Hypercalcemic crisis in third trimenon: evaluating the optimal treatment strategy

Area of Science:

• Endocrinology
• Obstetrics
• Surgical Management

Background:

• Primary hyperparathyroidism during pregnancy is a rare condition with significant risks for mother and fetus.
• Management guidelines for third-trimester hypercalcemia are not well-established, unlike the preference for parathyroidectomy in the second trimester.

Observation:

• A 26-year-old pregnant woman (29 weeks) presented with hypertension, intrauterine growth retardation, and polyhydramnios.
• Severe hypercalcemia (total calcium 3.34 mmol/l; PTH 216 pg/ml) was diagnosed, but ultrasound failed to localize the parathyroid gland.
• Medical management with calcitonin and cinacalcet was ineffective in controlling hypercalcemia.

Findings:

• Explorative parathyroid surgery successfully resected a parathyroid adenoma, normalizing serum calcium levels.
• The surgical procedure was well-tolerated by both mother and fetus.
• Maternal hypertension and polyhydramnios resolved post-surgery, prior to a C-section performed two weeks later.

Implications:

• This case highlights the critical need for early diagnosis and treatment of primary hyperparathyroidism in pregnancy.
• An interdisciplinary approach is essential for managing third-trimester hypercalcemia.
• Surgical parathyroid exploration should be considered for refractory hypercalcemia in the third trimester, even if localization is unsuccessful.