Hypercalcemic crisis in third trimenon: evaluating the optimal treatment strategy.

Hypercalcemia due to primary hyperparathyroidism during pregnancy is a rare condition and associated with increased morbidity and mortality for the mother and the unborn child. Whereas parathyroidectomy is favored during the second trimester, no clear recommendations exist for its management during the third trimenon. We here report the case of a 26-year-old woman in the 29th week of her first pregnancy, who was admitted to our clinic with hypertension, intra-uterine growth retardation and polyhydramnios. Severe hypercalcemia due to primary hyperparathyroidism was diagnosed (total calcium 3.34 mmol/l; PTH 216 pg/ml), but no enlarged parathyroid gland could be localized by ultrasound. Treatment with calcitonin and cinacalcet could not control hypercalcemia. Therefore explorative surgery was performed and a single parathyroid adenoma was resected, resulting in normalization of serum calcium levels. The surgical procedure was tolerated well by the mother and fetus. Hypercalcemia-induced hypertension and polyhydramnios ameliorated before C-section was performed two weeks later and unrelated to the intervention. This case report underlines the importance of early diagnosis and treatment of primary hyperparathyroidism during pregnancy. If diagnosed in the third trimenon, an interdisciplinary approach is crucial. If medical treatment fails to sufficiently control hypercalcemia, surgical parathyroid exploration should be considered even in cases of unsuccessful localization of adenomatous parathyroid glands.

Sobre Marx e a melancolia / On Marx and melancholy

Após um "tilt", como ele mesmo denomina, Hélio é encaminhado a uma enfermaria psiquiátrica. Hélio é professor "marxista" conforme a curiosa descrição em seu prontuário. A partir de atendimentos com uma terapeuta do hospital, pode-se compreender o significado da classificação "marxista" atribuída a Hélio e a importância desse ideal em sua vida. É a partir do processo de desilusão desse mesmo ideal que o "tilt" de Hélio revela as primeiras nuances da melancolia presente neste caso.

After a "tilt" as he calls it, Hélio is sent to a psychiatric ward. Hélio is a "Marxist" teacher according to the curious description of his medical records. It is from the sessions with a therapist in the hospital that one can understand the meaning of the classification "Marxist" attributed to Hélio and the importance of this ideal in his life. It is also from the process of disillusionment of that same ideal that one is faced with Helio's "tilt" and with the first shades of melancholy in this case.