Primary Hyperparathyroidism in Pregnancy with Successful Parathyroidectomy

Presentation Number: MON 310
Date of Presentation: April 3rd, 2017

Jagmeet Mangat* and Raju Panta
University At Buffalo, Buffalo, NY

Abstract

Introduction

Primary hyperparathyroidism (PHPT) in pregnancy is rare with increased maternal-fetal morbidity and mortality. Not only the diagnosis of primary hyperparathyroidism during pregnancy is challenging, but also there is a paucity of data on its management. We present a case of 27-year-old female with Primary hyperparathyroidism and successful parathyroidectomy at 20 weeks of gestation.

Case

A 19 weeks pregnant, 27-year-old female was referred to us for hypercalcemia found at 12 weeks of gestation. She was asymptomatic, had no significant past medical history and no family history of hypercalcemia.

Exam was normal except for palpable neck lump. Labs showed calcium of 12.7 mg/dl (8.5-10.5mg/dl), PTH 119 pg /ml (12-72 pg/ml), ionized calcium 7.6 mg/dl (4.7-5.3mg/dl), 25-hydroxyvitamin D 44ng/ml (30-100 ng/ml), 1,25-dihydroxyvitamin D 73 pg /ml (19.9-79.3 pg /ml), phosphorous 2.2mg/dl (2.5-4.8mg/dl) at 19 weeks of gestation. 24-hour urinary calcium was 330 mg/24hr (50-150mg/24hr). Neck ultrasound (USG) showed 38*20*18 mm mass subjacent to inferior pole of left lobe of thyroid gland, consistent with parathyroid adenoma. She had left inferior parathyroidectomy at 20 weeks of gestation. Pathology confirmed parathyroid adenoma weighing 7.3gm. At 33 weeks, calcium and PTH remained stable and fetal USG showed normal fetal growth.

CONCLUSION

Diagnosis of primary hyperparathyroidism in pregnancy is challenging. During normal pregnancy, 24-hr urinary calcium excretion is increased and a physiologic fall in serum albumin leads to fall in total calcium level but ionized calcium, phosphorous and 25-hydroxyvitamin D remain normal. Level of 1,25-dihydroxyvitamin D is increased due to secretion of 1 α hydroxylase from placenta causing 2-fold increase in intestinal calcium absorption and low-normal PTH.

USG of neck is preferred to localize parathyroid adenoma as sestamibi scan is contraindicated in pregnancy. Hypercalcemia in pregnancy is associated with maternal complications like nephrolithiasis, hyperemesis gravidarum, pancreatitis and fetal complications like low birth weight, preterm delivery, intrauterine death and neonatal hypocalcaemia, tetany. Conservative management should be considered during the first and third trimesters unless surgery is absolutely indicated. In cases of severe symptomatic hypercalcemia due to parathyroid adenoma parathyroidectomy can be performed during the second trimester to prevent maternal and fetal complications.

Our case highlights the importance of timely diagnosis and effective management of Primary hyperparathyroidism in pregnancy, for optimal prognosis of both mother and fetus.

 

Nothing to Disclose: JM, RP