Resistant hypercalcaemia in pregnancy – medicine to surgery
Manish Modi, Catherine Mitchell, Binu Krishnan, Rajee Baburaj, The Hillingdon Hospitals NHS Foundation Trust
Primary hyperparathyroidism (PHPT) during pregnancy poses significant risks to the mother and foetus. Prompt identification and management are essential in reducing the risk of complications such as hyperemesis, miscarriage, pre-eclampsia, intrauterine growth restriction, preterm delivery and post-partum neonatal hypocalcaemia.
Case: A 29 year old lady, known to be 8 weeks pregnant, presented to Hillingdon Hospital with persistent vomiting. She was found to be profoundly hypercalcaemic (3.30 mmol/L), with elevated parathyroid hormone levels (17.3 pmol/L), consistent with PHPT. She was initially managed with aggressive fluid rehydration. Due to resistant hypercalcaemia, she was then commenced on subcutaneous calcitonin. She was discharged once her calcium levels improved, with frequent monitoring planned in the joint endocrine and obstetric antenatal clinic. However, she required re-admission the following day due to refractory vomiting and exacerbated hypercalcaemia (3.19 mmol/L). The decision was made to stop calcitonin due to lack of significant effect. Following this, aggressive fluid resuscitation was instituted, with approximately 5 litres of intravenous fluid being administered daily for a month. An ultrasound scan of the neck identified a hypoechoic lesion in the thyroid gland, consistent with a parathyroid adenoma. In light of refractory hypercalcaemia >3mmol/L and the localisation of a parathyroid adenoma, the patient was transferred to the Endocrine surgery team at Hammersmith Hospital for further management. Following discussion with the medical obstetric team at Queen Charlotte’s Hospital, a parathyroidectomy was planned as she was now in her second trimester. She successfully underwent resection of two parathyroid glands. Her calcium levels returned to normal post operatively and she remains normocalcaemic with a normal parathyroid hormone level after 4 months.
Discussion: This case highlights that management of PHPT in pregnancy remains a significant challenge. As surgery remains the only definitive management most suited to the second trimester, the paucity of evidence on conservative treatment becomes more apparent. Appropriate management of this patient required valuable input from the multidisciplinary team, including the medical and surgical Endocrine teams, obstetrics and radiology.