Hyperparathyroidism during Pregnancy- A Diagnostic and Therapeutic Challenge

Primary hyperparathyroidism in pregnancy: observations from the Indian PHPT registry

PURPOSE

To present the data on primary hyperparathyroidism (PHPT) in pregnancy from India obtained from a large database maintained over 15 years.

METHODS

We retrieved data of all women with gestational PHPT from the Indian PHPT registry between July 2005 and January 2020, and compared their clinical, biochemical, and other characteristics with age-matched non-pregnant women with PHPT.

RESULTS

Out of 386 women, eight had gestational PHPT (2.1%). The common presenting manifestations were acute pancreatitis (50%) and renal stone disease (50%); two were asymptomatic. Five women (62.5%) had a history of prior miscarriages. Seven patients (88%) had preeclampsia during the present gestation. Serum calcium and intact parathyroid hormone (iPTH) were not statistically different from the age-matched non-pregnant PHPT group. Six patients with mild-to-moderate hypercalcemia were medically managed with hydration with/without cinacalcet while one patient underwent percutaneous ethanol ablation of the parathyroid adenoma; none underwent surgery during pregnancy. Mean serum calcium maintained from treatment initiation till delivery was 10.5 ± 0.4 mg/dl. One patient had spontaneous preterm delivery at 36 weeks; the remaining patients had normal vaginal delivery at term. None had severe preeclampsia/eclampsia. Fetal outcomes included low birth weight in three newborns (37.5%); two of them had hypocalcemic seizures.

CONCLUSION

The prevalence of gestational PHPT was 2.1% in this largest Indian PHPT cohort, which is higher than that reported from the West (< 1%). Gestational PHPT can lead to preeclampsia and miscarriage. Pregnant PHPT patients with mild-to-moderate hypercalcemia can be managed with hydration/cinacalcet; however, long-term safety data and large-scale randomized controlled trials are required.

A Giant Parathyroid Tumor during Pregnancy: Adenoma versus Carcinoma

Primary hyperparathyroidism (PHP) is one of the most common endocrine diseases. However, it is rare during pregnancy. 85% cases of the PHP are due to parathyroid adenoma (PA) and less than 1% because of parathyroid carcinoma (PC). Here we report a case of giant parathyroid adenoma (GPA) in a patient with first trimester pregnancy. Her calcium and parathyroid hormone (PTH) levels were very high. The tumor measured 5 cm in greatest dimension, weighed 37 grams, and was adherent to the surrounding tissues. Grossly, the tumor was encapsulated and composed of solid and cystic components. Cut surface was reddish brown and soft. Microscopically, the tumor had a thick irregular capsule with entrapped parathyroid cells and extensive foreign body type reactions. The tumor was composed of multiple cell types with areas of pleomorphism. The mitotic index was nonetheless low. Even though the tumor was large and adherent with the surrounding strap muscles, the gross appearance and the histological morphology favored benign parathyroid adenoma. In this paper, we have discussed some important differential aspects of GPA, PA, and PC.