Haemorrhage into the anterior pituitary during pregnancy after induction of ovulation with clomiphene

Gestational pituitary apoplexy: Case series and review of the literature

Pituitary apoplexy is an uncommon but potentially life-threatening emergency due to abrupt ischemic infarction or hemorrhage of the pituitary tumor. In many instances, pituitary apoplexy is the initial presentation in patients who were not previously diagnosed to have pituitary adenomas. Variety of precipitating factors have been linked to the occurrence of pituitary apoplexy, which include pregnancy. However, pituitary apoplexy related to pregnancy is limited to isolated case reports and very small case series. The main symptom is headache of sudden onset associated with visual disturbances, signs of meningeal irritation, and/or endocrine dysfunction. In the context of pregnancy the diagnosis of pituitary apoplexy can be challenging and confused with other complex conditions such as pre-eclampsia. Magnetic resonance imaging is the most sensitive sequence to confirm the diagnosis by revealing a pituitary tumor with hemorrhagic and/or necrotic components. 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 with dopamine agonists and glucocorticoid, this "wait and see approach" and trans-sphenoidal resection depend on the severity of neuro-ophtalmic signs and the gestational week. In this article, we present three cases of pituitary apoplexy related to pregnancy. Pituitary apoplexy occurred in the third trimester in the three cases. It was the first presentation of an unknown pituitary adenoma in two cases, and complicated a preexisting macroprolactinoma in the other case. All three cases of our patients had sudden onset of severe headache and deterioration of the visual field in two cases. The pituitary MRI performed in our patients was the essential tool confirming the diagnosis of pituitary apoplexy. In all the patients was prompt replacement of deficient hormones especially glucocorticoids with close surveillance. The trans-sphenoidal resection was indicated in two pregnant women; as the first choice treatment in one case presenting with papillary edema, and as the second line after the deterioration of the visual field in one case. In the lack of guidelines of management pituitary apoplexy in case of pregnancy, we review the existing literature with pertinent clinical presentation, radiological findings, management and maternal/fetal outcomes of this rare pathology. The aim is to provide a rational framework for therapeutic management of pituitary apoplexy during pregnancy.

The Pituitary Gland: An Infrequent but Multifaceted Contributor to Death

The pituitary gland has an important role in homeostasis and disorders of it can result in endocrine dysfunction and/or produce mass effect on surrounding structures, including the hypothalamus, which can cause significant morbidity and mortality. A definitive clinical diagnosis may be delayed or remain elusive and lead to life-threatening conditions. Specifically, pituitary adenomas, pituitary necrosis, hypophysitis, and abscesses have all been reported in the literature to cause sudden and unexpected death and may only be first encountered at autopsy. Recognition by the forensic pathologist of these rare entities is crucial for appropriate death certification. This review emphasizes the need for a comprehensive, detailed forensic examination, including autopsy and routine histologic sampling of the pituitary gland, in order to ascertain its potential role in sudden unexpected death with no other apparent cause.

Pituitary apoplexy in pregnancy: A case series and literature review

BACKGROUND

Severe headache during pregnancy is a challenging condition that may rarely imply endocrine disturbances. Rapid recognition of pituitary apoplexy is needed to improve pregnancy outcome.

OBJECTIVE

To review and compare maternal and fetal outcomes after pituitary apoplexy.

METHODS

Four cases of pituitary apoplexy during pregnancy in our centre are reported and literature review covering the past 54 years was performed.

RESULTS

In the four cases presented and the 33 reported in the literature, most women presented with severe headaches and systemic symptoms. Overall, 42% were treated surgically, 31% received bromocriptine or cabergoline and 61% were given hormone replacement. No major obstetrical complication was reported and all babies were healthy.

CONCLUSION

Pituitary apoplexy is a rare cause of sudden and severe headache during pregnancy. Rapid identification of this condition with potentially associated endocrine disturbances is important to ensure maternal and fetal well-being. A multidisciplinary team approach seems to reduce morbidity and mortality.

Pituitary apoplexy

Pituitary apoplexy is rare endocrine emergency which can occur due to infarction or haemorrhage of pituitary gland. This disorder most often involves a pituitary adenoma. Occasionally it may be the first manifestation of an underlying adenoma. There is conflicting data regarding which type of pituitary adenoma is prone for apoplexy. Some studies showed predominance of non-functional adenomas while some other studies showed a higher prevalence in functioning adenomas amongst which prolactinoma have the highest risk. Although pituitary apoplexy can occur without any precipitating factor in most cases, there are some well recognizable risk factors such as hypertension, medications, major surgeries, coagulopathies either primary or following medications or infection, head injury, radiation or dynamic testing of the pituitary. Patients usually present with headache, vomiting, altered sensorium, visual defect and/or endocrine dysfunction. Hemodynamic instability may be result from adrenocorticotrophic hormone deficiency. Imaging with either CT scan or MRI should be performed in suspected cases. Intravenous fluid and hydrocortisone should be administered after collection of sample for baseline hormonal evaluation. Earlier studies used to advocate urgent decompression of the lesion but more recent studies favor conservative approach for most cases with surgery reserved for those with deteriorating level of consciousness or increasing visual defect. The visual and endocrine outcomes are almost similar with either surgery or conservative management. Once the acute phase is over, patient should be re-evaluated for hormonal deficiencies.

Management of pituitary apoplexy

Pituitary apoplexy is a rare clinical syndrome caused by sudden haemorrhaging or infarction of the pituitary gland, generally within a pituitary adenoma. Headache of sudden and severe onset is the main symptom, associated with visual disturbances or ocular palsy. Signs of meningeal irritation or altered consciousness may complicate the diagnosis. Corticotropic deficiency (secondary adrenal failure) may be life-threatening if untreated. Computed tomography (CT) or magnetic resonance imaging (MRI) confirm the diagnosis by revealing a pituitary tumour with haemorrhagic and/or necrotic components: CT is most useful in the acute setting (24 - 48 h), MRI is useful for identifying blood components in the subacute setting (4 days to 1 month). Owing to the highly variable course of this syndrome and the limited individual experience, the optimal management of acute pituitary apoplexy is controversial. Some authors advocate early transphenoidal surgical decompression for all patients, whereas others adopt a more conservative approach for selected patients (those without visual acuity or field defects and with normal consciousness). Glucocorticoid treatment must always be initiated immediately, at a dose of hydrocortisone 50 mg every 6 h.

Pituitary apoplexy and inappropriate ADH secretion

Pituitary apoplexy may be associated with visual deterioration that may be severe in some cases. Misdiagnosis of this condition is not uncommon, resulting in delayed treatment, which may adversely affect the outcome and visual prognosis. We present a case of pituitary apoplexy, who presented with features of syndrome of inappropriate anti-diuretic hormone secretion (SIADH) and monocular blindness. He had remarkable improvement to normal vision along with normalisation of serum sodium following emergency trans-sphenoidal surgery.

Apoplexy of a pituitary macroadenoma with reversible third, fourth and sixth cranial nerve palsies following administration of hypothalamic releasing hormones: MR features

Pituitary apoplexy in patients with pituitary macroadenomas can occur either spontaneously or following various interventions. We present a case of a 71-year-old woman who developed third, fourth, and sixth cranial nerve palsies following administration of the four hypothalamic releasing hormones for routine preoperative testing of pituitary function. The MR examination showed interval tumor growth with impression of the floor of the third ventricle. There were also changes in signal intensity characteristics of the mass, suggestive of intratumoral bleeding. A transsphenoidal surgery with subtotal resection of the pituitary adenoma was performed. Microscopical examination revealed large areas of necrosis and blood surrounded by adenomatous tissue. Third, fourth, and sixth cranial nerve palsies completely resolved within 4 months. We conclude that MR imaging is useful in the demonstration of pituitary apoplexy following preoperative stimulation tests, but we suggest that these tests should be abandoned in patients with pituitary macroadenomas.

Pituitary apoplexy after pituitary function test: a report of two cases and review of the literature

BACKGROUND

Although most of pituitary apoplexy occur spontaneously, some precipitating factors have been reported. We experienced two cases of pituitary apoplexy after a pituitary function test.

METHODS

In order to clarify the causal relation between the pituitary function test and apoplexy, we presented our two cases and reviewed 20 cases in the literature.

RESULTS

(Case 1) A 48-year-old man with a pituitary macroadenoma received an injection of 500 micrograms thyrotropin-releasing hormone (TRH), 100 micrograms gonadotropin-releasing hormone (GnRH), and 0.1U/kg insulin as a preoperative test of pituitary function. Fifteen minutes later, he complained of diminished vision and headache. (Case 2) A 54-year-old man with a large cystic adenoma had an administration of 500 micrograms TRH and 100 micrograms GnRH. Ten minutes later, he complained of blurring of his left eye and headache. Although, in both cases, CT scans showed neither intratumoral hemorrhage nor infarction, the surgical specimen showed necrotic and hemorrhagic adenoma. The patients made excellent clinical recoveries after surgical decompression. Twenty-two reports including our two cases were reviewed. In 15 cases (68%), TRH was associated with apoplectic events and seemed to be the agent most likely to have an etiologic role because of its vasoactive properties. Eighteen patients (82%) had pituitary macroadenomas with suprasellar extension. In 72% of 18 surgical cases, some recovery of visual function was obtained.

CONCLUSIONS

An apparent relationship between the test and the apoplectic events raises the possibility of the development of pituitary apoplexy after a pituitary function test. Unless there is a specific indication, pituitary function test should be avoided especially in patients with a large pituitary tumor.

Complications of assisted reproductive techniques

OBJECTIVE

To review and appreciate the relevant data on assisted reproduction techniques and their potential complications.

DATA RESOURCES

Major publications on assisted reproduction that include the information concerning complications associated with this practice.

RESULTS

Assisted reproduction is a common practice in modern reproductive medicine. Complications are associated with ovulation induction and the extracorporeal methods that are used for IVF-ET, GIFT, and zygote intrafallopian transfer (ZIFT). These complications are associated with laparoscopy, anesthesia, oocyte retrieval, and laboratory facilities. Pregnancies resulting from assisted reproduction are more complicated than spontaneous pregnancies. There are higher rates of ectopic, heterotopic, and multifetal pregnancies; abortions; and premature deliveries. Increased rates of perinatal mortality and morbidity result from prematurity, and higher rates of maternal diseases in pregnancy (preeclampsia, diabetes mellitus, bleeding, anemia) contribute to fetal intra-uterine growth restriction and maternal morbidity.

CONCLUSIONS

Assisted reproduction practice should be well controlled in view of the potential for complications before and during pregnancies.

Pituitary apoplexy associated with cardiac surgery

Two cases of pituitary apoplexy were detected in the immediate postoperative period after cardiac surgery with extracorporeal bypass. Both patients had pituitary adenomas that were asymptomatic and previously undiagnosed. One patient, a 57-year-old man, had unilateral total ophthalmoplegia and blepharoptosis with sparing of the visual system. The second patient, a 55-year-old man, had headache, marked bilateral visual loss, and ophthalmoplegia with subsequent development of a hemiparesis. Pituitary apoplexy was confirmed pathologically in both cases. Hemodynamic instability during and immediately after surgery and anticoagulation are probable precipitating factors.

Pituitary apoplexy associated with a triple bolus test. Case report

The authors report a case of pituitary apoplexy resulting in bilateral internal carotid artery occlusion, with marked depression of consciousness and hemiplegia. After transsphenoidal tumor decompression, restoration of flow in both carotid arteries was documented angiographically and the patient made an excellent clinical recovery. The unique aspect of this case is that the pituitary apoplexy was apparently precipitated by neuroendocrine manipulation, performed as a preoperative test of pituitary function.

Pituitary apoplexy treated by transsphenoidal surgery. A clinicopathological and immunocytochemical study

✓ The authors report 13 patients with pituitary apoplexy who were treated at their institution between November, 1972, and September, 1982. The uncommon nature of this syndrome is suggested by the fact that, during this same period of time, 940 patients were treated for pituitary adenoma by transsphenoidal surgery. It is evident that prompt and accurate diagnosis of pituitary apoplexy is necessary to achieve optimal results from treatment. Although large hemorrhages occasionally necessitate craniotomy to decompress the suprasellar structures, usually this condition can be satisfactorily treated by transsphenoidal decompression and, in most cases, this is the procedure of choice.

Pregnancies in women with hyperprolactinaemia: clinical course and obstetric complications of 41 pregnancies in 27 women

Observations are reported on 41 pregnancies in 27 patients who initially had infertility and raised serum prolactin concentrations. Associated symptoms were secondary amenorrhoea (81 per cent) and galactorrhoea (81 per cent). All patients were at risk of pituitary expansion during pregnancy, especially these 19 (70 per cent) with radiological evidence of pituitary tumours. Fifteen patients had 21 pregnancies after pituitary implantation with 90yttrium; 14 patients had 20 pregnancies without prior pituitary implantation or any other attempt to prevent tumour expansion. During pregnancies, tumour enlargement as shown by diminished visual acuity, visual field defects, severe headaches, diabetes insipidus and radiological changes occurred only in 3 of the 14 patients who had not had implants. Two patients who became pregnant both before and after pituitary implantation suffered tumour expansion in their pregnancies before implantation, but not when pregnant after the operation. The induction and Cesarean section rates were about 30 per cent in 32 term pregnancies in 25 patients. Details of how pregnancy was achieved and the associated obstetric problems are given.