Hypercalcaemia in pregnancy – the need for timely multidisciplinary management.
Jennifer van Griethuysen, Danae Trokoudes, Fausto Palazzo, Catherine Mitchell.
A 34 year old lady (gravida 5, para 3) presented to the Emergency Department at 19 weeks gestation with acute abdominal pain and vomiting. Her past medical history included hepatoblastoma at 9 years and recent miscarriage. There was no personal or family history of hypercalcaemia and no history suggestive of multiple endocrine neoplasia.
On examination she was normotensive and euvolaemic, with normal neck examination and abdominal examination consistent with second trimester viable pregnancy. Urine dipstick was positive for blood with negative urine culture. Investigations revealed corrected calcium (cCa) 3.58 mmol/L (NR 2.2-2.6) associated with parathyroid hormone (PTH) of 35.6 pmol/L (NR 1.6-9.3), phosphate 0.47 mmol/L (NR 0.8-1.5), 24 hour-urine calcium of 32.8 nmol/24h (NR 2.5-7.5) and 25-hydroxy vitamin D 21 nmol/L. Urea and creatinine were within pregnancy normal ranges throughout admission. Ultrasound scanning showed a 27x27mm mixed echoic mass in the right inferior parathyroid region and mild right sided hydronephrosis but could not rule out an obstructing calculus. Renal tract MRI was not possible due to previous surgical clips.
The patient’s management required cross-site multi-disciplinary input from obstetric, endocrine and surgical teams. Initial management involved free oral fluid plus 4-6 hourly iv fluids. Nausea and vomiting was managed with antiemetics. Due to resistant severe hypercalcaemia despite high flow intravenous fluids and high miscarriage risk she was treated with calcitonin 100 units tds, whilst awaiting parathyroid surgery. Two renal calculi were passed with resolution of her abdominal pain. She was referred for parathyroidectomy with obstetric anaesthetic support and underwent resection of bilateral superior parathyroid glands at 20+ weeks gestation. Histology confirmed a right superior hypercellular parathyroid adenoma with central haemorrhage. Post-operatively PTH was <0.3pmol/L, cCa 2.69 mmol/L and phosphate 0.6 mmol/L. The patient recovered well and her estimated delivery date is the 15/3/15.
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