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Yanagisawa S, Oikawa Y, Endo M, Inoue K, Nakajima R, Yasuda S, Sato M, Iwata N, Fujisawa H, Suzuki A, Sugimura Y, Isshiki M, Shimada A. A Pregnant Woman with Excess Vasopressinase-Induced Diabetes Insipidus Complicated by Central Diabetes Insipidus like Lymphocytic Infundibulo-Neurohypophysitis. Case Rep Endocrinol 2024; 2024:8687054. [PMID: 38646198 PMCID: PMC11032210 DOI: 10.1155/2024/8687054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 03/11/2024] [Accepted: 04/01/2024] [Indexed: 04/23/2024] Open
Abstract
Background Gestational diabetes insipidus (DI) is a very rare complication of pregnancy. We present a case of gestational DI combining two different types of DI. Case Presentation. A 39-year-old pregnant woman suddenly presented with thirst, polydipsia, and polyuria after 31 gestation weeks (GWs). Based on laboratory findings of hypotonic urine (78 mOsm/kgH2O) with higher plasma osmolality (298 mOsm/kgH2O) and higher serum sodium levels (149 mEq/L), gestational DI was suspected, and the clinical course was monitored without therapy until the results of a measurement of plasma arginine vasopressin (AVP) levels were available. However, she subsequently developed acute prerenal failure and underwent an emergency cesarean section at 34 GWs. Her resected placenta weighed 920 g, nearly twice the normal weight. Immediately following delivery, intranasal 1-desamino-8-D-arginine vasopressin was administered, and her symptoms promptly disappeared. Afterward, her predelivery plasma AVP level was found to have been inappropriately low (0.7 pg/mL) given her serum sodium level. The patient's serum vasopressinase level just before delivery was 2,855 ng/mL, more than 1,000 times the upper limit of the normal range, suggesting excess vasopressinase-induced DI. The presence of anti-rabphilin-3A antibodies in the patient's blood, a hypertonic saline infusion test result, and loss of the high-intensity signal of the posterior pituitary on fat-suppressed T1-weighted magnetic resonance images without thickening of the stalk and enlargement of the neurohypophysis suggested concurrent central DI-like lymphocytic infundibulo-neurohypophysitis (LINH). Conclusion In addition to the degradation of AVP by excess placental vasopressinase due to the enlarged placenta, an insufficient compensatory increase in AVP secretion from the posterior pituitary gland due to LINH-like pathogenesis might have led to DI symptoms.
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Affiliation(s)
- Shinnosuke Yanagisawa
- Department of Endocrinology and Diabetes, Saitama Medical University, 38 Morohongo, Moroyama, Iruma, Saitama 350-0495, Japan
| | - Yoichi Oikawa
- Department of Endocrinology and Diabetes, Saitama Medical University, 38 Morohongo, Moroyama, Iruma, Saitama 350-0495, Japan
| | - Mai Endo
- Department of Endocrinology and Diabetes, Saitama Medical University, 38 Morohongo, Moroyama, Iruma, Saitama 350-0495, Japan
| | - Kazuyuki Inoue
- Department of Endocrinology and Diabetes, Saitama Medical University, 38 Morohongo, Moroyama, Iruma, Saitama 350-0495, Japan
| | - Ritsuko Nakajima
- Department of Endocrinology and Diabetes, Saitama Medical University, 38 Morohongo, Moroyama, Iruma, Saitama 350-0495, Japan
| | - Shigemitsu Yasuda
- Department of Endocrinology and Diabetes, Saitama Medical University, 38 Morohongo, Moroyama, Iruma, Saitama 350-0495, Japan
| | - Masayasu Sato
- Department of Obstetrics and Gynecology, Saitama Medical University, 38 Morohongo, Moroyama, Iruma, Saitama 350-0495, Japan
| | - Naoko Iwata
- Department of Endocrinology and Diabetes, Daido Hospital, 9 Hakusui-cho, Minami-ku, Nagoya, Aichi 457-8511, Japan
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192, Japan
| | - Haruki Fujisawa
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192, Japan
| | - Atsushi Suzuki
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192, Japan
| | - Yoshihisa Sugimura
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192, Japan
| | - Masashi Isshiki
- Department of Endocrinology and Diabetes, Saitama Medical University, 38 Morohongo, Moroyama, Iruma, Saitama 350-0495, Japan
| | - Akira Shimada
- Department of Endocrinology and Diabetes, Saitama Medical University, 38 Morohongo, Moroyama, Iruma, Saitama 350-0495, Japan
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Gheorghe AM, Trandafir AI, Stanciu M, Popa FL, Nistor C, Carsote M. Challenges of Pituitary Apoplexy in Pregnancy. J Clin Med 2023; 12:jcm12103416. [PMID: 37240522 DOI: 10.3390/jcm12103416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/02/2023] [Accepted: 05/07/2023] [Indexed: 05/28/2023] Open
Abstract
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.
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Affiliation(s)
- Ana-Maria Gheorghe
- Department of Endocrinology, "C.I. Parhon" National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Alexandra-Ioana Trandafir
- Department of Endocrinology, Doctoral School of "Carol Davila" University of Medicine and Pharmacy, "C.I. Parhon" National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Mihaela Stanciu
- Department of Endocrinology, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 50169 Sibiu, Romania
| | - Florina Ligia Popa
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy & Thoracic Surgery Department, "Dr. Carol Davila" Central Emergency University Military Hospital, 013058 Bucharest, Romania
| | - Mara Carsote
- Department of Endocrinology, "Carol Davila" University of Medicine and Pharmacy & "C.I. Parhon" National Institute of Endocrinology, 011683 Bucharest, Romania
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Terrault NA, Williamson C. Pregnancy-Associated Liver Diseases. Gastroenterology 2022; 163:97-117.e1. [PMID: 35276220 DOI: 10.1053/j.gastro.2022.01.060] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 01/21/2022] [Accepted: 01/26/2022] [Indexed: 12/14/2022]
Abstract
The liver disorders unique to pregnancy include hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, and preeclampsia-associated hepatic impairment, specifically hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP). Their importance lies in the significant maternal and fetal/neonatal morbidity and mortality. Expeditious diagnosis and clinical evaluation is critical to ensure timely, appropriate care and minimize risks to the pregnant woman and her fetus/baby. A multidisciplinary approach is essential, including midwives, maternal-fetal-medicine specialists, anesthetists, neonatologists, and hepatologists.
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Affiliation(s)
- Norah A Terrault
- Gastrointestinal and Liver Disease Division, University of Southern California, Los Angeles, California, USA.
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Studies on anti-rabphilin-3A antibodies in 15 consecutive patients presenting with central diabetes insipidus at a single referral center. Sci Rep 2022; 12:4440. [PMID: 35292721 PMCID: PMC8924241 DOI: 10.1038/s41598-022-08552-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 03/09/2022] [Indexed: 12/11/2022] Open
Abstract
Central diabetes insipidus (CDI) is a rare condition caused by various underlying diseases including inflammatory and autoimmune diseases, and neoplasms. Obtaining an accurate definitive diagnosis of the underlying cause of CDI is difficult. Recently, anti-rabphilin-3A antibodies were demonstrated to be a highly sensitive and specific marker of lymphocytic infundibuloneurohypophysitis (LINH). Here, we report a detailed case series, and evaluated the significance of anti-rabphilin-3A antibodies in differentiating the etiologies of CDI. A prospective analysis was conducted in 15 consecutive patients with CDI from 2013 to 2020 at a single referral center. Anti-rabphilin-3A antibodies were measured and the relationship between antibody positivity and the clinical/histopathological diagnoses was evaluated. Among 15 CDI patients, the positive anti-rabphilin-3A antibodies were found in 4 of 5 LINH cases, 3 of 4 lymphocytic panhypophysitis (LPH) cases, one of 2 sarcoidosis cases, and one intracranial germinoma case, respectively. Two Rathke cleft cyst cases and one craniopharyngioma case were negative. This is the first report of anti-rabphilin-3A antibodies positivity in CDI patients with biopsy-proven LPH. Measurement of anti-rabphilin-3A antibodies may be valuable for differentiating CDI etiologies.
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