Primary hyperparathyroidism and simultaneous bilateral fracture of the femoral neck during pregnancy

Primary Hyperparathyroidism in Pregnancy: Literature Review of the Diagnosis and Management

Background: Parathyroid disease is uncommon in pregnancy. During pregnancy, multiple changes occur in the calcium regulating hormones which may make the diagnosis of primary hyperparathyroidism more challenging. Close monitoring of serum calcium during pregnancy is necessary in order to optimize maternal and fetal outcomes. In this review, we will describe the diagnosis and management of primary hyperparathyroidism during pregnancy. Methods: We searched MEDLINE, CINAHL, EMBASE and Google scholar bases from 1 January 1990 to 31 December 2020. Case reports, case series, book chapters and clinical guidelines were included in this review. Conclusions: Medical management options for primary hyperparathyroidism during pregnancy are severely limited due to inadequate safety data with the various potential therapies available, and surgery is advised during the 2nd trimester of pregnancy in the presence of severe hypercalcemia (calcium adjusted for albumin greater than 3.0 mmol/L (12.0 mg/dL)). Hypercalcemia should be avoided during pregnancy in order to minimize maternal and fetal complications.

Primary Hyperparathyroidism During Pregnancy Treated With Parathyroidectomy: A Systematic Review

OBJECTIVES/HYPOTHESIS

The primary objective of this study was to assess the safety of parathyroidectomy during pregnancy as treatment for hyperparathyroidism (HPTH) in comparison to nonsurgical management plans. Secondary outcomes involved analyzing the safety of surgery in the third trimester and the benefit of operating on asymptomatic pregnant patients.

STUDY DESIGN

Systematic review.

METHODS

PRISMA-guided systematic review of all cases of primary hyperparathyroidism during pregnancy published in peer-reviewed English journals on PubMed/MEDLINE, EMBASE, and SCOPUS from 1980 to 2020.

RESULTS

A total of 75 manuscripts were included in this review describing 382 cases of gestational hyperparathyroidism. The median maternal age was 31 years. Overall, 108 cases (28.3%) underwent parathyroidectomy during pregnancy while 274 cases (71.7%) were treated nonsurgically. The majority of surgeries took place during the second trimester (67.6%). Complications and/or deaths were less likely to occur after surgery in the second trimester (4.48%) as compared to surgery in the third trimester (21.1%). Nine surgically treated cases resulted in infant complications and/or death; however, none of these nine cases had any surgical complications. Despite these complications, the overall infant complication rate for patients who underwent surgical treatment remained lower than that of patients treated with conservative therapy (9.1% vs. 38.9%).

CONCLUSIONS

This review suggests that for all pregnant patients with diagnosed HPTH, parathyroidectomy should be considered regardless of symptomatology. Our data suggest that parathyroidectomy is associated with fewer risks than more conservative treatments and results in better fetal outcomes. Surgery during the third trimester is feasible and surgery should be considered in both symptomatic and asymptomatic patients. Laryngoscope, 131:1915-1921, 2021.

A rare case of a non-traumatic neck of femur fracture in a 17-year-old boy associated with vitamin D deficiency

Hip fractures in the young, healthy population are rare and often the result of high-energy trauma. A previously healthy 17-year-old patient presented to our institution with a 5-week history of left hip and knee pain in the absence of any trauma. Pelvic radiograph revealed a subacute left femoral neck fracture. He subsequently underwent surgical fixation and made an uneventful recovery. Further endocrine evaluation revealed isolated vitamin D deficiency to be the likely underlying cause for this fracture. Multiple previous opportunities were missed to identify the cause for this patient's symptoms. An intracapsular fracture in a young adult requires early recognition and prompt anatomical reduction. This case emphasises the need to maintain a high index of suspicion for atraumatic fractures in healthy adolescents with unexplained joint pain. Further endocrine and metabolic investigations are warranted, and isolated vitamin D deficiency must be considered as a potential causative factor.

Primary hyperparathyroidism in pregnancy-a rare cause of life-threatening hypercalcemia: case report and literature review

Objective. To report a case of primary hyperparathyroidism in a pregnant patient, report the obstetric and neonatal outcomes, and review the relevant literature. Results. A 29-year-old primigravida was successfully treated for PHP with minimally invasive resection of a parathyroid adenoma in the second trimester of pregnancy. A healthy baby girl was delivered at 37-week gestation with an unremarkable neonatal course. To the best of our knowledge, this is the second case report in the literature utilizing intraoperative PTH during a parathyroidectomy in a pregnant woman. Conclusions. Primary hyperparathyroidism is a rare life-threatening condition that can present during pregnancy. The diagnosis can be difficult to establish during pregnancy, given the nonspecific symptoms related to hypercalcemia. However, a better understanding of the condition, improved diagnostic studies, and well-organized multidisciplinary management decisions can significantly reduce the morbidity and mortality associated with the disease during pregnancy. This case report is presented to highlight the value of early diagnosis and appropriate management of PHP during pregnancy.

Spontaneous bilateral femoral neck fractures associated with a low serum level of vitamin D in a young adult

Bilateral femoral neck fracture is an extremely rare injury in young adults. We report a young adult with bilateral femoral neck fracture after minimal stress. The current case did not demonstrate any abnormality on laboratory data, except for a low serum level of vitamin D(3). Although, in our case, the patient underwent bilateral femoral head arthroplasty, early diagnosis could have been helpful to avoid further displacement of the fracture and surgical treatment.

Sacral insufficiency fractures: current concepts of management

BACKGROUND

Sacral insufficiency fractures (SIFs) are often overlooked in elderly patients presenting with low back and pelvic pain following no or minimal trauma.

OBJECTIVE

The aim of this review is to raise awareness and outline the clinical presentation, methods of diagnosis and treatment of SIFs.

DISCUSSION

Insufficiency fractures represent a special category of stress fractures that occur in bones with reduced mineral content and elastic resistance. SIFs, a well-defined subgroup of the latter group, are not uncommon, but lack of clinical suspicion results in many being undiagnosed. SIFs are set to become an important clinical entity of both social and economic significance as the Western population ages. Subtle clinical presentations and signs coupled with radiographic findings that can mimic other unrelated or overlapping conditions, such as sacroiliac joint infection, spinal stenosis and metastatic bone disease, often make SIF diagnosis a challenge. The aim of this review is to increase awareness among clinicians, highlighting SIFs as an important differential diagnosis to be considered when patients present with low back and pelvic pain and subsequently allow prompt management. The paper provides an overview of epidemiology, anatomical considerations, relevant pathophysiology and risk factors, presenting symptoms and signs, investigations and imaging techniques, differential diagnoses and current treatment methods available for the management of SIFs.

Parathyroidectomy in the third trimester of pregnancy

The objective of this study was to estimate the incidence of complications when primary hyperparathyroidism (PHPT) is treated by parathyroidectomy in the third trimester of pregnancy. After searching the literature published through/including January 2005, we identified and analyzed 16 cases of PHPT treated surgically after 27 weeks of gestation. Parathyroid adenomas were detected in 81.2% of cases, hyperplasia in 6.3%, and carcinoma in 12.5%. Only one case failed surgical therapy. The postoperative incidence of clinically significant complications from the surgery was as low as 5.9% in fetuses and 0% in mothers. The incidence of clinically significant complications resulting from delayed diagnosis or postponed surgery ranged from 17.6% to 23.5% in fetuses and 18.8% to 25.0% in mothers. Postoperative hypocalcemia was detected in 62.5% of mothers and 17.6% of their newborns. All cases were easily treated with calcium replacement. Preeclampsia was diagnosed in 25% of cases. No clinically significant complications have been reported between 1993 and January 2005. This review suggests that parathyroidectomy performed in the third trimester of pregnancy is effective and has less risk than previously reported. Postponing surgery may be hazardous. Postoperative hypocalcemia is common but easily treated. Hyperparathyroidism should be considered a risk factor for preeclampsia.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to summarize the maternal and fetal complications of a delayed diagnosis and/or postponed surgery, recall that surgery of a parathyroid tumor can be safely performed in the third trimester, and describe pregnancy complications of hyperparathyroidism.

Postpartum sacral fracture presenting as lumbar radiculopathy: a case report

Although rare, sacral stress fractures may occur in pregnant women, and osteoporosis of pregnancy is a poorly understood entity. We present the case of a young, postpartum, recreational runner who developed low back pain (LBP) and radicular symptoms suggestive of L5 radiculopathy found to be secondary to sacral stress fracture. The patient had a good clinical outcome after several months and was able to resume her normal activities. This case illustrates that clinicians should have a high index of suspicion for sacral stress fracture in athletic pregnant or postpartum women presenting with LBP and/or lumbar radiculopathy. Also included are a brief review of osteoporosis in pregnancy and guidelines on the diagnosis and management of sacral stress fractures.