Gestational pituitary apoplexy: Case series and review of the literature

Pituitary apoplexy: a systematic review of non-gestational risk factors

PURPOSE

Pregnancy is a known risk factor for Pituitary Apoplexy (PA) but there is a lack of consistency in the literature regarding non-gestational risk factors responsible for PA.

METHODS

We did a systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify the non-gestational risk factors associated with the development of PA in adult patients with pituitary adenoma. Also, we discuss here a case of an elderly female with pituitary macroadenoma who was initially planned for pituitary resection electively but underwent emergency surgery after she developed PA.

RESULTS

As per screening and eligibility criteria, seven studies with 4937 study participants were included in this systematic review out of which 490 (9.92%) patients had PA, including asymptomatic subclinical PA (SPA) and symptomatic clinical PA (CPA). The macroadenomas and negative staining of the tumor were found to be a significant risk factor consistently in multivariate analysis in three and two retrospective studies, respectively. However, the results were varied for any significant difference in the risk factors for apoplexy between SPA and CPA. Similarly, there was no consistency among the studies for risk factors significantly responsible for CPA or PA compared to controls.

CONCLUSION

No single non-gestational risk factor is solely responsible for the development of PA in a pituitary adenoma compared to the control population. Tumor size (macroadenoma) and the non-functioning status of the adenoma are the only significant factors contributing independently toward an apoplectic event in most patients. Such patients can be prioritized for early pituitary tumor resection.

A Narrative Review on Neuro-Ophthalmological Manifestations That May Occur during Pregnancy

AIM

As a medical condition, pregnancy mandates the simultaneous treatment of both the mother and the fetus, making it a distinctive aspect of clinical medicine.

MATERIAL AND METHOD

We analyze the physiological changes occurring in the eyes and brain during pregnancy, as well as the neuro-ophthalmological manifestations that can occur during pregnancy. Studies published in both English and other languages, case reports, and reviews from 2011 to 2023 onwards were included. All surveys were acquired by exploring the databases.

RESULTS

We found a total of 2135 articles that showcase neuro-ophthalmic changes related to pregnancy: review and research articles (Science Direct 804, Web of Science 923, Scopus 345, and 63 Pub Med). In total, 86 studies were examined after applying the inclusion and exclusion criteria. Bilateral papilledema can be a warning sign for intracranial hypertension or cerebral venous sinus thrombosis. Additionally, when unilateral, it is important to differentially diagnose anterior ischemic optic neuropathy secondary to a hypercoagulant, compressive or inflammatory optic neuropathy, optic neuritis, or even orbital pseudotumor state. Severe eclampsia and preeclampsia can manifest as choroidal infarction, serous retinal detachment, and even cortical blindness. There can also be implications at the level of cranial nerves or transient Horner syndrome.

CONCLUSIONS

Evaluating and treating a pregnant woman with neuro-ophthalmological manifestations is challenging. The obstetrician closely follows and has a medical relationship with the pregnant woman; hence he/she might be the first to be informed about the general condition of the pregnant woman or might request an ophthalmologic examination tailored to each specific case.

Comparing MRI volume measurement techniques for pituitary macroadenoma: Investigating volume reduction and its relationship with biochemical control

Pituitary adenomas are one of the most common types of primary intracranial tumors. Measuring pituitary adenoma volume is fundamental for effective management. This study aimed to assess the reliability of the ellipsoid method in comparison with the perimeter method for measuring pituitary macroadenoma volume. In addition, we investigated the correlation between adenoma size reduction and biochemical control in functioning adenomas. This was a retrospective cross-sectional cohort study including 113 patients with pituitary macroadenomas. MRI was obtained for volume measurement by ellipsoid and perimeter methods using two types of DICOM viewer software. Both ellipsoid and perimeter methods exhibit positive, strong, and significant correlations in pituitary macroadenomas in pre-treatment and post-treatment volume (Spearman correlation coefficient 0.95, p-value <0.0001). There was no significant difference in the mean post-treatment pituitary adenoma volume measurements utilizing the ellipsoid and the perimeter methods in different treatment modalities. There were significant differences in the pre-treatment volume measurements between the two methods, both in NFPA and prolactinoma. No correlation was found between volume variability measured by ellipsoid and perimeter methods and the degree of hormonal control in functioning pituitary adenomas. Both the ellipsoid and perimetric methods can be utilized for pituitary adenoma volume measurements as they demonstrate a strong and positive correlation. However, it is important to note that the ellipsoid method tends to result in overestimated tumor volume. There was no correlation between the adenoma size reduction and the degree of biochemical response in functioning adenomas.

Challenges of Pituitary Apoplexy in Pregnancy

Our purpose is to provide new insights concerning the challenges of pituitary apoplexy in pregnancy (PAP) and the postpartum period (PAPP). This is a narrative review of the English literature using a PubMed search. The inclusion criteria were clinically relevant original studies (January 2012-December 2022). Overall, we included 35 original studies: 7 observational studies (selected cases on PA) and 28 case reports, including 4 case series (N = 49; PAP/PAPP = 43/6). The characteristics of PAP patients (N = 43) are as follows: maternal age between 21 and 41 (mean of 27.76) years; 21/43 subjects with a presentation during the third trimester (only one case during first trimester); average weak of gestation of 26.38; most females were prim gravidae; 19 (out of 30 patients with available data on delivery) underwent a cesarean section. Headache remains the main clinical feature and is potentially associated with a heterogeneous panel (including visual anomalies, nausea, vomiting, cranial nerve palsies, diabetes insipidus, photophobia, and neck stiffness). Pre-pregnancy medication included dopamine agonists (15/43) and terguride (1/43) in addition to subsequent insulin therapy for gestational diabetes (N = 2) and type 1 diabetes mellitus (N = 1). Overall, 29/43 females received the conservative approach, and 22/43 women had trans-sphenoidal surgery (TSS) (and 10/22 had the initial approach). Furthermore, 18/43 patients had a pituitary adenoma undiagnosed before pregnancy. Most PA-associated tumors were prolactinomas (N = 26/43), with the majority of them (N = 16/26) being larger than 1 cm. A maternal-fetal deadly outcome is reported in a single case. The characteristics of PAPP patients (N = 6) are as follows: mean age at diagnosis of 33 years; 3/6 subjects had PA during their second pregnancy; the timing of PA varied between 5 min and 12 days after delivery; headache was the main clinical element; 5/6 had no underlying pituitary adenoma; 5/6 patients were managed conservatively and 1/6 underwent TSS; pituitary function recovered (N = 3) or led to persistent hypopituitarism (N = 3). In conclusion, PAP represents a rare, life-threatening condition. Headache is the most frequent presentation, and its prompt distinction from other conditions associated with headache, such as preeclampsia and meningitis, is essential. The index of suspicion should be high, especially in patients with additional risk factors such as pre-gestation treatment with dopamine agonists, diabetes mellitus, anticoagulation therapy, or large pituitary tumors. The management is conservative in most cases, and it mainly includes corticosteroid substitution and dopamine agonists. The most frequent surgical indication is neuro-ophthalmological deterioration, although the actual risk of pituitary surgery during pregnancy remains unknown. PAPP is exceptionally reported. To our knowledge, this sample-case series study is the largest of its kind that is meant to increase the awareness to the benefit of the maternal-fetal outcomes from multidisciplinary insights.

Pituitary Apoplexy in Pregnancy: What do We Know?

Pituitary apoplexy refers to a rare clinical syndrome consisting of signs and symptoms that occur due to rapid expansion of the contents of the sella turcica. It can occur spontaneously or associated with pituitary tumors. It can have a broad clinical spectrum, but usually presents with severe headache, visual impairment and hypopituitarism. Sudden onset of symptoms associated to imagiologic confirmation makes the diagnosis. Surgical treatment is advised when there is important compression of the optic tract. We present a case report and a review of the literature on pituitary apoplexy in pregnancy. The cases were reviewed to obtain information on maternal characteristics, clinical presentation, diagnostic studies, therapeutic modalities and maternal and fetal outcomes. Our review found 36 cases of pituitary apoplexy in pregnancy. Most of the cases occurred in the second trimester of pregnancy and headache was the most frequent symptom at presentation. Surgical therapy was required in more than half of the patients. In what respect maternal and fetal outcomes, there were 3 cases of preterm delivery and one case of maternal death. Our clinical case and literature review reinforces the importance of an early diagnosis to avoid potential adverse consequences.

Surgical management of pituitary adenoma during pregnancy

BACKGROUND

Although conservative treatment is typically recommended for pregnant patients with pituitary adenoma (PA), surgical treatment is occasionally necessary for those with acute symptoms. Currently, surgical interventions utilized among these patients is poorly studied.

AIM

To evaluate the surgical indications, timing, perioperative precautions and postoperative complications of PAs during pregnancy and to provide comprehensive guidance.

METHODS

Six patients with PAs who underwent surgical treatment during pregnancy at Peking Union Medical College Hospital between January 1990 and June 2021 were recruited for this study. Another 35 pregnant patients who were profiled in the literature were included in our analysis.

RESULTS

The 41 enrolled patients had acute symptoms including visual field defects, severe headaches or vision loss that required emergency pituitary surgeries. PA apoplexies were found in 23 patients. The majority of patients (55.9%) underwent surgery in the second trimester of pregnancy. A multidisciplinary team was involved in patient care from the preoperative period through the postpartum period. With the exception of 1 patient who underwent an induced abortion and 1 fetus that died due to a nuchal cord, 39 patients delivered successfully. Among them, 37 fetuses were healthy until the most recent follow-up.

CONCLUSION

PA surgery during pregnancy is effective and safe during the second and third trimesters. Pregnant patients requiring emergency PA surgery require multidisciplinary evaluation and healthcare management.

Pituitary adenoma apoplexy in pregnancy: Case report and literature review

Gestational pituitary apoplexy is an extremely rare condition. It is characterised by an unexpected headache, vomiting, nausea, and visual disturbances. Pituitary apoplexy in pregnancy and postpartum is a challenging diagnosis with symptoms overlapping multiple conditions. There is a limited number of articles presenting cases or case series of gestational pituitary apoplexy. This is a potentially life-threatening emergency which requires a high index of suspicion for its diagnosis. This article presents a case of postpartum pituitary apoplexy and outlines the current stage of clinical, imagistic diagnosis and management options. A 26-year-old primipara was submitted to a Caesarean section, with no perioperative incidents. Forty-eight hours later she reported the apparition of frontal and temporal throbbing headaches, nausea, photophobia, and she was diagnosed with a pituitary tumor measuring 33x10.5x15.5 mm. Although initially conservative treatment was proposed, the clinical outcome was not favourable, thus the patient was submitted to endoscopic transsphenoidal resection. The histopathological studies demonstrated the presence of a pituitary macroadenoma. At the 2-year follow-up, the patient is free of disease. Although it represents an extremely rare condition, gestational pituitary apoplexy should be suspected whenever headache and neurological disorders such as nausea and photophobia are reported during the postpartum period.

Endoscopic Endonasal Transsphenoidal Approach for the Surgical Treatment of Pituitary Apoplexy and Clinical Outcomes

Purpose: This study investigated the clinical manifestations, surgical method, and treatment outcomes of patients with pituitary apoplexy and evaluated the safety and effectiveness of the endoscopic endonasal transsphenoidal approach in the treatment of pituitary adenomas. Patients and methods: In this retrospective study, were analyzed the data of patients with symptomatic pituitary apoplexy who received surgical treatment by endoscopic endonasal transsphenoidal approach from January 2017 to June 2020 at the Department of Neurosurgery of the First Affiliated Hospital of Bengbu Medical College. Patients were followed up through outpatient visits and telephone interviews. Results: Data for 24 patients including 13 males and 11 females with an average age of 46.46 years were analyzed. Headache (83.33%) and visual disturbances (75.00%) were the most common preoperative manifestations. In the 24 patients, 21 (87.50%) tumors were completely removed and 3 (12.50%) were partly removed. Intractable headache improved in all patients over a mean follow-up time of 25.16 months, and postoperative improvement in visual acuity was achieved in 17 of 18 patients (94.44%) with vision defects. Four patients (16.67%) experienced transient urinary collapse after the operation. No intracranial infection, carotid artery injury, or death occurred. Conclusion: The endoscopic endonasal transsphenoidal approach is a safe and effective method for the treatment of pituitary apoplexy.

Pituitary apoplexy of a giant prolactinoma during pregnancy

AIMS AND METHODS

Prolactinomas are a common cause of sexual dysfunction and infertility. We aimed, through this case report, to illustrate the difficulties of management of women with giant prolactinoma, especially in cases of desire of pregnancy.

RESULTS

A 30-year-old woman was referred to our department for secondary amenorrhea. Investigations showed a prolactin level of 5168 ng/mL and giant pituitary adenoma of 4 cm in diameter. Cytoreductive surgery was performed after failure to normalize prolactin levels during three years with medical treatment by cabergoline. After seven months, menstrual cycles have resumed, and after 13 months, the patient became pregnant. At 22nd week of gestation, she was admitted in our hospital for pituitary apoplexy. Medical treatment with bromocriptine was chosen. The vaginal premature delivery at 28 weeks gave birth to twins weighing 1 Kg each who died on the 7th day of life.

CONCLUSION

This is a relevant clinical case that illustrates the efficacy of cytoreductive surgery in case of insufficient response to dopamine agonists to restore gonadal function. The possibility of a pregnancy should be considered in these patients since it can be associated with high maternal and fetal risks.

Management of sellar and parasellar tumors becoming symptomatic during pregnancy: a practical algorithm based on multi-center experience and systematic literature review

INTRODUCTION

Sellar/parasellar tumors (SPTs) very rarely become symptomatic during pregnancy. No specific guidelines exist for their management, that is extremely challenging as mother and fetus health can be jeopardized.

MATERIALS AND METHODS

Data of patients with SPTs becoming symptomatic during pregnancy treated at two Italian referral Centers were retrospectively collected. Systematic literature review was also performed.

RESULTS

Our series consisted of 6 cases, 3 meningiomas, 1 ACTH-secreting adenoma, 1 pituicytoma and 1 craniopharyngioma. Mean age at presentation was 33.6 ± 6.0 years. Five patients complained of visual disturbances, associated with headache in one case, that occurred between gestation week (GW) 22 and 34. In 5 cases, pregnancy was uneventful with the delivery of a healthy baby between GW 33 and 35, followed by endoscopic surgical tumor exeresis (n = 4) or proton bean therapy (n = 1). Another patient presented with stigmata typical of Cushing's syndrome and rapidly worsening pre-eclampsia, that required pregnancy interruption and adenomectomy. Based on personal and literature cases, a practical algorithm was proposed to help clinicians dealing with these patients.

CONCLUSIONS

SPTs becoming symptomatic in pregnancy deserve careful monitoring and multidisciplinary management. Overall, wait-and-see approach is suggested, reserving surgery to patients with rapidly progressive/life-threatening situations, significant risk of permanent neurological impairment or malignant lesions.

Pituitary apoplexy associated with acute COVID-19 infection and pregnancy

PURPOSE

We report a case of a pregnant female presenting with pituitary apoplexy and simultaneous SARS-CoV-2 infection with a focus on management decisions.

CLINICAL HISTORY

A 28-year-old G5P1 38w1d female presented with 4 days of blurry vision, left dilated pupil, and headache. She tested positive for SARS-CoV-2 on routine nasal swab testing but denied cough or fever. Endocrine testing demonstrated an elevated serum prolactin level, and central hypothyroidism. MRI showed a cystic-solid lesion with a fluid level in the pituitary fossa and expansion of the sella consistent with pituitary apoplexy. Her visual symptoms improved with corticosteroid administration and surgery was delayed to two weeks after her initial COVID-19 infection and to allow for safe delivery of the child. A vaginal delivery under epidural anesthetic occurred at 39 weeks. Two days later, transsphenoidal resection of the mass was performed under strict COVID-19 precautions including use of Powered Air Purifying Respirators (PAPRs) and limited OR personnel given high risk of infection during endonasal procedures. Pathology demonstrated a liquefied hemorrhagic mass suggestive of pituitary apoplexy. She made a full recovery and was discharged home two days after surgery.

CONCLUSION

Here we demonstrate the first known case of successful elective induction of vaginal delivery and transsphenoidal intervention in a near full term gravid patient presenting with pituitary apoplexy and acute SARS-CoV-2 infection. Further reports may help determine if there is a causal relationship or if these events are unrelated. Close adherence to guidelines for caregivers can greatly reduce risk of infection.

Headaches during pregnancy

Headache during pregnancy is frequent and challenging. A secondary headache is diagnosed in one third of women, and most causes are vascular and infectious disorders. Anamnestic and clinical features must be investigated, and brain imaging is often required. Primary headaches are commonly modified during pregnancy. Migraine is mainly improved in this context, especially migraine without aura. Particular cautions about treatment must be applied, and non-pharmacological measures must be preferred. Tension-type headache and cluster headache seem to be less hormone-dependent.