Volume 182 - Issue 12
Life-threatening milk-alkali syndrome resulting from antacid ingestion during pregnancy
Authors: Michelle V Gordon, P Shane Hamblin and Lawrence P McMahon
Med J Aust 2005; 182 (12): 654-655. || doi: 10.5694/j.1326-5377.2005.tb06866.x
Published online: 20 June 2005
Published online: 20 June 2005
Michelle V Gordon,* P Shane Hamblin,† Lawrence P McMahon‡
* Registrar, † Head, Department of Endocrinology, Western Hospital, Private Bag, Gordon Street, Footscray, VIC 3011; ‡ Head, Department of Obstetric Medicine, Sunshine Hospital, St Albans, VIC.
hamblin1ATbigpond.net.au
In reply: Our case appears to be consistent with typical milk-alkali syndrome. While measuring fibroblast growth factor-23 (FGF-23) level might have been of hypothetical interest, it is unlikely that it would have influenced management. Vitamin D intoxication was considered once the 25-hydroxyvitamin D results became available, and we closely questioned our patient in relation to this possibility. She was insistent that she had not taken any vitamin D supplements. It is possible either that the patient did not wish to admit to taking vitamin D or that the assay was misleading, as suggested by Tran. We agree that bisphosphonate therapy should not be advocated when the diagnosis of milk-alkali syndrome is clear. In this case, however, the patient was drowsy and very ill; the full history relating to antacid ingestion was not obtained until after the bisphosphonate therapy had been given.
With regard to Morton’s comments, the hypercalcaemia settled promptly, so fortunately calcitonin treatment and other measures did not need to be considered. Drug safety in pregnancy is a difficult issue, as the effects of fetal or neonatal damage may carry lifelong implications, and even relatively rare associations need to be considered with care. In addition, many pregnant women are uncomfortable about taking prescription medications during pregnancy, even though their doctors may have a more relaxed view. Currently, over-the-counter antacids are classed as category A drugs for pregnancy, whereas H2-receptor antagonists and proton-pump inhibitors are category B1 and B3, respectively. Cimetidine has been associated rarely with neonatal hepatic abnormalities,1 and it is still too early to state with confidence that proton-pump inhibitors are “safe”, despite promising initial analyses. Ironically, the potential dangers of over-the-counter calcium-containing antacids, as demonstrated in this case report and others, are not currently adequately acknowledged. We have written to the manufacturers of Rennie tablets requesting a package label warning advising consumers not to exceed six tablets a day.
References
- Glade G, Saccar CL, Pereira GR. Cimetidine in pregnancy: apparent transient liver impairment in the newborn. Am J Dis Child 1980; 134: 87-88. JBHFDHIC