Hyperparathyroidism in pregnancy: options for localization and surgical therapy.
BACKGROUND
Hyperparathyroidism in pregnancy is a threat to the health of both mother and fetus. The mothers suffer commonly from nephrolithiasis, hyperemesis, or even hypercalcemic crisis. Untreated disease will commonly complicate fetal development and fetal death is a significant risk. Treatment options, including medical and surgical therapy, are debated in the literature.


METHODS
This is a case series comprising seven patients with primary hyperparathyroidism in pregnancy. Data collected included symptoms at diagnosis, biochemical abnormalities, pathologic findings, treatment regimes, and subsequent maternal and fetal outcomes.


RESULTS
Seven women, aged 20 to 39 years, presented with hyperparathyroidism during pregnancy. The earliest presented at 8 weeks and the latest at 38 weeks. Four of seven patients experienced renal calculi. Calcium levels were 2.7-3.5 mmol/l. All were found to have solitary parathyroid adenomas, of which two were in ectopic locations. Fetal complications included three preterm deliveries and one fetal death with no cases of neonatal tetany. Maternal and fetal complications could not be predicted based on duration or severity of hypercalcemia. Three patients were treated during pregnancy with surgery, and two of these had ectopic glands that required reoperations with a novel approach using Tc-99m sestamibi scanning during pregnancy to assist in localizing the abnormal gland. Four cases were treated postpartum with a combination of open and minimally invasive approaches after localization. No operative complications or fetal loss related to surgery were observed in this cohort.


CONCLUSIONS
Primary hyperparathyroidism in pregnancy represents a significant risk for maternal and fetal complications that cannot be predicted by duration of symptoms or serum calcium levels. Surgical treatment should be considered early, and a minimally invasive approach with ultrasound is best suited to mitigating risk to mother and fetus. Equally important, Tc-99m sestamibi imaging may be used safely for localization of the parathyroids after negative cervical explorations.
McMullen
Todd P W
TP
Department of Surgery 2D, Walter C. Mackenzie Health Science Centre, 8440-112 Street, Edmonton, AB, T6G 2B7, Canada. todd.mcmullen@ualberta.net
Learoyd
Diana L
DL
Williams
David C
DC
Sywak
Mark S
MS
Sidhu
Stan B
SB
Delbridge
Leigh W
LW
D000328:Adult; D005260:Female; D005313:Fetal Death; D006801:Humans; D006961:Hyperparathyroidism / Q000000981:diagnostic imaging* / Q000601:surgery*; D007231:Infant, Newborn; D010282:Parathyroid Neoplasms / Q000000981:diagnostic imaging* / Q000601:surgery*; D011247:Pregnancy; D011248:Pregnancy Complications / Q000000981:diagnostic imaging* / Q000601:surgery*; D011256:Pregnancy Outcome; D047928:Premature Birth; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi
D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi
Am J Surg. 1976 Mar;131(3):328-37
769583
J Matern Fetal Neonatal Med. 2002 Nov;12(5):349-52
12607769
Am J Surg. 1999 Jan;177(1):66-8
10037311
Br J Surg. 1998 Dec;85(12):1605-16
9876061
J Am Soc Nephrol. 2001 Feb;12 Suppl 17:S3-9
11251025
Obstet Gynecol Surv. 2005 Oct;60(10):672-82
16186784
Surg Endosc. 2008 Sep;22(9):1917-27
18553201
Health Phys. 1997 Nov;73(5):756-69
9378651
Ann Surg. 1981 Jun;193(6):805-9
7247524
ANZ J Surg. 2006 Dec;76(12):1048-50
17199687
J Obstet Gynaecol. 2004 Apr;24(3):318-9
15203643
Am J Obstet Gynecol. 1981 Aug 1;140(7):840-2
7258268
Gynecol Endocrinol. 2004 Aug;19(2):111-4
15624273
Am J Obstet Gynecol. 1989 Nov;161(5):1178-85
2589435
J Pediatr Endocrinol Metab. 2001 Jun;14(6):785-7
11453530
Langenbecks Arch Surg. 2009 Sep;394(5):765-84
19590890
Z Geburtshilfe Perinatol. 1994 May-Jun;198(3):96-9
7941630
Eur J Nucl Med. 1998 Feb;25(2):193-9
9473270
Dig Surg. 2001;18(5):409-17
11721118
Anesthesiology. 1986 Jun;64(6):790-4
3717642
J Reprod Med. 1998 May;43(5):451-4
9610470
Obstet Gynecol. 1980 Apr;55(4):431-4
7366898
N Engl J Med. 1962 Sep 27;267:637-42
14467191
Br J Surg. 1989 Nov;76(11):1207-8
2597981
Obstet Gynecol Surv. 2002 Jun;57(6):365-76
12140371
Clin Endocrinol (Oxf). 1996 Jul;45(1):1-6
8796131
Am J Med Sci. 2000 Mar;319(3):191-4
10746832
Br J Surg. 1979 Sep;66(9):648-50
497655
Arch Gynecol Obstet. 1998;261(4):209-14
9789652
J Med Soc N J. 1981 Feb;78(2):113-5
6938711
Surgery. 1991 Dec;110(6):1028-33; discussion 1033-4
1745971
Endocr Pract. 1999 Nov-Dec;5(6):337-42
15251655
Acta Endocrinol (Copenh). 1964 Dec;47:549-64
14250391
Surgery. 1985 Mar;97(3):326-30
3975852
J Gen Intern Med. 1992 Jul-Aug;7(4):448-53
1506954
Surg Today. 2008;38(3):222-6
18306995
Arch Surg. 2006 Aug;141(8):777-82; discussion 782
16924085
Postgrad Med J. 1998 Apr;74(870):233-4
9683978
Am J Surg. 2006 Mar;191(3):418-23
16490559
Am J Surg. 2005 Sep;190(3):467-73
16105538
Acta Obstet Gynecol Scand. 1993 Aug;72(6):488-92
8394630
Br J Surg. 1984 Mar;71(3):217-8
6697128
Surgeon. 2007 Oct;5(5):301-8
17958230