Hypercalcaemia in pregnancy
V. Stokes1, N. Whitelaw1, R. Mihai2 & A. Ali1
A 28 year old female with no significant medical history, 25 weeks into her second pregnancy was referred to endocrinology with adjusted calcium of 2.99 mmol/l. She had a short history of generalised aches and tiredness. Examination did not reveal any stigmata of MEN1 or the HPT-JT syndromes. There was no known family history of endocrine disorders. Her PTH was 7 pmol/l, confirming primary hyperparathyroidism. As parathyroid Tc-scintigraphy would be contraindicated in pregnancy, an MRI of her neck was reviewed by a radiologist with special expertise in parathyroid imaging. The scan showed evidence of a right sided adenoma. An uncomplicated parathyroidectomy was performed under sedation and bilateral cervical block, without the use of opiates. The histology of the mass was compatible with a benign adenoma. Molecular genetic analysis did not show deletions, duplications or mutations in either MEN1 or RET. She has remained normocalcaemic after 1 year of follow up. Definitive treatment during pregnancy is recommended as hypercalcaemia increases the risk of pregnancy associated complications. Maternal complications such as nephrolithiasis, pancreatitis and bone disease are reported in 67% of mothers. Foetal complications are reported in up to 80%, including preterm labour, neonatal tetany, IUGR and foetal death.
After localising the tumour preoperatively without the use of ionising radiation, surgery should be performed during the second trimester where possible, but may be indicated at any stage of gestation. This case highlights the approach to diagnosing and managing a rare presentation of a common condition. Radiological expertise is required for successful pre operative localisation of parathyroid tumours in pregnancy. In addition to timely surgery, patients should also be investigated for underlying genetic causes as in all young patients with hyperparathyroidism. Although not backed by evidence, long term follow up of these patients with periodic calcium measurement is recommended.
Declaration of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.
Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.