HYPERCALCEMIC CRISIS: A CASE OF PRIMARY HYPERPARATHYROIDISM DURING PREGNANCY

Objectives: Primary hyperparathyroidism (PHP) is the third most common endocrine disorder. Women are affected by PHP twice as often as men. Hyperparathyroidism is diagnosed in 0.5-1.4% of pregnant women. Symptoms of PHP are nonspecific and could be mistaken as complaints naturally present during pregnancy; however, maternal complications in patients with hyperparathyroidism can be as high as 67%. We present a case of a pregnant patient who presented in hypercalcemic crisis with a concomitant diagnosis of PHP.

Methods:

Results: Patient is a 43-year-old female, gravida 4, para 2-0-1-2 at 17 weeks gestation, unknown prior to arrival, who presented with complaints of 3-4 months of abdominal pain, nausea/vomiting, and malaise. Admission laboratory values significant for calcium 14.9 mg/dL, intact PTH 352.0 pg/mL, and vitamin D 29.6 mg/dL.

Physical examination performed revealed a gravid uterus and left-sided neck fullness. Ultrasound performed identified a 2.2x1.2x1.4 cm hypoechoic, hypervascular structure, concerning for a parathyroid adenoma. Patient was subsequently taken to the operating room for a parathyroidectomy with intraoperative neuromonitoring.

Patient's PTH level and calcium decreased to 71.6 pg/mL and 11.7 mg/dL, respectively, immediately following adenoma resection. Her calcium level normalized to 9 mg/dL on postoperative day one. She recovered well postoperatively and was discharged home in stable condition on postoperative day four.

Conclusion: Symptoms associated with calcium levels >12 mg/dL include fatigue, anorexia, vomiting, constipation, depression and blurred vision; however, once levels exceed 13 mg/dL, patient’s typically have more profound findings, such as renal impairment, mental status change, cardiac arrhythmias, renal calculi, osteopenia, peptic ulcer disease, pseudogout, and muscle atrophy. Levels of >14 are rare and typically present as a medical emergency with hypercalcemic crisis that can result in uremia, coma, cardiac arrest, or death.

Maternal-fetal complications can occur with hypercalcemia during pregnancy. Maternal complications are reported as high has 67%, and fetal complications are reported to be as high as 80%. Although there is limited data, one study indicates a 1 in 3 chance of miscarriage or stillbirth. Other data indicates an increased risk of preterm labor, 50% rate of neonatal tetany, and a 25% chance of neonatal death.

Data is lacking for treatment of PHP during pregnancy because of the rarity of cases. However, previous studies comparing outcomes in pregnant women with expectant management versus surgery, surgical candidates who underwent definitive treatment had better outcomes. Current data suggests surgery be performed during the second trimester, in the presence of severe hypercalcemia, to minimize maternal and fetal complications.