Hyperparathyroidism in early pregnancy: a case report.
Ling Y, Falinska A, Woods D, Vakilgilani T, Tanday R, Todd JF
Imperial College Healthcare NHS Trust.
A 36 year old lady (gravida 2 para 0) presented with subfertility, dysmenorrhoea and mild hyperprolactinaemia (prolactin of 881 mu/l no macroprolactin). She was also found to be hypercalcaemic whilst on calcium supplements. Despite a negative home pregnancy test, her beta-HCG was elevated at 1471 IU/l confirming she was pregnant.
She remained hypercalcaemic despite stopping calcium supplements and starting colecalciferol. At 9 weeks into her pregnancy, her corrected calcium (cCa) 2.67 mmol/l, phosphate 1.12mmol/l, vitamin D 52.3nmol/l and PTH 8.8 pmol/l. Urinary calcium creatinine clearance ratio of 0.0272 which was consistent with primary hyperparathyroidism (PHPT). MEN-1 genetic testing was negative. Her early foetal scans were normal.
She has a long history of liquorice ingestion hence was advised to stop in view of her hypercalcaemia. Her cCa ranged between 2.58 and 2.78 mmol/l. There were no nephrocalcinosis. Ultrasound (US) of parathyroid suggested a possible left inferior lesion in the tip of the thyroid measuring 8 x 3 mm which on US guided fine needle aspiration confirmed it was thyroid tissue (Thy 2). It was thought that further imaging would carry more risks than benefits.
She was referred to Endocrine surgeons and underwent a neck exploration with parathyroidectomy in her second trimester. 4 parathyroid glands were identified and left inferior gland appeared to be an adenoma which was excised. Histology confirmed a 1.5cm left inferior parathyroid adenoma weighing 2.27g.
Her biochemistry results (cCa 2.29mmol/l, PTH 2 pmol/l) post-parathyroidectomy confirmed she has been successfully treated. She went on to deliver a healthy girl at term.
Primary hyperparathyroidism in pregnancy is an important diagnosis to manage promptly due to the high risk of complications to both mother and foetus. It can be difficult to diagnosis due to the non-specific symptoms and maternal physiological changes. The definitive management option would be parathyroidectomy, usually in second trimester.