Pituitary adenoma apoplexy in pregnancy: Case report and literature review

Unveiling postpartum pituitary apoplexy through atypical presentation: A case report and review of literature

Our case details the atypical presentation of postpartum pituitary apoplexy in a 20-year-old female, who exhibited general weakness, dizziness, and brief loss of consciousness following an uncomplicated vaginal delivery. Despite normal vital signs except for bradycardia, imaging revealed a pituitary hemorrhage, leading to the diagnosis of pituitary apoplexy. Managed conservatively with IV hydrocortisone and intensive care, the patient experienced persistent bradycardia and severe abdominal pain, requiring transfer to another ICU. This case highlights the diagnostic challenges posed by the rarity and complexity of pituitary apoplexy during pregnancy and the postpartum period, emphasizing the importance of early diagnosis and tailored treatment strategies. The discussion further contrasts this case with existing literature, particularly in the context of postpartum pituitary apoplexy, and explores the broader implications for managing such rare cases, reinforcing the viability of conservative management in the absence of visual field disturbances.

Medical and Surgical Approaches for a Non-functioning Pituitary Adenoma During Pregnancy

Non-functioning pituitary adenomas (NFPA) are most commonly found in post-menopausal women and men above the age of 50. They are mainly revealed by a tumor syndrome. The incidence of symptomatic NFPA during pregnancy is rare, with only nine documented cases in the literature. The patient was 39 years old with no previous medical or surgical history and was 17 weeks pregnant. A large pituitary macroadenoma measuring 17 x 18 x 19 mm was discovered radiologically in the presence of a pituitary tumor syndrome. Clinical examination revealed no signs of hormone deficiency or hypersecretion. A corticotropic and thyrotropic deficit was ruled out following a hormonal workup. Ophthalmological examination revealed reduced visual acuity and bilateral visual field damage. Treatment with cabergoline at a dose of 3 mg/week was initiated following written consent from the patient. The patient underwent vaginal delivery of a healthy newborn at term. Hormonal assessment at three months postpartum definitively ruled out hormonal hypersecretion. She underwent transsphenoidal surgery, with a histological examination of the resection specimen revealing a pituitary adenoma binding adrenocorticotrophic hormone (ACTH), prolactin (PRL), and growth hormone (GH). The postoperative evaluation revealed a corticotropic and somatotropic deficit with the presence of an adenomatous residue on imaging. Substitutive treatment was then initiated along with therapeutic education. To the best of our knowledge, this is the third case in which cabergoline treatment was initiated. Cabergoline treatment enabled the pregnancy to continue, improved the patient's clinical condition, stabilized the size of the adenoma, and prevented potential apoplexy.

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.

Delayed identification of massive pituitary apoplexy in pregnancy: A case report

Introduction and importance

Pituitary apoplexy is a very rare cause of sudden and severe headache with a neuro-ophthalmic deficit during pregnancy due to hemorrhage or infarction in the pituitary gland. Delayed identification can be life-threatening to both mother and baby.

Case presentation

A 40-year-old nulliparous female without any prior comorbidities in her 21 weeks of gestation presented with complaints of severe headache, vomiting, decreased vision, and altered sensorium for five days. On a low index of suspicion of pituitary apoplexy, she was managed in the line of impending eclampsia at a local center. On presentation to our center; the neurological deficit had progressed. CT head showed massive pituitary apoplexy with sellar and suprasellar extension. She underwent emergency right pterional craniotomy and resection of the tumor with hematoma evacuation but lost her life on her 2nd postoperative day.

Discussion

In the context of pregnancy, the diagnosis of pituitary apoplexy can get tricky and overlap with other common conditions such as preeclampsia or eclampsia. Magnetic resonance imaging (MRI) is the most sensitive investigation to confirm the diagnosis. Corticotropic deficiency with adrenal insufficiency is a potentially life-threatening disorder for both mother and the fetus if left untreated. The choice between conservative management and surgical approach depends on the neuro-ophthalmic signs, MRI findings, and gestational week.

Conclusion

Pituitary apoplexy should be a differential diagnosis of acute severe headache in pregnancy which when suspected should be investigated promptly. Early identification and multi-disciplinary team management are imperative for better outcomes.

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Pituitary apoplexy is a very rare condition in pregnancy.

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It presents with a sudden and severe headache with neuro-ophthalmic deficits due to hemorrhage in the pituitary gland.

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Delayed identification can have a grave outcome to both mother and baby.