Gestational Primary Hyperparathyroidism Due to Ectopic Parathyroid Adenoma: Case Report and Literature Review

Pregnancy Complicated by Primary Hyperparathyroidism-A Case Report on the Use of Cinacalcet

Adverse outcomes are common in pregnant women with primary hyperparathyroidism, but no established guidelines are available. Parathyroidectomy is advised in the second trimester. Cinacalcet, though category C, appears to be safe and may be used for moderate to severe hypercalcemia. Aspirin should be considered for preeclampsia prevention.

Use of Cinacalcet for the Management of Primary Hyperparathyroidism in Pregnancy

Primary hyperparathyroidism in pregnancy is uncommon. Consequently, there are no randomized controlled studies that address treatment of primary hyperparathyroidism in pregnancy, and the efficacy and safety of medical management with cinacalcet in this setting is unknown. We report a case of a 28-year-old woman with primary hyperparathyroidism and hypercalcemia that worsened during her third trimester of pregnancy. Cinacalcet led to achievement of normocalcemia, allowing the delay of parathyroidectomy until after delivery of the baby. We also review the published literature on cinacalcet use in the management of primary hyperparathyroidism during pregnancy. Cinacalcet is typically reserved for pregnant patients with severe and symptomatic hypercalcemia, primarily serving as a last resort to delay parathyroidectomy until either the second trimester or the postpartum period.

Gestational Ectopic Hyperparathyroidism: A Case Report of Perioperative and Perinatal Outcomes

In the realm of obstetric care, discerning the subtle signs of primary hyperparathyroidism (PHPT) amidst common pregnancy symptoms remains a formidable challenge. Our exploration into a case of gestational hypercalcemia peels back the layers of this complexity, revealing the clinical conundrum posed by overlapping gastrointestinal manifestations. The journey from diagnosis through surgical intervention to the resolution of symptoms underscores the importance of vigilance for PHPT in pregnant patients. This case further prompts consideration of gamma-aminobutyric acid (GABA) as a potential piece in the puzzle of persistent symptoms post-calcium normalization, inviting a broader dialogue on the intricacies of parathyroid pathology in pregnancy.

Expert consensus on multidisciplinary approach to the diagnosis and treatment of primary hyperparathyroidism in pregnancy in China

Primary hyperparathyroidism in pregnancy is a rare disease that can have detrimental effects on both maternal and fetal/neonatal outcomes. The physiological changes that occur during pregnancy can complicate the diagnosis, imaging examinations, and treatment of this disorder. To enhance our understanding and management of primary hyperparathyroidism in pregnancy, experts from various fields, including endocrinology, obstetrics, surgery, ultrasonography, nuclear medicine, pediatrics, nephrology, and general practice in China, collaborated to develop a consensus addressing the critical aspects of the diagnosis and treatment of primary hyperparathyroidism in pregnancy with a multidisciplinary team approach. This consensus provides valuable guidance for healthcare professionals in managing this condition, ultimately improving outcomes for both mothers and their babies.

Parathyroid adenoma in pregnancy: A case report and systematic review of the literature

OBJECTIVE

Primary hyperparathyroidism is a common disorder of the parathyroid glands. Parathyroid adenoma (PA) in pregnancy is a relatively rare disease, whose diagnosis and treatment is a challenging task. The aim of the present study is to present a new case of parathyroid adenoma during pregnancy and to give a detailed account of all reported cases of parathyroid adenoma during pregnancy in the literature.

STUDY DESIGN

A bibliographic research was performed, and characteristics of parathyroid adenomas in pregnancy such as age, gestational week at diagnosis, ionized calcium levels, genetic testing result, symptomatology, radiological method of localization, treatment method, gestational week at operation, and maternal/fetal complications were recorded.

RESULTS

A 34-year-old woman at her 25 weeks' gestation was diagnosed with parathyroid adenoma and was referred to our Surgical Department due to contraindication for conservative treatment. A parathyroidectomy was performed, and the maternal and fetal postoperative period was uneventful. Two hundred eleven cases of parathyroid adenoma in pregnancy were recorded in the literature, and statistical analysis was performed. The median gestational week at diagnosis was 21 ± 9.61 weeks. The mean level of ionized calcium was 2.69 mmol/l [SD = 0.75 (2.55-2.84 95% CI)]. Most cases were familiar (72.4%), while surgery was the preferred treatment option (67.3%). The majority of cases were asymptomatic (21.7%), and the main radiological method applied for localization was ultrasound (63.4%).

CONCLUSION

Parathyroid adenoma in pregnancy is a rare condition. The early diagnosis is of great importance as surgical treatment at the second trimester of pregnancy outweighs the maternal and fetal risks.

Hypercalcemia in Pregnancy

Hypercalcemic disorders are rare in pregnant women and are usually due to primary hyperparathyroidism. Clinical manifestations of hypercalcemia are nonspecific and can be masked by the physiologic changes of pregnancy. Furthermore, routine antenatal screening does not include serum calcium measurement and a hypercalcemia diagnosis may therefore be delayed until term or even after delivery. Timely recognition and appropriate interventions are essential to decrease maternal and fetal complications. Conservative measures are appropriate in the presence of mild hypercalcemia. Parathyroidectomy remains the mainstay of treatment for primary hyperparathyroidism with significant hypercalcemia not responding to conservative measures.

Surgical management of primary hyperparathyroidism during pregnancy: a systematic review of the literature

OBJECTIVE

Gestational primary hyperparathyroidism (PHPT) is an endocrinological disorder with serious outcomes for both women and neonates. The aim of our study was to present the current evidence concerning the perioperative outcomes of pregnant women with PHPT who underwent parathyroidectomy during pregnancy.

METHODS

A meticulous systematic review of the literature published before February 2020 and all studies which presented perioperative and pregnancy outcomes off pregnant women who underwent parathyroidectomy for PHPT, were included.

RESULTS

A total of 53 were finally included, which reported 92 pregnant women who had parathyroidectomy during their pregnancy. A total of 46 patients were hospitalized due to significant complications of PHPT before their parathyroidectomy. With regards to surgical approach, 52.2% of patients underwent minimally invasive parathyroidectomy (MIP), while bilateral neck exploration (BNE) was 41.3% of cases. Only 4 women was not cured, whereas transient hypocalcemia was occurred in 18 patients. All cases proceeded to deliveries of healthy neonates, after their parathyroidectomy.

CONCLUSIONS

Parathyroidectomy during pregnancy is a safe and effective treatment option with minimum complications and probably should be considered as the treatment of choice in specific group of pregnant women with PHPT.

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.

Right ectopic paraesophageal parathyroid adenoma with refractory hypercalcemia in pregnancy: A case report and review of the literature

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Ectopic parathyroid adenoma (EPA) is rare during pregnancy but poses multiple challenges in diagnosis and treatment.

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EPA presents with refractory hypercalcemia which leads to symptoms and complications in the mother and fetus.

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Preoperative localization of EPA is important and allows for a focused surgical procedure.

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Surgery is a definitive treatment and can safely be performed during the 2nd trimester of pregnancy.

Introduction

Ectopic parathyroid adenoma is rare during pregnancy but poses multiple challenges in treatment. It presents as primary hyperparathyroidism which leads to symptoms and complications of hypercalcemia in both the mother and fetus.

Presentation of case

A 38-year-old Sudanese female presented with diffuse bone pain and polyuria. Laboratory investigations revealed elevated serum calcium and parathyroid hormone. Ultrasound of the neck did not show any abnormal lesion, however 99mTc-sestamibi scan showed a right sided parathyroid adenoma, and an earlier CT scan showed the adenoma to be in an ectopic paraesophageal position. Focused surgical neck exploration was done, and the ectopic parathyroid adenoma was excised.

Discussion

Preoperative localization of the ectopic parathyroid adenoma allows for a focused surgical procedure. Ultrasound is the safest during pregnancy, but 99mTc-sestamibi and CT scan may be necessary if ultrasound or initial bilateral neck exploration do not detect any adenoma. Mild elevations in maternal serum calcium can have detrimental effects on the fetus which suggests that a surgical approach may be necessary in the majority of cases.

Conclusions

Ectopic parathyroid adenoma is rare during pregnancy and is detrimental to both the mother and fetus. Preoperative localization allows for a focused surgery which is a definitive treatment and can safely be performed during the 2nd trimester of pregnancy.

Seventeen Cases of Primary Hyperparathyroidism in Pregnancy: A Call for Management Guidelines

Context

The risks of primary hyperparathyroidism (pHPT) to pregnant women and their fetuses appear to increase commensurate with serum calcium levels. The management strategy for pHPT must be adapted in pregnancy and should reflect the severity of hypercalcemia. However, no guidelines exist to assist clinicians.

Methods

The experience of a high-volume multidisciplinary endocrine surgical service in treating a consecutive series of pregnant women with pHPT referred for parathyroidectomy is presented and data are compared with a nonpregnant cohort with pHPT. A review of pHPT and pregnancy outcomes in the literature is provided.

Results

Seventeen pregnant women and 247 age range-matched nonpregnant women with pHPT were referred for surgery over 11 years. Mean serum calcium level was higher in the pregnant cohort (2.89 vs 2.78 mmol/L; P = 0.03). Preoperative localization with ultrasound succeeded in eight pregnant women (47%) and sestamibi scanning did in two of six (33% imaged preconception), compared with 84 (34%) and 102 (42%) control subjects, respectively (not significant). Parathyroidectomy was performed under general anesthesia between 12 and 28 weeks' gestation with no adverse pregnancy outcomes resulting. Cure rate was 100% vs 96% in controls.

Conclusion

pHPT in pregnancy is a threat to mother and child. Medical management may be appropriate in mild disease, but in moderate to severe disease, parathyroidectomy under general anesthesia in the second trimester is safe. Localization using ionizing radiation/MRI is unnecessary, because surgical intervention in a high-volume multidisciplinary setting has excellent outcomes. Guidelines on the topic would assist clinicians.

A CASE OF HYPERPARATHYROIDISM TREATED WITH CINACALCET DURING PREGNANCY

Objective

Hyperparathyroidism during pregnancy is associated with increased maternal and neonatal complications. Cinacalcet is a calcimimetic medication that is used in the treatment of hyperparathyroidism; its use in pregnancy is limited to a few case reports.

Methods

Case report and literature review.

Results

We are reporting on a 37-year-old patient who was admitted to the hospital with dyspnea at 24 weeks gestation. A routine blood test revealed hypercalcemia; corrected calcium level was 3.17 mmol/L, and parathyroid hormone was elevated at 168 pg/mL. The patient was asymptomatic. Following her last delivery 10 years previously, her newborn developed severe tetany and needed treatment with intravenous (IV) calcium. Neck ultrasound was normal. Due to obesity and history of recurrent deep venous thrombosis, neck exploration was not favored. Initial treatment included calcitonin and IV fluids. The aim was to keep her calcium level as normal as possible to avoid any fetal complications. She was started on cinacalcet 15 mg once per day, which was increased later to 15 mg twice daily. By 36 weeks gestation, corrected calcium levels were down to <2.60 mmol/L. The patient was scheduled to deliver via elective cesarean section at 38 weeks, but she presented at 37 weeks in labor pain and delivered via emergency cesarean section. Postdelivery, the neonate calcium levels remained normal.

Conclusion

During pregnancy, parathyroid surgery is the recommended treatment. Cinacalcet could be one of the options in severe cases of hypercalcemia if surgery cannot be performed. Further studies are needed to examine the safety of cinacalcet in pregnancy.

Hypercalcaemia during pregnancy: Review of maternal and fetal complications, investigations, and management

Introduction

Asymptomatic mild primary hyperparathyroidism is increasingly being identified during pregnancy. Recent studies have demonstrated inconsistent findings with regard to pregnancy complications and the need for surgical intervention during pregnancy.

Method

A retrospective audit of outcomes of pregnancies complicated by hypercalcaemia over a 15-year period was performed.

Results

Twenty-nine pregnancies to 26 women with hypercalcaemia were identified, corresponding to 37 cases per 100,000 deliveries. Hypercalcaemia was due to primary hyperparathyroidism in 90% of cases, with mean serum calcium of 2.89 mmol/l and mean ionised calcium 1.43 mmol/l. Four women underwent successful neck exploration during pregnancy. Pregnancy complications were limited to three cases of pre-eclampsia and one case of symptomatic neonatal hypoparathyroidism.

Conclusion

Close observation without surgical intervention would seem reasonable in women with mild hypercalcaemia during pregnancy.

Gestational Gigantomastia Complicated by PTHrP-Mediated Hypercalcemia

CONTEXT

Gestational gigantomastia is an uncommon condition characterized by abnormal and excessive growth of breast tissue during an otherwise uncomplicated pregnancy. Gestational gigantomastia may be accompanied by hypercalcemia, which in some cases has been associated with elevated serum levels of PTHrP. The source of the PTHrP in these cases has been suggested to be the enlarged breasts.

OBJECTIVE

To describe the rapid resolution of hypercalcemia and normalization of serum PTHrP after elective termination of pregnancy, indicating that the placenta was the source of the PTHrP.

DESIGN

A retrospective analysis of clinical and biochemical data over a 2-year interval and review of literature.

SETTING

An academic medical center.

PATIENT

A 33-year-old G8P4 female who presented at week 8 of pregnancy with gestational gigantomastia and subsequently developed marked hypercalcemia at week 13. Serum levels of PTH were suppressed but circulating PTHrP was elevated. There was no history of hypercalcemia or significant breast growth during previous pregnancies.

INTERVENTION

Hypercalcemia was poorly responsive to IV saline, prednisone, calcitonin, and cinacalcet. She requested termination of pregnancy at week 20.

RESULTS

Serum levels of calcium, PTH, and PTHrP normalized within 48 hours of termination of pregnancy.

CONCLUSION

The rapid resolution of hypercalcemia after termination of pregnancy, despite persistent gigantomastia, provides evidence for a pathologic role of the placenta in the excess production of PTHrP, possibly through an as yet uncharacterized placenta-breast hormonal axis.

Use of Cinacalcet and 99mTc-sestamibi Imaging During Pregnancy

A case report is reviewed, in which two nontraditional interventions were used in a patient with gestational primary hyperparathyroidism: cinacalcet and technetium-99m methoxyisobutylisonitrile imaging. The rationale for these decisions is considered in view of the available data.