Endocrine Abstracts

A 26-year-old primigravida woman presented with hypercalcaemia at 8-weeks gestation. Initial symptoms included nausea, vomiting and palpitations, with an admission serum adjusted calcium of 3.8 mmol/l. A biochemical diagnosis of primary hyperparathyroidism (PHPT) was supported by a raised PTH and a 24-hour urinary calcium-creatinine ratio of 2.0 mmol/ mmol, excluding familial hypocalciuric hypercalcaemia. Initial management with intravenous fluids and antiemetics was unable to control the hypercalcaemia, resulting in multiple hospital admissions. A multidisciplinary team comprising a Consultant Obstetrician, Endocrinologist and Endocrine Surgeon discussed management options available, including conservative measures, cinacalcet (currently unlicensed) and surgery. Investigations were limited due to radiation exposure in pregnancy. An ultrasound identified a 7 mm lesion on the right, suggestive of a parathyroid adenoma. Comprehensive counselling was undertaken on the risks of hypercalcaemia to both the mother and foetus, highlighting the potential foetal risk reaching up to 40% at term. Maternal complications include hyperemesis, nephrolithiasis, pancreatitis and hypercalcaemic crisis. Neonatal complications included hypocalcaemia, tetany, preterm delivery, low birth weight and foetal death. After detailed consent, a bilateral neck exploration was performed in the second trimester. Four normal parathyroid glands were identified, with no ectopic parathyroid seen in excised thymic tissue. Intraoperative PTH levels remained elevated. Postoperatively, calcium levels remained elevated at 2.95 mmol/l and low-dose cinacalcet was initiated. Discharge after 7 days with calcium levels between 2.65-2.75 mmol/l. At 24 weeks and 3 days gestation, 17 days postoperatively, she presented with an adjusted calcium of 3.2 mmol/l and 24-hours of vaginal discharge in the surgical clinic. Cinacalcet dose was increased. Premature labour occurred. Despite successful delivery, the neonate developed sepsis and regrettably died 7 days later. Postnatally, despite improvement in hyperemesis, calcium and PTH levels remained elevated. Genetic screening was negative. Postpartum, a 99Tc-MIBI SPECT/CT scan was reported as negative for localising an ectopic parathyroid gland. A PET-Choline CT scan and Four-dimensional parathyroid CT scan suspected a 10 mm isodense, enhancing nodule in the mediastinal left thymus, likely to represent a parathyroid adenoma. A radiology review confirmed the lesion on all imaging. A robotic thoracoscopic resection of her left mediastinal thymus was performed, successfully removing a histologically confirmed 8 mm parathyroid adenoma. The patient is now cured, normocalcemic, and has since given birth to a baby girl. PHPT is relatively uncommon during pregnancy. However, it carries significant maternal and foetal risks. Early recognition and management are imperative for the safety of both mother and foetus. The role of cinacalcet is still under discussion.