A Case of Hyperparathyroidism and HELLP Syndrome

Presentation Number: MON 309
Date of Presentation: April 3rd, 2017

Juan Diego Palacios*1, Zeina Carolina Hannoush2, Maria Pilar Solano3 and Violet Lagari -Libhaber4
1UNIVERSITY OF MIAMI/JACKSON MEMORIAL HOSPITAL, Miami, FL, 2University of Miami Miller School of Medicine, Miami, FL, 3University Of Miami, Key Biscayne, FL, 4University Of Miami

Abstract

Background

Case reports have described severe hypercalcemia associated with primary hyperparathyroidism(pHPT) and preeclampsia in pregnancy. We report a hypercalcemic crisis in a pregnant woman with primary hyperparathyroidism and HELLP syndrome.

Clinical case

A 46 year-old Ethiopian woman was admitted at 33.4 weeks gestation for epigastric pain, nausea, and hypertension. Blood pressure was 138/98 mmHg, pulse 95 beats/minute. She was afebrile. Evaluation of the neck and thorax was unremarkable. She had a soft gravid nontender abdomen with a viable fetus. No history of renal stones, fractures or other endocrinopathies. Family history was negative for calcium disorders; she was on prenatal vitamins. Laboratory evaluation included calcium 12.7 (8.4- 10.2 mg/dl), phosphorous 2.1 (2.5-4.5 mg/dl), albumin 1.9 (3.5 -5.5mg/dl), PTH 339.2 (15- 65 pg/ml), 25-hydroxyvitaminD 8.8(30 – 100 ng/ml), platelets 90 (140-400 mcl) SGOT 141 ( 9 – 52 u/l) , SGPT 145 (15-46 u/l). Therapy included fluids and anti-hypertensives. Due to frequent fetal decelerations, worsening thrombocytopenia and increased transaminases, C-section was performed, delivering a female fetus weighing 1740 gr.

48 hours following delivery, hypertension resolved, but the patient developed hypercalcemic crisis: calcium 16mg/dl, albumin 2.2mg/dl, ionized calcium 1.78 (1.13 – 1.32 mmol/L). In the setting of persistent hypercalcemia, intravenous pamidronate was given, 99mTc-Sestamibi showed abnormal uptake within the left inferior thyroid lobe. The patient underwent a right parathyroidectomy; pathology demonstrated an atypical parathyroid adenoma, 1.5 cm in largest dimension. PTH and calcium levels normalized after surgery. The neonate developed transitory hypocalcemia, but was eventually discharged.

Discussion

During pregnancy, primary hyperparathyroidism (pHPT) has an annual incidence of eight per 100,000(1). Maternal hypertension and preeclampsia have been observed in 25% of patients during pregnancy (2). PTH directly affects the renin aldosterone system, the sympathetic system and the vascular endothelium (3)(4). Hypercalcemic crises occur frequently after delivery as the placental distribution of calcium to the fetus is higher during the third trimester. Following delivery this protective effect is lost, thus increasing the risk of maternal hypercalcemia and neonatal hypocalcemia (5). Future studies are needed to guide the management of pHPT during pregnancy.

 

Nothing to Disclose: JDP, ZCH, MPS, VL