Introduction: Primary hyperparathyroidism (PHPT) is rarely diagnosed in pregnancy and if left untreated has the potential to lead to serious maternal and neonatal complications. We describe a case of PHPT with associated complicated pre-eclampsia. Clinical Case29-year-old primigravida admitted at 33 + 6 weeks with fatigue, 10lbs weight gain and elevated BP. Labs revealed potassium 2.9 (3.5-5.2mmol/L), corrected serum calcium (Ca)11.62 (8.4-10.2mg/dL), ionized calcium 1.69 (1.15-1.33mmol/L), PTH 163.9 (15-65pg/mL) and vitamin D 24.6 (30-100ng/mL). Other labs were normal. Urine studies showed 315mg/24h proteinuria and urine calcium of 129.5 mg/24hrs (100-300mg/24hrs). She was started on magnesium sulphate along with labetalol for BP control, given betamethasone for stimulation of fetal lung maturity as well as potassium repletion. Hypercalcemia (HCa) was initially managed with fluids and Lasix intravenously. At 34 + 2 weeks she developed SOB, orthopnea, headaches with new 9lbs weight gain over 5 days and sustained BP elevation. Urgent C-section was done for pre-eclampsia with severe features. Post-operatively, she suffered from postpartum hemorrhage, managed with transfusion of packed red cells and transient placement of a Bakri balloon. Her HCa worsened with Ca 12.56 and cinacalcet was started after delivery. This coincided with gradual improvement of her BP and Ca to 10.8. She declined additional work-up and was discharged in stable condition. Clinical LessonPHPT often goes undiagnosed in pregnancy, with symptoms of fatigue and constipation mimicking common complaints of pregnancy. Studies have also suggested that up to 25% of patients with PHPT during pregnancy present with hypertension and pre-eclampsia and that there is an association between preeclampsia and the presence of parathyroid adenomas. The pathophysiology is unclear but is thought to be due to endothelial dysfunction triggered by hypercalcemia as well as abnormal placentation. No clear guidelines exist for the management of PHPT during pregnancy, with observation and rehydration being the preferred initial options. The use of cinacalcet as well as curative surgical parathyroidectomy when Ca levels persist >11 in the second trimester have also been described. Our patient presented similarly, with severe pre-eclampsia needing urgent C-section, further complicated by persistent severe HCa. Early diagnosis of PHPT, along with treatment including cinacalcet improved her Ca. It is therefore important that PHPT be considered in patients presenting like ours, progressing to severe pre-eclampsia as early reduction of serum calcium may reduce morbidity and mortality. ReferencesMcCarthy, A., Howarth, S., Khoo, S., Hale, J., Oddy, S., Halsall, D., ... & Samyraju, M. (2019). Management of primary hyperparathyroidism in pregnancy: a case series. Endocrinology, diabetes & metabolism case reports, 2019(1).
The opioid crisis represents one of the largest public health problems in the United States. Over the period 1999-2018, over 450,000 people have died from misused opioids, including prescription pain relievers and heroin users. In 2018, over 50% of opioid related deaths were prescribed by physicians. We aim to identify problems with in patient opioid prescribing patterns, and implement mechanisms to improve them. METHODS:Pre-intervention retrospective data was collected from 100 charts during July and August 2019 on 5 hospital floors, including surgical and medical patients. Reports were run in our electronic medical record to identify patients who had received any opiates during their hospital stay. Patients on the oncology floor, or on comfort care were excluded. For each chart, various parameters including demographics, length of stay, types and frequency of opiates used, number of doses administered and the discharge instructions. After gathering data and defining the problems, ongoing data collection was done from September 2, 2019-March 15, 2020 with interventions during this time to include: educational sessions, change in opioid prescribing order sets and automatic discharge instructions for patients receiving opioids. Data collection was halted early to facilitate response to the pandemic.RESULTS: Intravenous (IV) hydromorphone was the most frequently used opiate, with patients receiving this for an average of 2.8 days. Only 4% of patients that were discharged on opiates received opiate discharge instructions. Of all patients discharged with opiates, 24% did not receive/require opiates 48 hours prior to discharge. To address these findings, the first intervention was to change the expiry date on intravenous opiates from 5 days to 1, which resulted in a statistical significant trend toward the goal of 1 day. Secondly, opiate discharge instructions were automatically populated for patients discharged on opiates resulting in a statistically significant improvement to 100%. Interventions to decrease discharge prescriptions to patients who did not require any 48 hours prior to discharge, resulted in a shift in data points, corresponding with a possibly statistical improvement. However, this improvement was not sustainable, as education alone, rather than forced functions, is not a long-lasting intervention. CONCLUSIONS:We should aim to decrease our opioid use in hospitals in an effort to stem the tide in this epidemic. Forced functions are needed to ensure best practices are adhered to, and changing order sets will lead to significant improvements. CLINICAL IMPLICATIONS:The Society of Hospital Medicine indicates that: IV opiates administered for more than 24 h after an initial IV dose in patients not NPO is inappropriate and can increase the risk of dependence and opioid related morbidity and mortality.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.