calcium of > 15 mg/dl with normal serum albumin. Further workup for hypercalcemia showed an elevated ionized calcium level of 2.04 mmol/l, PTH of 350 pg/ml, Vitamin D 1–25 dihydroxy level of 43.1 pg/ml, vitamin D 25 hydroxy level of 15.9 ng/ml. She received intravenous fluids for acute pancreatitis. Ultrasound of the neck revealed a 1.9 × 1.6.1.7 cm nodule suspicious for parathyroid adenoma. The patient received aggressive IV fluid resuscitation, two intramuscular injections of 300 units of calcitonin, and 60 mg of cinacalcet twice daily. Despite medical management, her serum calcium level remained elevated for a week, requiring and a right inferior parathyroidectomy. After surgery, her serum calcium level normalized.

Case two

A 30-year-old lady G1P1001 at 40 weeks of gestation who presented with concerns of decreased fetal movements. She underwent emergent cesarean due to non-reassuring fetal heart tones. The infant was born with hypoglycemia. Initial workup was significant for serum calcium of 14.1 mg/dl with normal serum albumin. Given the hypercalcemia, the patient received aggressive intravenous fluid resuscitation, 200 units of subcutaneous calcitonin twice daily, 30 mg of cinacalcet twice daily. Further workup for hypercalcemia showed ionized serum calcium level of 1.61 mmol/l, PTH of 302.6 pg/ml, vitamin D 25 hydroxy level of 20.4 ng/ml. Her hypercalcemia manifested as several episodes of coarse upper and lower extremity tremors. An ultrasound of the neck illustrated a 2.5 × 2.5 cm parathyroid nodule consistent with a parathyroid adenoma. Despite medical management, serum calcium levels remained high after a week. She underwent left inferior parathyroidectomy, and her calcium levels normalized after the surgery.

Compared to conservative management, surgical treatment with parathyroidectomy is associated with better maternal and fetal outcomes, as it has shown a decreased incidence of pre-eclampsia and preterm delivery. Hence, gestational hyperparathyroidism is a clear indication for an early parathyroidectomy in both symptomatic and asymptomatic patients.