Aim and objective: Report a very rare case of atypical parathyroid adenoma in pregnancy presenting as a hypercalcemic crisis, acute pancreatitis, and acute kidney injury and also discuss the issues related to localization of parathyroid adenoma, management of hypercalcemia and its complications, and timing of surgery. Background: Primary hyperparathyroidism (PHPT) is rare in pregnancy and often unrecognized, as serum calcium is not routinely measured and the physiological changes of pregnancy can mask its diagnosis. In addition, non-specific gastrointestinal symptoms associated with hypercalcemia can mimic that of early pregnancy. Vitamin D deficiency can mask hypercalcemia associated with PHPT. Case description: A 29-year-old pregnant lady of 23 weeks of gestation presented to the emergency department with an acute abdomen and was diagnosed to have a hypercalcemic crisis associated with acute pancreatitis and acute kidney injury. The evaluation revealed PHPT with parathyroid adenoma. While in hospital she developed complications such as pneumonia, sepsis, anemia, and hypoalbuminemia and was managed by a multidisciplinary team. Subsequently, when her condition was stable, she underwent parathyroidectomy. Histopathology of the specimen revealed atypical parathyroid adenoma. By elective cesarean section at 39 weeks of gestation, she delivered a healthy female baby weighing 2.8 kg. Presently, 1 year after surgery, she has remained eucalcemic. Conclusion: Hypercalcemia due to PHPT is often unrecognized in pregnancy. Correct diagnosis with localization of adenoma, along with appropriate medical treatment and surgery will improve maternal and fetal outcomes. Clinical significance: A high index of clinical suspicion is needed for the diagnosis of PHPT in pregnancy. Vitamin D deficiency can mask hypercalcemia associated with PHPT. Effective medical and surgical management will lead to better outcomes.