scholarly journals MANAGEMENT OF ENDOCRINE DISEASE: Hypoparathyroidism in pregnancy: review and evidence-based recommendations for management

2019 ◽  
Vol 180 (2) ◽  
pp. R37-R44 ◽  
Author(s):  
Aliya A Khan ◽  
Bart Clarke ◽  
Lars Rejnmark ◽  
Maria Luisa Brandi
Keyword(s):  
Calcium Homeostasis ◽  
Best Practice ◽  
Calcium Absorption ◽  
Normal Serum ◽  
Evidence Based ◽  
Close Monitoring ◽  
Optimal Care ◽  
Uncomplicated Pregnancy ◽  
Increased Risk ◽  
In Pregnancy

Purpose Review calcium homeostasis in pregnancy and provide evidence-based best practice recommendations for the management of hypoparathyroidism in pregnancy. Methods We searched MEDLINE, EMBASE and Cochrane databases from January 2000 to April 1, 2018. A total of 65 articles were included in the final review. Conclusions During pregnancy, calcitriol levels increase by two- to—three-fold resulting in enhanced intestinal calcium absorption. The renal filtered calcium load increases leading to hypercalciuria. PTHrP production by the placenta and breasts increases by three-fold, and this may lower the doses of calcium and calcitriol required during pregnancy in mothers with hypoparathyroidism. The literature however describes a wide variation in the required doses of calcium and calcitriol during pregnancy in hypoparathyroid mothers, with some women requiring higher doses of calcitriol, whereas others require lower doses. Close monitoring is necessary as hypercalcemia in the mother may suppress the fetal parathyroid gland development. Also hypocalcemia in the mother is harmful as it may result in secondary hyperparathyroidism in the fetus. This may be associated with demineralization of the fetal skeleton and the development of intrauterine fractures. Inadequate treatment of hypoparathyroidism may also result in uterine contractions and an increased risk of miscarriage. Treatment targets during pregnancy are to maintain a low normal serum calcium. Calcium, calcitriol and vitamin D supplements are safe during pregnancy. Close monitoring of the mother with a multidisciplinary team is advised for optimal care. If calcium homeostasis is well controlled during pregnancy, most women with hypoparathyroidism have an uncomplicated pregnancy and give birth to healthy babies.

scholarly journals MON-LB64 Primary Hyperparathyroidism With Severe Hypercalcemia During Pregnancy: A Challenging Diagnosis and Management

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Gemy M George ◽  
Rachel L Slotcavage ◽  
Elena Ambrogini
Keyword(s):  
Kidney Stones ◽  
Calcium Absorption ◽  
Second Trimester ◽  
Third Trimester ◽  
Maternal Complications ◽  
Diagnosis And Management ◽  
Dihydroxyvitamin D ◽  
Severe Hypercalcemia ◽  
Increased Risk ◽  
In Pregnancy

Abstract Background:Primary Hyperparathyroidism (PHPT) is rare in pregnancy and the physiological adaptations in mineral and skeletal homeostasis that occur during gestation need to be taken into consideration for the diagnosis and management. Clinical case:A 30-year-old primgravid woman with history of kidney stones presented at our institution during the 13th week of twin gestation with severe nausea and vomiting. She had previously been hospitalized at 9 weeks for hypercalcemia and acute kidney injury, and treated with steroids for presumed granulomatous disease without improvement. She was on prenatal vitamins and family history was significant for kidney stones, but not hypercalcemia. At admission, calcium was 14.4 mg/dl, ionized calcium 1.89 mmol/L (1.16-1.32), PTH 15.2 pg/ml (12-88), albumin 3.4 g/dl, phosphorus 2.1 mg/dl, and creatinine 1.8 mg/dl. PTHrP was <2 pmol/L (<4.2) and 1, 25-dihydroxyvitamin D was 191 pg/mL (2nd trimester range 72-160 pg/ml). She was treated with IV hydration, but her calcium remained elevated and severe hypercalcemia recurred after stopping hydration. She underwent neck exploration and right upper parathyroidectomy in the second trimester. The other parathyroid glands were noted to be normal. Intraoperative PTH dropped from 25.2 pg/mL to 4.4 pg/mL. Final pathology showed a hypercellular parathyroid. Her calcium dropped to normal levels in the early postoperative period. Calcitonin was initiated by another provider two weeks postoperatively for persistent mild hypercalcemia. Her calcium levels remained at the upper limit of normal during her 2nd and 3rd trimesters. PTH remained suppressed at 3.2 pg/ml. She had a C-section at 34 weeks for premature rupture of membranes. Her twins did not develop hypocalcemia or hypoparathyroidism. The most recent postpartum calcium was 9.2 mg/dl with PTH 3.3 pg/ml.Conclusions:Our case highlights the challenge in the diagnosis and management of PHPT in pregnancy. During pregnancy, PHPT is diagnosed by elevated ionized or albumin corrected calcium and non-suppressed PTH level. It is important to note that 1,25-dihydroxyvitamin D levels physiologically increase in the second and third trimester. Since both PHPT and pregnancy cause intestinal calcium absorption and bone resorption, PHPT during pregnancy has increased risk of severe hypercalcemia, pancreatitis and renal stones. During the third trimester the transfer of calcium through the placenta and the uptake of calcium by the fetal skeleton can protect against severe hypercalcemia. However, hypercalcemic crisis can occur because of the peak release of PTHrP by the placenta and breasts, or after delivery due to loss of calcium transfer to the placenta. Parathyroidectomy is preferably performed in the second trimester to reduce fetal and maternal complications. After delivery neonatal hypocalcemia can have a delayed onset, a prolonged course and could be permanent.

scholarly journals OBSTETRIC CHOLESTASIS

2003 ◽  
Vol 41 (142) ◽  
pp. 335-340
Author(s):  
Pramila Pradhan
Keyword(s):  
Perinatal Mortality ◽  
Maternal Morbidity ◽  
Post Partum ◽  
Active Management ◽  
Close Monitoring ◽  
The Third ◽  
Oestrogen Level ◽  
Increased Risk ◽  
Third Stage ◽  
In Pregnancy

Obstetric Cholestasis is the commonest liver disease that causes pruritis and is uniqueto pregnancy. Pruritis can be so intense as to lead insomnia.The Significance of thisdisease has been highlighted more recently due to the associated perinatal mortalityand maternal morbidity. Aetiology and pathophysiology still uncertain. There, appearsto be genetic predisposition in certain individuals resulting in an increasedsusceptibility to the high oestrogen levels found in pregnancy specially in 3rdtrimesterand resolving promptly after delivery when oestrogen level falls rapidly. Pruritis iscentral in origin and thus fails to respond to commonly used antihistamines and lotiocalamine locally. Recently ursodeoxycholic acid an exogenous bile acid is increasinglybeing used and showed improved both pruritis and liver function and favourablechanges were observed in the foetus as well. Delivery planned at 37-38 weeks ofgestation reduced perinatal mortality. Because of increased rate of adverse intrapartumevents, close monitoring is appropriate. Active management of the third stage isnecessary because of the increased risk of post partum haemorrhage.Key Words: Pruritis, pregnancy, planned delivery, perinatal mortality and maternal morbidity.

scholarly journals Spontaneous Bilateral Adrenal Hemorrhage in Pregnancy

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A158-A158
Author(s):  
Nami Safai Haeri ◽  
Jagdeesh Ullal ◽  
Hussain Mahmud
Keyword(s):  
Abdominal Pain ◽  
Adrenal Hemorrhage ◽  
Intrauterine Fetal Death ◽  
New Right ◽  
Adrenal Crisis ◽  
Close Monitoring ◽  
Ct Angiogram ◽  
Increased Risk ◽  
History Of ◽  
In Pregnancy

Abstract Introduction: Spontaneous Adrenal Hemorrhage (SAH) in pregnancy is a rare occurrence with estimated prevalence of 0.03% to 1.8%. SAH usually involves the right gland and can be easily mistaken with other conditions due to its nonspecific symptoms. We hereby report 2 cases of spontaneous bilateral SAH that occurred during the 3rd trimester of pregnancy. Case 1: 28-year-old female with history of IBS presented during 35th week of her first pregnancy with right-sided abdominal pain. Abdominal MRI revealed a 4.7 x 2.8 cm right adrenal hemorrhage. Due to stability of her vitals, steroids were not initiated and she was discharged. She returned 4 days later with similar pain but this time on the left side. MRI did not reveal adrenal bleeding. Due to Blood Pressure (BP) of 90/70 mmHg, hydrocortisone IV 50mg every 8 hours was started. 36 hour later she became tachycardic and tachypneic. CT angiogram (CTa) ruled out Pulmonary Emboli (PE), but was remarkable for interval development of a 5.3 x 3 cm left adrenal hemorrhage. There were no findings indicative of Primary Adrenal Insufficiency (PAI). Patient was discharged home on physiologic dose of hydrocortisone and delivered a healthy baby 2 weeks later at term. Case 2: 30-year-old female with history of hypertension and polycystic kidney disease presented at 31st week of her 2nd pregnancy with left-sided abdominal pain. Abdominal CT scan showed a 2.3 x 3.1 cm left adrenal hemorrhage. Due to BP of 85/50 mmHg at presentation, she was started on hydrocortisone IV 50 mg one dose followed by 25 mg every 8 hours, which improved her BP. 3 days later she developed new right flank pain. MRI was remarkable for features indicative of adrenal hyperplasia but did not confirm presence of hemorrhage. 1 day later she developed hypoxia and underwent CTa to rule out PE, which was remarkable for a new right adrenal hemorrhage. She did not have findings indicative of PAI and was discharged home on physiologic dose of hydrocortisone. Unfortunately, the pregnancy resulted in intrauterine fetal death at 36 weeks. Discussion: Adrenal cortex hyperplasia secondary to physiological elevation of ACTH plus adrenal venous constriction due to increased catecholamine release, have been suggested as possible mechanisms for increased risk of SAH in pregnancy. Common manifestations of SAH include abdominal pain, fever, fatigue, dizziness, anemia and hypotension. Features of PAI such as hyponatremia and hyperkalemia should be expected in cases of over 90% damage of adrenal cortices. Management in pregnancy involves fluid resuscitation, close monitoring for findings suggestive of adrenal crisis, fetal monitoring and glucocorticoid +/- mineralocorticoid replacement if indicated. Possibility for development of bilateral SAH should always be considered in patients who develop unilateral SAH. If left unrecognized, SAH is associated with poor outcomes and high fatality rate for both mother and fetus.

Type 1 Diabetes in Pregnancy: A Review of Complications and Management

2021 ◽  
Vol 18 ◽  
Author(s):  
Farah Jaffar ◽  
Kate Laycock ◽  
Mohammed S.B. Huda
Keyword(s):  
Type 1 Diabetes ◽  
Microvascular Disease ◽  
Evidence Based ◽  
Current Guideline ◽  
Diabetes In Pregnancy ◽  
Fetal Outcomes ◽  
Increased Risk ◽  
Fetal Complications ◽  
In Pregnancy

Background: Pre-gestational diabetes can pose significant risk to the mother and infant, thus requiring careful counselling and management. Since Saint Vincent’s declaration in 1989, adverse maternal and fetal outcomes, such as preeclampsia, perinatal mortality, congenital anomalies, and macrosomia, continue to be associated with type 1 diabetes. Although pregnancy is not considered an independent risk factor for the development of new onset microvascular complications, it is known to exacerbate pre-existing microvascular disease. Strict glycaemic control is the optimal management for pre-existing type 1 diabetes in pregnancy, as raised HbA1C is associated with increased risk of maternal and fetal complications. More recently, time in range on Continuous Glucose Monitoring glucose profiles has emerged as another useful evidence-based marker of fetal outcomes. Objective: This review summarises the complications associated with pre-gestational type 1 diabetes, appropriate evidence-based management, including preparing for pregnancy, intrapartum and postpartum care. Methods: A structured search of the PubMed and Cochrane databases was conducted. Peer-reviewed articles about complications and management guidelines on pre-gestational type 1 diabetes were selected and critically appraised. Results: One hundred and twenty-three manuscripts were referenced and appraised in this review, and international guidelines were summarised. Conclusion: This review provides a comprehensive overview of the recurring themes in the literature pertaining to type 1 diabetes in pregnancy: maternal and fetal complications, microvascular disease progression, and an overview of current guideline-specific management.

scholarly journals Pregnancy vs. Paycheck: A qualitative study of patient’s experience with employment during pregnancy at high risk for preterm birth

2020 ◽  
Author(s):  
Sarahn M. Wheeler ◽  
Kelley E. C. Massengale ◽  
Konyin Adewumi ◽  
Thelma A. Fitzgerald ◽  
Carrie B. Dombeck ◽  
...  
Keyword(s):  
Preterm Birth ◽  
High Risk ◽  
Prenatal Care ◽  
Pregnant Women ◽  
Structured Interview ◽  
Close Monitoring ◽  
Risk Pregnancy ◽  
Increased Risk ◽  
History Of ◽  
In Pregnancy

Abstract Background: Pregnant women with a history of preterm birth are at risk for recurrence, often requiring frequent prenatal visits for close monitoring and/or preventive therapies. Employment demands can limit uptake and adherence to recommended monitoring and preterm birth prevention therapies. Method: We conducted a qualitative descriptive study using in-depth interviews (IDIs) of pregnant women with a history of preterm birth. IDIs were conducted by trained qualitative interviewers following a semi-structured interview guide focused on uncovering barriers and facilitators to initiation of prenatal care, including relevant employment experiences, and soliciting potential interventions to improve prompt prenatal care initiation. The IDIs were analyzed via applied thematic analysis. Results: We described the interview findings that address women’s employment experiences. The current analysis includes 27 women who are majority self-described as non-Hispanic Black (74%) and publically insured (70%). Participants were employed in a range of professions; food services, childcare and retail were the most common occupations. Participants described multiple ways that being pregnant impacted their earning potential, ranging from voluntary work-hour reduction, involuntary duty hour reductions by employers, truncated promotions, and termination of employment. Participants also shared varying experiences with workplace accommodations to their work environment and job duties based on their pregnancy. Some of these accommodations were initiated by a collaborative employee/employer discussion, others were initiated by the employer’s perception of safe working conditions in pregnancy, and some accommodations were based on medical recommendations. Participants described supportive and unsupportive employer reactions to requests for accommodations. Conclusions: Our findings provide novel insights into women’s experiences balancing a pregnancy at increased risk for preterm birth with employment obligations. While many women reported positive experiences, the most striking insights came from women who described negative situations that ranged from challenging to potentially unlawful. Many of the findings suggest profound misunderstandings likely exist at the patient, employer and clinical provider level about the laws surrounding employment in pregnancy, safe employment responsibilities during pregnancy, and the range of creative accommodations that often allow for continued workplace productivity even during high risk pregnancy.

scholarly journals Prenatal Management of Compromised Fetus

2016 ◽  
Vol 28 (2) ◽  
pp. 92-99
Author(s):  
Shamsun Nahar Begum ◽  
Nazneen Kabir ◽  
Fahima Akhter
Keyword(s):  
Evidence Based ◽  
Therapeutic Approaches ◽  
Fetal Medicine ◽  
Fetal Diseases ◽  
Diagnostic Skills ◽  
Increased Risk ◽  
Relative Rarity ◽  
Prenatal Management ◽  
In Pregnancy ◽  
Fetal Compromise

Compromised fetuses are those who are at increased risk in intrauterine life due to various factor resulting in increased mortality & morbidity. Fetal compromise in pregnancy is difficult to assess. Diagnostic skills for fetal diseases have improved enormously, but therapeutic approaches remains limited. “The Fetus should be considered as a separate individual and fetal medicine now needs to move into phase of evidence based management. Due to relative rarity of fetal disorder, a multicentre study is needed and this is the challenge for the next decade of fetal medicine.Bangladesh J Obstet Gynaecol, 2013; Vol. 28(2) : 92-99

scholarly journals Pregnancy vs. paycheck: a qualitative study of patient’s experience with employment during pregnancy at high risk for preterm birth

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Sarahn M. Wheeler ◽  
Kelley E. C. Massengale ◽  
Konyin Adewumi ◽  
Thelma A. Fitzgerald ◽  
Carrie B. Dombeck ◽  
...  
Keyword(s):  
Preterm Birth ◽  
High Risk ◽  
Prenatal Care ◽  
Pregnant Women ◽  
Structured Interview ◽  
Close Monitoring ◽  
Risk Pregnancy ◽  
Increased Risk ◽  
History Of ◽  
In Pregnancy

Abstract Background Pregnant women with a history of preterm birth are at risk for recurrence, often requiring frequent prenatal visits for close monitoring and/or preventive therapies. Employment demands can limit uptake and adherence to recommended monitoring and preterm birth prevention therapies. Method We conducted a qualitative descriptive study using in-depth interviews (IDIs) of pregnant women with a history of preterm birth. IDIs were conducted by trained qualitative interviewers following a semi-structured interview guide focused on uncovering barriers and facilitators to initiation of prenatal care, including relevant employment experiences, and soliciting potential interventions to improve prompt prenatal care initiation. The IDIs were analyzed via applied thematic analysis. Results We described the interview findings that address women’s employment experiences. The current analysis includes 27 women who are majority self-described as non-Hispanic Black (74%) and publically insured (70%). Participants were employed in a range of professions; food services, childcare and retail were the most common occupations. Participants described multiple ways that being pregnant impacted their earning potential, ranging from voluntary work-hour reduction, involuntary duty hour reductions by employers, truncated promotions, and termination of employment. Participants also shared varying experiences with workplace accommodations to their work environment and job duties based on their pregnancy. Some of these accommodations were initiated by a collaborative employee/employer discussion, others were initiated by the employer’s perception of safe working conditions in pregnancy, and some accommodations were based on medical recommendations. Participants described supportive and unsupportive employer reactions to requests for accommodations. Conclusions Our findings provide novel insights into women’s experiences balancing a pregnancy at increased risk for preterm birth with employment obligations. While many women reported positive experiences, the most striking insights came from women who described negative situations that ranged from challenging to potentially unlawful. Many of the findings suggest profound misunderstandings likely exist at the patient, employer and clinical provider level about the laws surrounding employment in pregnancy, safe employment responsibilities during pregnancy, and the range of creative accommodations that often allow for continued workplace productivity even during high risk pregnancy.

scholarly journals Evidence for an Association Between Endometriosis and Allergic and Non-allergic Food Hypersensitivity Is Lacking

2021 ◽  
Vol 3 ◽  
Author(s):  
Jocelyn O'Malley ◽  
Marina Iacovou ◽  
Sarah J. Holdsworth-Carson
Keyword(s):  
Best Practice ◽  
Systematic Approach ◽  
Food Hypersensitivity ◽  
Research Quality ◽  
Evidence Based ◽  
Inclusion Criteria ◽  
Essential Step ◽  
Increased Risk ◽  
The Many

Endometriosis effects up to 1 in 9 women, and can be a severe and debilitating disease. It is suggested that there is a link between endometriosis and allergic hypersensitivities, including allergic and non-allergic food hypersensitivity. Best practice for managing endometriosis symptoms is holistic and includes broad multi-disciplinary care. Therefore, improving our understanding of common endometriosis comorbidities, including allergic and non-allergic food hypersensitivity, will assist in improving patient quality of life. This mini-review with systematic approach aims to explore the literature for evidence surrounding an association between endometriosis and allergic and/or non-allergic food hypersensitivity from the last 20 years. Of the 849 publications identified, five fulfilled the inclusion criteria. Only one publication reported a statistically significant increased risk for non-allergic food hypersensitivity in patients with endometriosis (P = 0.009), however, the endometriosis group was not uniform in diagnostic criteria and included individuals without laparoscopically visualized disease. No studies elucidated a statistically significant link between allergic food hypersensitivity alone and endometriosis. Therefore, based on a small number of studies with limited research quality, evidence does not support the existence of a link between endometriosis and allergic or non-allergic food hypersensitivity. Sufficiently powered evidence-based research is required, including information which better characterizes the patient's endometriosis symptoms, importantly the gastrointestinal sequalae, as well as specific allergic and non-allergic food hypersensitivities and method of diagnoses. Unequivocally confirming a link between endometriosis and food hypersensitivities is an essential step forward in dispelling the many myths surrounding endometriosis and improving management of disease.

scholarly journals Pregnancy vs. Paycheck: A qualitative study of patient’s experience with employment during pregnancy at high risk for preterm birth

2020 ◽  
Author(s):  
Sarahn M. Wheeler ◽  
Kelley E. C. Massengale ◽  
Konyin Adewumi ◽  
Thelma A. Fitzgerald ◽  
Carrie B. Dombeck ◽  
...  
Keyword(s):  
Preterm Birth ◽  
High Risk ◽  
Prenatal Care ◽  
Pregnant Women ◽  
Structured Interview ◽  
Close Monitoring ◽  
Risk Pregnancy ◽  
Increased Risk ◽  
History Of ◽  
In Pregnancy

Abstract Background: Pregnant women with a history of preterm birth are at risk for recurrence, often requiring frequent prenatal visits for close monitoring and/or preventive therapies. Employment demands can limit uptake and adherence to recommended monitoring and preterm birth prevention therapies. Method: We conducted a qualitative descriptive study using in-depth interviews (IDIs) of pregnant women with a history of preterm birth. IDIs were conducted by trained qualitative interviewers following a semi-structured interview guide focused on uncovering barriers and facilitators to initiation of prenatal care, including relevant employment experiences, and soliciting potential interventions to improve prompt prenatal care initiation. The IDIs were analyzed via applied thematic analysis. Results: We described the interview findings that address women’s employment experiences. The current analysis includes 27 women who are majority self-described as non-Hispanic Black (74%) and publically insured (70%). Participants were employed in a range of professions; food services, childcare and retail were the most common occupations. Participants described multiple ways that being pregnant impacted their earning potential, ranging from voluntary work-hour reduction, involuntary duty hour reductions by employers, truncated promotions, and termination of employment. Participants also shared varying experiences with workplace accommodations to their work environment and job duties based on their pregnancy. Some of these accommodations were initiated by a collaborative employee/employer discussion, others were initiated by the employer’s perception of safe working conditions in pregnancy, and some accommodations were based on medical recommendations. Participants described supportive and unsupportive employer reactions to requests for accommodations. Conclusions: Our findings provide novel insights into women’s experiences balancing a pregnancy at increased risk for preterm birth with employment obligations. While many women reported positive experiences, the most striking insights came from women who described negative situations that ranged from challenging to potentially unlawful. Many of the findings suggest profound misunderstandings likely exist at the patient, employer and clinical provider level about the laws surrounding employment in pregnancy, safe employment responsibilities during pregnancy, and the range of creative accommodations that often allow for continued workplace productivity even during high risk pregnancy.

scholarly journals Parathyroid Disease in Pregnancy and Lactation: A Narrative Review of the Literature

Biomedicines ◽  
2021 ◽  
Vol 9 (5) ◽  
pp. 475
Author(s):  
Elena Tsourdi ◽  
Athanasios D. Anastasilakis
Keyword(s):  
Bone Loss ◽  
Primary Hyperparathyroidism ◽  
Calcium Homeostasis ◽  
Calcium Absorption ◽  
Treatment Strategies ◽  
Review Of The Literature ◽  
Fetal Health ◽  
Pregnancy And Lactation ◽  
Parathyroid Disease ◽  
In Pregnancy

Pregnancy and lactation are characterized by sophisticated adaptations of calcium homeostasis, aiming to meet fetal, neonatal, and maternal calcium requirements. Pregnancy is primarily characterized by an enhancement of intestinal calcium absorption, whereas during lactation additional calcium is obtained through resorption from the maternal skeleton, a process which leads to bone loss but is reversible following weaning. These maternal adaptations during pregnancy and lactation may influence or confound the presentation, diagnosis, and management of parathyroid disorders such as primary hyperparathyroidism or hypoparathyroidism. Parathyroid diseases are uncommon in these settings but can be severe when they occur and may affect both maternal and fetal health. This review aims to delineate the changes in calcium physiology that occur with pregnancy and lactation, describe the disorders of calcium and parathyroid physiology that can occur, and outline treatment strategies for these diseases in the above settings.

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