Hypercalcemic crisis in third trimenon: evaluating the optimal treatment strategy

Abstract

Hypercalcemia due to primary hyperparathyroidism during pregnancy is a rare condition and associated with increased morbidity and mortality for the mother and the unborn child. Whereas parathyroidectomy is favored during the second trimester, no clear recommendations exist for its management during the third trimenon. We here report the case of a 26-year-old woman in the 29th week of her first pregnancy, who was admitted to our clinic with hypertension, intra-uterine growth retardation and polyhydramnios. Severe hypercalcemia due to primary hyperparathyroidism was diagnosed (total calcium 3.34 mmol/l; PTH 216 pg/ml), but no enlarged parathyroid gland could be localized by ultrasound. Treatment with calcitonin and cinacalcet could not control hypercalcemia. Therefore explorative surgery was performed and a single parathyroid adenoma was resected, resulting in normalization of serum calcium levels. The surgical procedure was tolerated well by the mother and fetus. Hypercalcemia-induced hypertension and polyhydramnios ameliorated before C-section was performed two weeks later and unrelated to the intervention. This case report underlines the importance of early diagnosis and treatment of primary hyperparathyroidism during pregnancy. If diagnosed in the third trimenon, an interdisciplinary approach is crucial. If medical treatment fails to sufficiently control hypercalcemia, surgical parathyroid exploration should be considered even in cases of unsuccessful localization of adenomatous parathyroid glands.

Chinese abstract

妊娠期间原发性甲状旁腺功能亢进引起的高钙血症是一种罕见的疾病, 与母胎发病率和死亡率增加有关。尽管提倡在妊娠中期行甲状旁腺切除术, 但目前对于孕晚期高钙血症的管理没有明确的建议。我们在这里报告了一例孕29周的病例, 26岁女性, 初次妊娠, 因高血压, 胎儿宫内发育迟缓和羊水过多入院。诊断为原发性甲状旁腺功能亢进引起的严重高钙血症（总钙3.34mmol/L; PTH 216 pg/ml）, 但超声检查未见甲状旁腺局部增大。降钙素和西那卡塞治疗不能控制高钙血症。因此, 进行了探索性手术切除了单个甲状旁腺腺瘤, 术后血清钙水平恢复正常。母亲及胎儿对外科手术的耐受情况很好。两周后进行剖宫产, 术前高钙血症诱导的高血压和羊水过多即已得到改善, 与手术无关。本病例报告强调了早期诊断和治疗妊娠期原发性甲状旁腺功能亢进的重要性。如果在孕晚期确诊, 跨学科诊疗方法至关重要。如果药物治疗不能充分控制高钙血症, 即使在甲状旁腺腺瘤不能成功定位的情况下, 也应考虑进行甲状旁腺探查术。

Keywords:

• Primary hyperparathyroidism
• pregnancy
• cinacalcet
• calcitonin
• operation

Acknowledgements

We thank the patient and her family for their consent to publication.

Disclosure statement

No potential conflict of interest was reported by the authors.