Poster Presentation Society of Obstetric Medicine of Australia and New Zealand ASM 2018

Pregnant bones, moans, stones and abdominal groans  (#44)

Emily Brooks 1 , David Watson 1 , Kunwarjit Sangla 1 , Vasant Shenoy 1
  1. Department of Endocrinology, The Townsville Hospital, QLD, Australia

Primary hyperparathyroidism (PHPT) complicates 0.03% of pregnancies (1). It may be under-diagnosed as patients are often asymptomatic or have non-specific symptoms attributed to pregnancy. Normal physiological changes of pregnancy also reduce total serum calcium but not ionised or corrected calcium (1). PHPT can cause significant maternal and fetal complications (Table 1)(2).


A 26-year-old female primip was referred to our institution at 10-weeks-gestation with parathyroid hormone dependent hypercalcaemia and symptoms of fatigue, constipation and ostalgia. She had no significant personal or family medical history and only medication was multivitamins. Clinical examination revealed a small right thyroid mass. Baseline laboratory values are shown in Table 1. Ultrasonography demonstrated a viable pregnancy and an irregular hypoechoic 1.2x2.6x1.4cm right thyroid nodule (Figure 1) but did not identify a parathyroid adenoma.  Fine needle aspiration reported benign thyroid nodule histology. She was admitted and managed with hydration, frusemide and electrolyte and fetal monitoring. There was no improvement in hypercalcaemia and bilateral neck exploration and right hemi-thyroidectomy was performed. Calcium levels declined within hours post-operatively and normalised the following day. Operative findings and histology confirmed normal parathyroid glands. Right hemi-thyroid histology confirmed an intra-thyroidal parathyroid adenoma. Genetic testing for MEN-1 was negative and CDC73 is pending.  The patient continues to be monitored regularly and is progressing with her pregnancy without further complications.


Management of hypercalcaemia during pregnancy is limited as commonly used antiresorptive agents are contraindicated. Parathyroidectomy reduces complications and is recommended when corrected calcium exceeds 2.75mmol/L and ideally during the second trimester (3).  Two cases of ectopic parathyroid adenomas during pregnancy have been reported (4, 5). Pre-operative localisation is challenging. Ultrasonography is safe, however Sestamibi and 4DCT are limited by radiation exposure and MRI is less specific.  Bilateral neck exploration is considered the standard of care (4, 6).  This case highlights PHPT management during pregnancy, including maternal and fetal complications of hypercalcaemia, surgery indications, localising parathyroid adenomas during pregnancy and genetic testing and follow-up planning.



Table 1. Complications of hypercalcaemia in pregnancy (2)

Maternal Complications

Fetal Complications


Intrauterine fetal demise


Preterm delivery

Bone Disease

Low birth weight


Neonatal hypocalcaemia


Neonatal tetany

Renal insufficiency




Table 2. Baseline laboratory values

Laboratory value


Reference Range

CCa2+ mmol/L



Ionised calcium mmol/L



Phosphate mmol/L



Alkaline phosphatase U/L



Parathyroid hormone pmol/L



25-hydroxyvitamin D nmol/L



1, 25 dihydroxyvitamin D umol/L



Creatinine umol/L



Urine Ca2+:creatinine clearance






Calcitonin pmol/L



Prolactin mIU/L



Cortisol nmol/L






IGF-1 nmol/L





Figure 1. Thyroid ultrasonography






  1. 1. Rey et al. Hypercalcaemia in pregnancy- a multifaceted challenge: case reports and literature review. Clin Case Rep. 2016;4:1001-1008
  2. 2. Nilsson et al. Primary Hyperparathyroidism in Pregnancy: A Diagnostic and Therapeutic Challenge. J Womens Health. 2010;19:1117-1121
  3. 3. Norman J et al. Hyperparathyroidism during pregnancy and the effect of rising calcium on pregnancy loss: a call for earlier intervention. Clin Endocrinol. 2009:71;104-109
  4. 4. Horton et al. Gestational Primary Hyperparathyroidism Due to Ectopic Parathyroid Adenoma: Case Report and Literature Review. Journal of the Endocrine Society. 2017; 1:1150-1155
  5. 5. Saad et al. Management of Ectopic Parathyroid Adenoma in Pregnancy. Obstet and Gynecol. 2014: 124; 478-480
  6. 6. Walker A et al. “Parathyroidectomy in pregnancy”- a single centre experience with review of evidence and proposal for treatment algorithm. Gland Surgery. 2014;3; 158-164
  7. 7. Kuzminski et al. Update in Parathyroid Imaging. Magn Reson Imaging Clin N Am. 2018:26; 151-166
  8. 7. Kuzminski et al. Update in Parathyroid Imaging. Magn Reson Imaging Clin N Am. 2018:26; 151-166