FRI336 A Case Of Pituitary Apoplexy In Late Pregnancy

Abstract

Abstract Disclosure: H. Abdelrahman: None. S. Rasiah: None. S. Braunthal: None. L. Mahoney: None. R.M. Carneiro: None. K.K. Chen: None. Case: A 20-year-old primigravida presented at 36 weeks gestation due to persistent left-sided headache of 4 weeks duration. MRI brain demonstrated pituitary enlargement (15x17x14 mm) with hemorrhage as well as suprasellar extension and mass effect upon the optic chiasm, consistent with pituitary apoplexy (PA). She has no known medical history or prior endocrinopathies. Serum prolactin was appropriately elevated for pregnancy (299 ng/mL). She was started on levothyroxine for secondary hypothyroidism (TSH 3.4 mcg/dL, free T4 0.8ng/dL (0.7-1.5 ng/dL)) and hydrocortisone for prevention of adrenal insufficiency. She was admitted for semi-urgent induction of labor following the discovery of visual field defects on formal perimetry testing by ophthalmology. After discussion with neurosurgery and maternal fetal medicine, she was permitted to have a trial of vaginal delivery with a brief period of Valsalva but she ended up requiring an emergency C-section due to failure to progress. Her delivery was complicated by significant blood loss (∼5000ml), resulting in bilateral uterine artery embolization followed by an emergency hysterectomy. Repeat MRI brain with contrast following delivery demonstrated a cystic pituitary lesion, possibly a Rathke’s cleft cyst. She underwent endoscopic transnasal exploration and resection two days following delivery. Discussion: Pituitary apoplexy is a rare cause of acute headache in pregnancy. The majority of PA occurs in the setting of undiagnosed pituitary adenomas. Rapid treatment of possible adrenal insufficiency is imperative. Conservative versus surgical treatment plans are tailored to the patient’s obstetric care and neurological status. The earliest reported PA occurrence is at 7 weeks gestation (associated with subsequent miscarriage). Coordination of care between different specialists is paramount especially in late pregnancy. It is theoretically possible that Valsalva during vaginal delivery may increase intracranial pressure and exacerbate hemorrhage. Women with pituitary adenomas are recommended to undergo standard obstetric care with close surveillance, as C-section deliveries can also be associated with increased blood loss. Timing of surgery in gestational pituitary apoplexy is variable; it may be up to one month after delivery. Dopamine agonist therapy may be started during pregnancy for confirmed prolactinomas. The European Society of Endocrinology recommends transsphenoidal surgery in the second trimester for symptomatic adenomas. In the third trimester, preterm delivery may be considered. Post-operative adverse events are not uncommon due to the high risk nature of these pregnancies. After surgery, most patients should experience some degree of vision improvement but many will continue to need hormone replacement. Presentation: Friday, June 16, 2023