Endocrine Abstracts

Introduction: Hyperparathyroidism (HPT) during pregnancy is rare but requires a specific approach for its diagnosis HPT is associated with a high incidence of associated maternal, fetal and neonatal complications, including miscarriage (3,5x-fold higher than expected), IUGR, prematurity and pre-eclampsia(1,2,3). The severity of complications is proportional to degree of maternal calcium level.

Case report: We report the case of moderate hypercalcaemia on primary hyperparathyroidism (PHPT) in a 43-year-old patient, 26 weeks pregnant, with a history of renal colic in 2015 and a caesarean delivery at 35 weeks for severe pre-eclampsia. The current pregnancy is marked by several episodes of lipothymia and hypertensive crises, therefore, given her history of severe pre-eclampsia, the patient is currently treated with Asaflow 160 mg and Aldomet 250 mg once daily. Hypercalcaemia was detected for the first time on 14 February 2023 at 14 weeks’ gestation, with a blood calcium level of 3.38 mmol/l. Following a lapse in treatment, the first visit to an endocrinologist was on 11 May 2023 at 26 weeks’ amenorrhoea. A biological workup was performed on 22/05/2023 and showed hypercalcemia corrected for hypoalbuminemia at 3.2mmol/l. In view of the risks inherent to hypercalcemia during pregnancy, it was decided to perform a parathyroidectomy (PTX) on the patient on 02/06/23. The preoperative localization work-up consisted of an ultrasound scan demonstrating the presence of a 14 x 9mm ovoid nodular lesion in the left lower pole, a localization confirmed by intraoperative palpation. Post-operative follow-up was marked by resolution of hypercalcemia and the absence of hungry bone syndrome. The 2-week post-operative foetal ultrasound follow-up was normal. Concomitantly we observed a postoperative resolution of the patient’s hypertension.

Discussion: Current guidelines recommend that pregnant women with PHPT and an albumin-adjusted total calcium level consistenly >2.85 mmol/l should undergo PTX at the beginning of the second trimester(4). The purpose of this timing is to reduce the risk of the surgery and miscarriage, which occurs mainly in the second trimester(2). By contrast, there is still some controversy whether mild hypercalcemia is associated with adverse pregnancy outcomes. In te present case, the therapeutic decision was complicated by the fact that the first endocrinology referral took place during the 3rd trimester, a trimester in which operative complications are more common. On re-reading the case history, hypercalcemia was already present during the first pregnancy and may have favoured the occurrence of pre-eclampsia.

Conclusion: Hyperparathyroidism during pregnancy is under-recognized despite its high complication rate. We emphasize the importance of recognizing its presence ideally before pregnancy or as early as possible during pregnancy. If diagnosed, surgery should be proposed especially if the calcemia is above 2.85 mmol/l.

Bibliography: 1. Dupuy O, Aubert P, Dumuis ML, Bordier L, Mayaudon H, Bauduceau B. Hyperparathyroïdie et grossesse: association à risque pour la mère et l’enfant. 11): e9 10.2. Norman J, Politz D, Politz L. Hyperparathyroidism during pregnancy and the effect of rising calcium on pregnancy loss: a call for earlier intervention. Clin Endocrinol (Oxf). 2009;71(1):104 9.3. Pal R, Bhadada SK, Gupta N, Behera A, Aggarwal N, Aggarwal A, et al. Primary hyperparathyroidism in pregnancy: observations from the Indian PHPT registry. J Endocrinol Invest. 1 juill 2021;44(7):1425 35.4. Kamenicky P, Bollerslev J, Rejnmark L, Zahn A, Heck A, Appelman-Dijkstra NM and al.; 2021 PARAT Working Group. European Expert Consensus on Practical Management of Specific Aspects of Parathyroid Disorders in Adults and in Pregnancy: Recommendations of the ESE Educational Program of Parathyroid Disorders. Eur J Endocrinol. 2022 Jan 13;186(2):R33-R63