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Primary Hyperparathyroidism and Hypercalcemia During Pregnancy.

Dear Editors, Primary hyperparathyroidism (PHPT) during pregnancy is uncommon and often unrecognized until the baby is born. It can negatively impact the health of the mother and the newborn. Hyperemesis and nephrolithiasis are common complications in the mother but PHPT may also lead to more severe complications including pancreatitis, hypercalcemic crisis, and a 5-fold increase in the chance of miscarriage [1, 2]. The rate of fetal loss rises with an increasing maternal serum calcium level. In the offspring, PHPT may cause growth retardation in utero, neonatal hypoparathyroidism and hypocalcemic tetany, which may be life threatening [1]. The reported incidence of PHPT during pregnancy is less than 1 %, but is very likely to be underestimated as many PHPT cases may be mild and not prompt further endocrine evaluation. During pregnancy, many hormonal adaptations occur [3]. Longitudinal changes in calcium, phosphorus, and calcitropic hormone levels during pregnancy and lactation are reviewed in reference [4]. Maternal vitamin D deficiency and insufficiency during pregnancy may represent an independent risk factor for preeclampsia and eclampsia and appears to be associated with an increased risk of an autism spectrum disorder [5–8]. Serum 25-hydroxy(OH) vitamin D levels of less than 37.5 nmol/l were reported in approximately 29 % of black pregnant women living in the northeastern United States [9]. We evaluated a 34-year old black African American woman at 14 weeks gestation who presented to a rural hospital emergency room (ER) with intractable nausea and vomiting for 3 weeks duration. Initial laboratory data in the ER showed severe hypercalcemia with a serum calcium level of 14 mg/dl and normal renal function (creatinine 0.5 mg). She was hydrated with intravenous normal saline and subsequently transferred to a tertiary care hospital for further workup and management. With hydration, her serum calcium gradually declined to 11 mg/dl over a period of 24 h. Ionized calcium was 1.54 mmol/l (normal, 1.22–1.38). Albumin was 3.1 g/dl. Phosphorus was 3.4 mg/dl. Her 25-OH vitamin D level was found to be low at 12.2 ng/ml. The intact parathyroid hormone (PTH) level was elevated at 102 pg/ml (normal, 15–65). 24-h urinary calcium was 164 mg and creatinine 400 mg (calcium/creatinine ratio: 0.023). Her personal and family history were negative for any renal stones. She had no history of hematuria, atraumatic fracture, stomach ulcers or any features of an endocrine neoplasia syndrome. This was her fourth pregnancy (G1: vaginal delivery, G2: spontaneous abortion, G3: cesarean section at 36 weeks gestation). She did not have any headaches or vision changes. She had a history of essential hypertension with non-compliance to medication (nifedipine). Blood pressure ranged from 140 to 160 mm Hg systolic to 78 to 100 mg Hg diastolic. An ultrasound of the neck revealed an intrathyroidal nodule in the upper pole of the left lobe. The configuration and echogenicity was suggestive of an intrathyroidal lymph node, but presence of a parathyroid adenoma could not be definitively ruled out. Her calcium gradually declined to 10.1 mg/dl within 72 h but on the 4th day of hospitalization, she developed acute epigastric pain. An ultrasonogram of the right upper quadrant of the abdomen showed a thickened wall of the gallbladder with sludge, Primary Hyperparathyroidism and Hypercalcemia During Pregnancy