Hyperemesis in pregnancy not the usual suspects
JM Rosenthal, G Bano, A Hameed, A Sharma & S Nussey
Nausea and vomiting is common in pregnancy. Severe symptoms with metabolic upset (hyperemesis gravidarum) occurs in 0.2 percent of pregnancies, We present 2 cases of primary hyperparathyroidism in pregnancy. Both women (19 & 34y) presented in the 1st trimester of pregnancy with lethargy, vomiting, thirst and headache. Serum calcium and parathyroid hormone concentrations were elevated:2.69 milli mole per litre (2.18 to 2.47 ) PTH 20.5 pica mole per litre (1.1 to 6.9 ); 3.28 milli mole per litre and 19.5 pica mole per litre. Circulating thyroid hormone and TSH concentrations were normal. Both had increased urinary calcium excretion and neither had renal impairment or nephrocalcinosis. They were admitted to hospital and rehydrated parenterally. In both cases a single parathyroid adenoma was identified by ultrasound and parathyroidectomies were performed in the second trimester (16 & 17 weeks) One woman has delivered with no complications to herself or the fetus. The other continues in her pregnancy.
Hyperparathyroidism presenting in pregnancy was first reported in 1930 & until 1990, 109 cases have been reported. It can be associated with both maternal and fetal morbidity and mortality (abortion, intrauterine death, premature labour, pancreatitis, nephrolithiasis & neonatal tetany). The treatment of choice is parathyroidectomy between 16th and 26th week, after fetal systems have developed. Avoiding surgery near the time of delivery reduces risk of neonatal tetany. The rarity of hyperparathyroidism in pregnancy has been taken to imply that either fertility is decreased or that the increased calcium demands of pregnancy serve to mask milder cases of hyperparathyroidism. Whilst the exact incidence is unknown, the disease appears to be more severe, in terms of symptoms, biochemistry, and the extent of pathologic findings. We suggest that serum calcium measurement should be included in the routine investigation of hyperemesis.