phpt in pregnancy 1
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HYPERCALCAEMIA IN PREGNANCY
DR SANDEEP Kr GARG MD DMDr SUDHI KAMBOJ MS Mch
• 29/F• 6.5 months pregnancy• P/W• Recurrent severe UTI with fever• Gen body weakness • Gen bony pains, off and on • Mild abdominal pain• Detected hypercalcemia in
preliminary investigations • Confirmed PHPT biochemically on
extensive work up
Investigations Serum Calcium TotalIonized
15.5 mg/dl (8-10)1.92 mmol/L (1.15-1.29)
S iPTH 1154 pg/ml (15-68)
Serum iPhosphorous
S Alkaline Phosphatase 322 U/L (30-120)
S Creatinin 1.2 mg/dl
S 25 OH Vitamin D Insufficient
LFT WNL
Na/ K / Cl 133/ 4.2/ 105
TSH 0.64
Hb 9
TLC 17,600
Urine 8-10 pus cell/hpf
Localization
• USG Neck• 2.6x0.9x1.6 cm predominantly hypoechoic
SOL postero-lateral to the inferior pole of right lobe of thyroid. Thyroid- normal
• Sestamibi scan- not done in view of pregnancy
Management
• Intravenous hydration -300-500 ml/hr• S/c Calcitonin• Iv Bisphosphonates• Susten p/v• Iv betamethasone• Iv antibiotics and supportives
Provisional diagnosis
Primary hyper-parathyroidism with hypercalcemic crises with 6.5 months pregnancy ? Left inferior parathyroid tumorTo rule out ? Malignancy ? MEN syndrome
DISCUSSION
Diagnostic approach to hypercalcemia
PREFERRED APPROACH• Mild hypercalcemia — Asymptomatic or mildly
symptomatic hypercalcemia (Ca<12mg/dL [3 mmol/L]) do not require immediate Tt
• They should avoid– Thiazide diuretics– Lithium– Volume depletion– Prolonged bed rest or inactivity– High calcium diet (>1000 mg/day).
• They should have – Adequate hydration– Additional therapy depends upon the cause
MODERATE HYPERCALCEMIA
• Asymptomatic or mildly symptomatic, moderate hypercalcemia (calcium between 12 and 14 mg/dL[3 to 3.5 mmol/L]) may not require immediate therapy.
• Should follow precautions for mild hypercalcemia.• Acute rise of these concentrations may cause
marked changes in sensorium, which requires more aggressive therapy as in severe hypercalcemia
SEVERE HYPERCALCEMIA
• Calcium >14 mg/dL (3.5 mmol/L) require aggressive therapy
• The acute therapy of such patients consists of a three-pronged approach– Saline– Calcitonin– Bisphosphnates
SEVERE HYPERCALCEMIA• Volume expansion with isotonic saline at an initial
rate of 200 to 300 mL/hour that is then adjusted to maintain the urine output at 100 to 150mL/hr
• In the absence of CKD or CHF, loop diuretic not recommended
• Administration of salmon calcitonin (4 iu/kg) repeat measurement of S.Ca in several hrs
• If hypocalcemic response is noted, then the pt is calcitonin-sensitive & calcitonin can be repeated every 6 to 12 hours (4 to 8 iu/kg)
• Administer calcitonin (along with a bisphosphonate) in pts with calcium >14 mg/dL who are also symptomatic
SEVERE HYPERCALCEMIA
• Concurrent administration of zoledronic acid (ZA; 4 mg IV over 15 min) or pamidronate (60 to 90 mg over 2 hrs), preferably ZA
• Administration of calcitonin + saline should result in substantial reduction in S.Ca within 12-48 hrs.
• Bisphosphonate will be effective by 2nd to 4th day, failed to reverse hypercalcemia, mental status changes, and hypophosphatemia due to primary hyperparathyroidism
SEVERE HYPERCALCEMIA
• Hypercalcemia due to calcitriol, usually lasts only one to two days because of the relatively short biologic half-life
• Hypercalcemia caused by vit D lasts longer, so that more aggressive therapy such as glucocorticoids & ZA or pamidronate
• Hypercalcemia is not treated in FHH because it is mild & produces few symptoms
SEVERE HYPERCALCEMIA
• More aggressive measures are necessary in the rare patient with very severe, symptomatic hypercalcemia
• Hemodialysis should be considered, in addition to the above treatments, in pts who have serum calcium concentrations in the range of 18 to 20 mg/dL (4.5 to 5 mmol/L) & neurologic symptoms but a stable circulation, or in those with severe hypercalcemia complicated by renal failure
THANK YOU
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