Primary Hyperparathyroidism in Pregnancy

1. HYPERCALCAEMIA IN
PREGNANCY
DR SANDEEP Kr GARG MD DM
Dr SUDHI KAMBOJ MS Mch

2. • 29/F
• 6.5 months pregnancy
• P/W
• Recurrent severe UTI with fever
• Gen body weakness
• Gen bony pains, off and on
• Mild abdominal pain
• Detected hypercalcemia in
preliminary investigations
• Confirmed PHPT biochemically on
extensive work up

3. Investigations
Serum Calcium
Total
Ionized
15.5 mg/dl (8-10)
1.92 mmol/L (1.15-1.29)
S iPTH 1154 pg/ml (15-68)
Serum iPhosphorous
S Alkaline Phosphatase 322 U/L (30-120)
S Creatinin 1.2 mg/dl
S 25 OH Vitamin D Insufficient
LFT WNL
Na/ K / Cl 133/ 4.2/ 105
TSH 0.64
Hb 9
TLC 17,600
Urine 8-10 pus cell/hpf

4. Localization
• USG Neck
• 2.6x0.9x1.6 cm predominantly hypoechoic
SOL postero-lateral to the inferior pole of right
lobe of thyroid. Thyroid- normal
• Sestamibi scan- not done in view of pregnancy

5. Management
• Intravenous hydration -300-500 ml/hr
• S/c Calcitonin
• Iv Bisphosphonates
• Susten p/v
• Iv betamethasone
• Iv antibiotics and supportives

6. Provisional diagnosis
Primary hyper-parathyroidism with
hypercalcemic crises with 6.5 months
pregnancy ? Left inferior parathyroid tumor
To rule out ? Malignancy ? MEN syndrome

8. DISCUSSION
Diagnostic approach to hypercalcemia

9. PREFERRED APPROACH
• Mild hypercalcemia — Asymptomatic or mildly
symptomatic hypercalcemia (Ca<12mg/dL
[3 mmol/L]) do not require immediate Tt
• They should avoid
– Thiazide diuretics
– Lithium
– Volume depletion
– Prolonged bed rest or inactivity
– High calcium diet (>1000 mg/day).
• They should have
– Adequate hydration
– Additional therapy depends upon the cause

10. MODERATE HYPERCALCEMIA
• Asymptomatic or mildly symptomatic, moderate
hypercalcemia (calcium between 12 and
14 mg/dL[3 to 3.5 mmol/L]) may not require
immediate therapy.
• Should follow precautions for mild hypercalcemia.
• Acute rise of these concentrations may cause
marked changes in sensorium, which requires
more aggressive therapy as in severe
hypercalcemia

11. SEVERE HYPERCALCEMIA
• Calcium >14 mg/dL (3.5 mmol/L) require
aggressive therapy
• The acute therapy of such patients consists of
a three-pronged approach
– Saline
– Calcitonin
– Bisphosphnates

12. SEVERE HYPERCALCEMIA
• Volume expansion with isotonic saline at an initial
rate of 200 to 300 mL/hour that is then adjusted to
maintain the urine output at 100 to 150mL/hr
• In the absence of CKD or CHF, loop diuretic not
recommended
• Administration of salmon calcitonin (4 iu/kg)
repeat measurement of S.Ca in several hrs
• If hypocalcemic response is noted, then the pt is
calcitonin-sensitive & calcitonin can be repeated
every 6 to 12 hours (4 to 8 iu/kg)
• Administer calcitonin (along with a
bisphosphonate) in pts with calcium
>14 mg/dL who are also symptomatic

13. SEVERE HYPERCALCEMIA
• Concurrent administration of zoledronic acid (ZA;
4 mg IV over 15 min) or pamidronate (60 to 90
mg over 2 hrs), preferably ZA
• Administration of calcitonin + saline should result
in substantial reduction in S.Ca within 12-48 hrs.
• Bisphosphonate will be effective by 2nd to 4th
day, failed to reverse hypercalcemia, mental
status changes, and hypophosphatemia due to
primary hyperparathyroidism

14. SEVERE HYPERCALCEMIA
• Hypercalcemia due to calcitriol, usually lasts
only one to two days because of the relatively
short biologic half-life
• Hypercalcemia caused by vit D lasts longer, so
that more aggressive therapy such as
glucocorticoids & ZA or pamidronate
• Hypercalcemia is not treated in FHH because
it is mild & produces few symptoms

15. SEVERE HYPERCALCEMIA
• More aggressive measures are necessary in
the rare patient with very severe,
symptomatic hypercalcemia
• Hemodialysis should be considered, in
addition to the above treatments, in pts who
have serum calcium concentrations in the
range of 18 to 20 mg/dL (4.5 to 5 mmol/L) &
neurologic symptoms but a stable circulation,
or in those with severe hypercalcemia
complicated by renal failure

16. THANK YOU