Primary Hyperparathyroidism in a Pregnant Immigrant Facing Healthcare Hurdles: A Case Report.

Introduction: PHPT in pregnancy is a rare condition that may be difficult to recognize due to nonspecific symptoms and physiologic changes that can mask hypercalcemia. Delayed diagnosis is associated with significant maternal and fetal morbidity. Case Presentation: A 36-year-old Spanish-speaking gravida 5 para 3 woman at 30 weeks gestation presented with decreased fetal movement in the setting of absent prenatal care. Evaluation revealed severe polyhydramnios, fetal growth restriction, and nonimmune fetal hydrops. Laboratory studies demonstrated hypercalcemia with elevated parathyroid hormone levels, consistent with PHPT, with preserved renal function and concurrent vitamin D insufficiency. Ultrasound identified a parathyroid adenoma. Initial management with intravenous hydration and calcitonin resulted in only partial improvement in calcium levels. Ongoing management was complicated by competing priorities between treatment of maternal hypercalcemia and obstetric concerns, as escalation of fluid therapy was limited by the risk of fluid overload in the setting of severe polyhydramnios. Despite medical management, worsening fetal status, including abnormal umbilical artery Doppler findings, necessitated preterm cesarean delivery. The neonate required intubation and admission to the neonatal intensive care unit for management of hydrops fetalis. Following delivery, the patient underwent definitive surgical management with parathyroidectomy, resulting in normalization of calcium and parathyroid hormone levels and confirming biochemical cure. Conclusion: This case highlights the diagnostic challenges of PHPT in pregnancy and the complexity of management when standard treatment pathways are limited. It also demonstrates how delayed access to prenatal care and language discordance may contribute to more advanced disease at presentation. Early recognition and coordinated multidisciplinary care may improve maternal and fetal outcomes. This case supports consideration of PHPT in pregnant patients with hypercalcemia and informs clinical approaches to management in complex presentations.