Management of a patient with an intra-partum pituitary haemorrhage.
R W Carroll, V Kolovou, A Amin, A Ghaffar, A Dornhorst, J F Todd
Imperial Centre for Endocrinology
ZW, a 35 year old female with type 1 diabetes, presented at 30 weeks gestation with sudden onset headache associated with photophobia. Her background included early delivery during her first pregnancy with resultant severe foetal complications, and termination of her second pregnancy due to sight threatening retinopathy. She had been managed by the antenatal team with use of an insulin pump due to severe hypoglycaemia in early pregnancy. CT head scan and subsequent MRI excluded venous sinus thrombosis but revealed a pituitary haemorrhage. Prolactin concentration was used as a surrogate of pituitary sufficiency and was noted to reduce from 3658mU/L on day 0 to 1558mU/L on day 5. A 9am cortisol of 358 nmol/L was also felt to be low for 28 week gestation and therefore Hydrocortisone replacement therapy was commenced as a result with advice regarding sick day management.
ZW represented at 34+5 with a 24 hour history of facial swelling. Hypertension was noted, proteinuria was documented, and a diagnosis of pre-eclampsia was made. Blood pressure was controlled with a Labetelol infusion on the delivery unit. On the morning of day 4, ZW was found unresponsive with evident seizure activity. There were two possible precipitants; a blood pressure of 220/120 and a blood glucose of 1.5mmol/L-both of which were corrected. The patient was transferred to theatre for emergency caesarean section with delivery of a healthy baby girl. Post partum she was well with a controlled blood pressure on a continuous labetolol infusion.
However, 24 hours post-delivery ZW complained once again of a severe sudden onset headache associated with photophobia. Urgent CT head scan suggested progression of the pituitary haemorrhage, and following neurology and neurosurgical consultation, ZW was transferred to the neurosurgical unit for evacuation of the haemorrhage. Operative exploration did not confirm further haemorrhage, and her recovery was uneventful.
The case illustrates the diagnosis of pituitary haemorrhage and common presenting features, along with the difficulties of assessing pituitary, and especially adrenal, function in pregnancy. Appropriate medical management in the context of pituitary apoplexy, along with the role of surgery is discussed.