E-Poster Presentation ESA-SRB-ANZBMS 2021

Successful parathyroidectomy for primary hyperparathyroidism in the first trimester of pregnancy: case report and review of the literature (#407)

Dianna Luong 1 2 , Mahiban Thomas 3 4 , Sujatha Thomas 5 , Sarah Bayman 6 , Sridhar Chitturi 2
  1. School of Medicine, University of Queensland, Brisbane, Queensland, Australia
  2. Department of Endocrinology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
  3. Department of Maxillofacial/Head & Neck Surgery, Royal Darwin Hospital, Darwin, Northern Territory, Australia
  4. School of Medicine, Flinders University, Darwin, Northern Territory, Australia
  5. Department of Obstetrics & Gynaecology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
  6. Department of Anaesthesiology, Royal Darwin Hospital, Darwin, Northern Territory, Australia

Introduction

Primary hyperparathyroidism in pregnancy is rare, with an estimated prevalence of 1%.1 Symptoms of hypercalcaemia are often non-specific in pregnancy.2 At calcium levels >2.86mmol/L, a 3.5-fold increase in pregnancy loss is observed in those with primary hyperparathyroidism.3 Curative parathyroidectomy is often delayed until the second trimester of pregnancy given the theoretical risk of miscarriage with anaesthesia and surgery.4 However, hypercalcaemic-related miscarriages often occur during first, or early second trimester of pregnancy; suggesting the need for earlier intervention.3

Case Presentation

We describe a case of a 37-year-old woman who underwent a successful parathyroidectomy at six weeks gestation for primary hyperparathyroidism.

M.M. initially presented with anxiety, malaise and a three-week prodrome of constipation and polydipsia, despite consuming 3L of water a day. On examination, she was normotensive with no palpable neck masses or lymphadenopathy. She had a miscarriage four months prior, whereby a corrected calcium was elevated at 3.06mmol/L.

Serial biochemistry was consistent with primary hyperparathyroidism; corrected calcium of 3.16mmol/L, PTH 27.6pmol/L, phosphate 0.75mmol/L, ALP 72U/L and Vitamin D 53nmol/L. Serum Beta-CTx was 1500ng/L and urine calcium:creatinine ratio was 1033mmol/mol (see Table 1).

A 20x6x8mm parathyroid gland was localised on ultrasonography and she underwent a minimally invasive parathyroidectomy two days after her initial presentation. Successful resection of the lesion was demonstrated by an intraoperative PTH fall from 21.4pmol/L to 3.6pmol/L over ten minutes. She experienced no post-operative complications and was discharged 2 days after surgery. She continues to progress well through her pregnancy.

 

Currently, no guidelines exist for managing primary hyperparathyroidism in pregnancy. Only two cases of parathyroidectomy in first trimester of pregnancy have been described.5,6 Our case report and literature review add additional insight into the growing body of evidence surrounding the safety of early surgical intervention in severe symptomatic primary hyperparathyroidism to prevent adverse maternal-foetal outcomes.

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  1. Nastos C, Paspala A, Mavroeidi I, Stavratis F, Lampadiari V, Kalantaridou S, Peppa M, Pikoulis E. Surgical management of primary hyperparathyroidism during pregnancy: a systematic review of the literature. Gynecol Endocrinol. 2021 May 28:1-10. doi: 10.1080/09513590.2021.1932801. Epub ahead of print.
  2. Abood A, Vestergaard P. Pregnancy outcomes in women with primary hyperparathyroidism. Eur J Endocrinol. 2014 Jul;171(1):69-76. doi: 10.1530/EJE-13-0966. Epub 2014 Apr 17.
  3. Norman J, Politz D, Politz L. Hyperparathyroidism during pregnancy and the effect of rising calcium on pregnancy loss: a call for earlier intervention. Clin Endocrinol (Oxf). 2009 Jul;71(1):104-9. doi: 10.1111/j.1365-2265.2008.03495.x. Epub 2008 Dec 5.
  4. Khan AA, Hanley DA, Rizzoli R, Bollerslev J, Young JE, Rejnmark L, Thakker R, D'Amour P, Paul T, Van Uum S, Shrayyef MZ, Goltzman D, Kaiser S, Cusano NE, Bouillon R, Mosekilde L, Kung AW, Rao SD, Bhadada SK, Clarke BL, Liu J, Duh Q, Lewiecki EM, Bandeira F, Eastell R, Marcocci C, Silverberg SJ, Udelsman R, Davison KS, Potts JT Jr, Brandi ML, Bilezikian JP. Primary hyperparathyroidism: review and recommendations on evaluation, diagnosis, and management. A Canadian and international consensus. Osteoporos Int. 2017 Jan;28(1):1-19. doi: 10.1007/s00198-016-3716-2. Epub 2016 Sep 9.
  5. Sharma SG, Levine SN, Yatavelli RK, Shaha MA, Nathan CAO. Parathyroidectomy in First Trimester of Pregnancy. J Endocr Soc. 2020 Feb 5;4(3):bvaa015. doi: 10.1210/jendso/bvaa015.
  6. Tachamo N, Timilsina B, Dhital R, et al. Primary Hyperparathyroidism in Pregnancy: Successful Parathyroidectomy during First Trimester. Case Reports in Endocrinology. 2018 ;2018:5493917. doi: 10.1155/2018/5493917.