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John Levy Barnett M. A Scoping Review of the Apparent Phenomenon of the Improvement in Hypoparathyroidism in Pregnant and Postpartum Females. Cureus 2023; 15:e46123. [PMID: 37790033 PMCID: PMC10544865 DOI: 10.7759/cureus.46123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2023] [Indexed: 10/05/2023] Open
Abstract
Hypoparathyroidism requires management with both calcium supplementation and active vitamin D to avert a state of hypocalcemia. During late gestation and the postpartum period (specifically lactation), there is an under-recognized, yet intriguing occurrence of apparent 'pseudohyperparathyroidism', whereby supplementation dosages may need to either be reduced or discontinued, to prevent hypercalcemia. The explanation for this apparent phenomenon of improved parathyroid status ('remission' or 'resolution') is incompletely understood; the purpose of this review is to analyze the case reports of this enigma within the medical (and grey) literature, providing an overall pathophysiological explanation and recommendation for the management of such patients. A literature search was conducted through PubMed/Medline, CINAHL, Cochrane Library Database, Scopus, UpToDate, Google Scholar, and the grey literature without a time-restricted period, analyzing all available articles within the literature describing an apparent improvement in parathyroid status in late-gestation and postpartum (lactating) females. Non-hypoparathyroid case reports were also included to further analyze and synthesize an overall likely pathophysiological explanation. Through the literature search, 24 papers were identified covering such a phenomenon in patients with hypoparathyroidism, alongside multiple additional reports of a similar occurrence in patients without underlying hypoparathyroidism. The pathophysiology is believed to occur due to the placental production of parathyroid hormone-related peptide (PTHrP) during gestation, with further production from the lactating mammary glands during the postpartum period. A typical pattern is observed, with increased PTHrP and suppressed PTH throughout both gestation and lactation (present in both normal and hypoparathyroid subjects). The concept of PTHrP-induced hypercalcemia is further demonstrated in patients without hypoparathyroidism, including subjects with placental hypersecretion and mammary gland enlargement. It is evident that patients with hypoparathyroidism may require a dosage reduction during late gestation and lactation, due to the risk for hypercalcemia. In addition to patients with hypoparathyroidism, this pathophysiological phenomenon occurs in unsuspecting patients, demonstrating the need for all clinicians in contact with pregnant females to be aware of this uncommon - yet perilous - occurrence.
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Sun C, Ghassaban K, Song J, Chen Y, Zhang C, Qu F, Zhu J, Wang G, Haacke EM. Quantifying calcium changes in the fetal spine using quantitative susceptibility mapping as extracted from STAGE imaging. Eur Radiol 2023; 33:606-614. [PMID: 36044065 PMCID: PMC10662431 DOI: 10.1007/s00330-022-09042-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/11/2022] [Accepted: 07/19/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate calcium deposition in the fetal spine in vivo during the second and third trimesters using quantitative susceptibility mapping (QSM). METHODS Fifty-four pregnant women in their second and third trimesters underwent a 2D multi-echo STrategically Acquired Gradient Echo (STAGE) MR imaging protocol at 3T covering the fetal spine. The first echo data was used for QSM processing. A linear regression model was used to assess the correlation between magnetic susceptibility and gestational age (GA). A paired sample t-test was used to compare the consistency of QSM measurements from each sequence. RESULTS The magnetic susceptibility of the fetal spine decreased linearly with advancing GA, with a slope of -52.3 parts per billion (ppb)/week and a Pearson correlation coefficient (r) of 0.83 (p < 0.001). In 37 subjects for whom the STAGE local QSM data were available from both flip angles, the average magnetic susceptibility values were -1111 ± 278 ppb and -1081 ± 262 ppb for FA = 8° and FA = 40°, respectively. These means were not statistically different according to a paired sample t-test (p = 0.156). CONCLUSIONS QSM is a reliable technique for evaluating calcium deposition and bone mineral density of fetal vertebrae. Our results demonstrate an increase in fetal calcium levels as a function of GA. These measures might be able to provide reference values for calcium content in the fetal spine during the second and third trimesters. KEY POINTS • Calcium deposition and mineralization in the fetal spine, evaluated by vertebral magnetic susceptibility, increased with advancing gestational age. • Our results provide reference values for calcium content in the fetal spine during the second and third trimesters.
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Affiliation(s)
- Cong Sun
- Department of Radiology, Shandong Provincial Hospital, Shandong University, Jinan, China
- Department of Radiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Kiarash Ghassaban
- Department of Radiology, Wayne State University, Detroit, MI, USA
- SpinTech MRI Inc., Bingham Farms, MI, USA
| | - Jiaguang Song
- Department of Ultrasound, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yufan Chen
- Department of Radiology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Chao Zhang
- Department of Radiology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Feifei Qu
- MR Collaboration, Siemens Healthineers Ltd., Shanghai, China
| | - Jinxia Zhu
- MR Collaboration, Siemens Healthineers Ltd., Beijing, China
| | - Guangbin Wang
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 324, Jingwu Road, Jinan, 250021, Shandong, China.
| | - E Mark Haacke
- Department of Radiology, Wayne State University, Detroit, MI, USA.
- SpinTech MRI Inc., Bingham Farms, MI, USA.
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Ajong AB, Kenfack B, Ali IM, Yakum MN, Onydinma UP, Mangala FN, Aljerf L, Telefo PB. Ionised and total hypocalcaemia in pregnancy: An analysis of prevalence and risk factors in a resource-limited setting, Cameroon. PLoS One 2022; 17:e0268643. [PMID: 35584129 PMCID: PMC9116680 DOI: 10.1371/journal.pone.0268643] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 05/04/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Hypocalcaemia remains a prevalent laboratory finding in pregnancy, capable of inducing adverse maternofoetal outcomes. This study compares the prevalence of hypocalcaemia in apparently healthy pregnant women from the ionised, and total calcaemia viewpoints and further identifies factors associated with total crude and ionised hypocalcaemia in pregnancy. Methods A hospital-based cross-sectional study was conducted between November 2020 and September 2021, targeting apparently healthy pregnant women received in late pregnancy in four maternities in the Nkongsamba Health District, Cameroon. Blood samples were collected and analysed for serum ionised calcium concentrations and pH (by ion-selective electrode potentiometry), and for total calcium and albumin concentration (by atomic absorption spectrophotometry). Sociodemographic, obstetric and nutritional data were collected using an interviewer-administered questionnaire. Results The average age of the 1074 participants included in the study was 28.20±6.08 years. The prevalence of total crude and total albumin-corrected hypocalcaemia in this study was 61.64 [58.69–64.50]% and 56.70 [53.72–59.64]%, respectively (p-value = 0.000). The prevalence of ionised hypocalcaemia was very low (2.89 [2.04–4.07]%) compared with the prevalence of total hypocalcaemia (p-value = 0.000). Monthly income below 100.000FCFA (179 USD) (AOR = 0.73, p-value = 0.024), taking more than 2 meals daily (AOR = 0.68, p-value = 0.006) and taking desserts (AOR = 0.73, p-value = 0.046) reduced the odds of total crude hypocalcaemia, while having banana/plantain and tubers as the content of their most consumed meal significantly increased the odds of total crude hypocalcaemia (AOR = 1.37, p-value = 0.012). Single women (AOR = 2.54, p-value = 0.021), with a higher education (AOR = 3.27, p-value = 0.017), who initiated antenatal care before 4 months (AOR = 2.47, p-value = 0.029), had their odds of ionised hypocalcaemia significantly increased. On the other hand, women below 30 years (AOR = 0.44, p-value = 0.039), with occupations other than housewife (AOR = 0.34, p-value = 0.027), and women who took desserts between meals (AOR = 0.45, p-value = 0.034) had their odds of ionised hypocalcaemia significantly reduced. Taking calcium supplements simultaneously with other supplements also significantly reduced the odds of total hypocalcaemia in pregnancy (OR = 0.69, p-value = 0.027). Conclusion Ionised hypocalcaemia in pregnancy is a rare finding. Only 2.89% of all apparently healthy pregnant women have ionised hypocalcaemia in late pregnancy, while 56.70% have total hypocalcaemia. Factors like the daily number of meals, taking of desserts, the content of the most consumed meal and monthly revenue significantly affect the prevalence of total hypocalcaemia in pregnancy. On the other hand, factors like age above 30 years, having a higher education, being single, having initiated antenatal care before 4 months of pregnancy, being a housewife and not taking desserts between meals have a significantly positive association with ionised hypocalcaemia.
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Affiliation(s)
- Atem Bethel Ajong
- Kekem District Hospital, Kekem, West Region, Cameroon
- Department of Biochemistry, University of Dschang, Dschang, West Region, Cameroon
- * E-mail: (ABA); (PBT)
| | - Bruno Kenfack
- Department of Obstetrics / Gynaecology and Maternal Health, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, West Region, Cameroon
| | - Innocent Mbulli Ali
- Department of Biochemistry, University of Dschang, Dschang, West Region, Cameroon
| | - Martin Ndinakie Yakum
- Department of Epidemiology and Biostatistics, School of Medical and Health Sciences, Kesmonds International University, Bamenda, Cameroon
| | | | - Fulbert Nkwele Mangala
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
- Maternity Unit, Nkongsamba Regional Hospital, Nkongsamba, Littoral Region, Cameroon
| | - Loai Aljerf
- Department of Basic Sciences, Faculty of Dentistry, Damascus University, Damascus, The Syrian Arab Republic
- Key Laboratory of Organic Industries, Department of Chemistry, Faculty of Sciences, Damascus University, Damascus, The Syrian Arab Republic
| | - Phelix Bruno Telefo
- Department of Biochemistry, University of Dschang, Dschang, West Region, Cameroon
- * E-mail: (ABA); (PBT)
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Marcucci G, Altieri P, Benvenga S, Bondanelli M, Camozzi V, Cetani F, Cianferotti L, Duradoni M, Fossi C, Degli Uberti E, Famà F, Mantovani G, Marcocci C, Masi L, Pagotto U, Palermo A, Parri S, Ruggeri RM, Zatelli MC, Brandi ML. Hypoparathyroidism and pseudohypoparathyroidism in pregnancy: an Italian retrospective observational study. Orphanet J Rare Dis 2021; 16:421. [PMID: 34627337 PMCID: PMC8501695 DOI: 10.1186/s13023-021-02053-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 09/20/2021] [Indexed: 12/01/2022] Open
Abstract
Background Hypoparathyroidism (HypoPT) or pseudo-hypoparathyroidism (pseudo-HypoPT) during pregnancy may cause maternal and fetal/neonatal complications. In this regard, only a few case reports or case series of pregnant or lactating women have been published. The purpose of this study was to describe clinical and biochemical course, pharmacological management, and potential adverse events during pregnancy and post-partum in pregnant women with HypoPT or pseudo-HypoPT. This was a retrospective, observational, multicenter, study involving nine Italian referral centers for endocrine diseases affiliated with the Italian Society of Endocrinology and involved in “Hypoparathyroidism Working Group”. Results This study identified a cohort of 28 women (followed between 2005 and 2018) with HypoPT (n = 25, 84% postsurgical, 16% idiopathic/autoimmune) and pseudo-HypoPT (n = 3). In HypoPT women, the mean calcium carbonate dose tended to increase gradually from the first to third trimester (+ 12.6%) in pregnancy. This average increase in the third trimester was significantly greater compared to the pre-pregnancy period (p value = 0.03). However, analyzing the individual cases, in 44% the mean calcium dosage remained unchanged throughout gestation. Mean calcitriol doses tended to increase during pregnancy, with a statistically significant increase between the third trimester and the pre-pregnancy period (p value = 0.02). Nevertheless, analyzing the individual cases, in the third trimester most women with HypoPT (64%) maintained the same dosage of calcitriol compared to the first trimester. Both mean calcium carbonate and calcitriol doses tended to decrease from the third trimester to the post-partum six months. Most identified women (~ 70%) did not display maternal complications and (~ 90%) maintained mean serum albumin-corrected total calcium levels within the low-to-mid normal reference range (8.5 ± 0.8 mg/dl) during pregnancy. The main complications related to pregnancy period included: preterm birth (n = 3 HypoPT women), and history of miscarriages (n = 6 HypoPT women and n = 2 pseudo-HypoPT women). Conclusion This study shows that mean serum albumin-corrected total calcium levels were carefully monitored during pregnancy and post-pregnancy, with limited evaluation of other biochemical parameters, such as serum phosphate, 24 h urinary calcium, 25-OH vitamin D, and creatinine clearance. To avoid complications in mothers affected by (HypoPT) or (pseudo-HypoPT) and offspring, intense biochemical, clinical and pharmacological monitoring during pregnancy and breastfeeding is highly recommended.
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Affiliation(s)
- Gemma Marcucci
- Bone Metabolic Diseases Unit, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Paola Altieri
- Endocrinology Unit and Prevention and Care of Diabetes, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Marta Bondanelli
- Department of Medical Sciences, Section of Endocrinology and Internal Medicine, University of Ferrara, Ferrara, Italy
| | - Valentina Camozzi
- Endocrinology Unit, Department of Medicine (DIMED), University of Padua, Padua, Italy
| | - Filomena Cetani
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luisella Cianferotti
- Bone Metabolic Diseases Unit, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Mirko Duradoni
- Department of Information Engineering, University of Florence, Florence, Italy
| | - Caterina Fossi
- Bone Metabolic Diseases Unit, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Ettore Degli Uberti
- Department of Medical Sciences, Section of Endocrinology and Internal Medicine, University of Ferrara, Ferrara, Italy
| | - Fausto Famà
- Division of Endocrine and Minimally Invasive Surgery Department of Human Pathology in Adulthood and Childhood "G. Barresi",, University Hospital "G. Martino" of Messina, Messina, Italy
| | - Giovanna Mantovani
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Laura Masi
- Bone Metabolic Diseases Unit, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Uberto Pagotto
- Endocrinology Unit and Prevention and Care of Diabetes, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Andrea Palermo
- Unit of Endocrinology, Campus Bio-Medico University, Rome, Italy
| | - Simone Parri
- Bone Metabolic Diseases Unit, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy
| | - Rosaria Maddalena Ruggeri
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Messina, Messina, Italy
| | - Maria Chiara Zatelli
- Department of Medical Sciences, Section of Endocrinology and Internal Medicine, University of Ferrara, Ferrara, Italy
| | - Maria Luisa Brandi
- Bone Metabolic Diseases Unit, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Florence, Italy.
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Ali DS, Dandurand K, Khan AA. Hypoparathyroidism in Pregnancy and Lactation: Current Approach to Diagnosis and Management. J Clin Med 2021; 10:jcm10071378. [PMID: 33805460 PMCID: PMC8038023 DOI: 10.3390/jcm10071378] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 12/11/2022] Open
Abstract
Background: Hypoparathyroidism is an uncommon endocrine disorder. During pregnancy, multiple changes occur in the calcium-regulating hormones, which may affect the requirements of calcium and active vitamin D during pregnancy in patients with hypoparathyroidism. Close monitoring of serum calcium during pregnancy and lactation is ideal in order to optimize maternal and fetal outcomes. In this review, we describe calcium homeostasis during pregnancy in euparathyroid individuals and also review the diagnosis and management of hypoparathyroidism during pregnancy and lactation. Methods: We searched the MEDLINE, CINAHL, EMBASE, and Google scholar databases from 1 January 1990 to 31 December 2020. Case reports, case series, book chapters, and clinical guidelines were included in this review. Conclusions: During pregnancy, rises in 1,25-dihydroxyvitamin D (1,25-(OH)2-D3) and PTH-related peptide result in suppression of PTH and enhanced calcium absorption from the bowel. In individuals with hypoparathyroidism, the requirements for calcium and active vitamin D may decrease. Close monitoring of serum calcium is advised in women with hypoparathyroidism with adjustment of the doses of calcium and active vitamin D to ensure that serum calcium is maintained in the low-normal to mid-normal reference range. Hyper- and hypocalcemia should be avoided in order to reduce the maternal and fetal complications of hypoparathyroidism during pregnancy and lactation. Standard of care therapy consisting of elemental calcium, active vitamin D, and vitamin D is safe during pregnancy.
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