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