Fasting hypoglycaemia due to insulinoma in pregnancy

Insulinoma in pregnancy (a case presentation and systematic review of the literature)

Insulinomas are rare, benign and functional tumors that coincidentally may become overt during pregnancy or in the post-partum period. As the general symptoms of a pregnancy might cover the clinical presentation, diagnosing remains challenging. We present one additional case of a post-partum insulinoma, combined with a systematic review of the literature to sum up relevant details in diagnosis and treatment. A systematic request of Pubmed/Medline was conducted using the following terms: "insulinoma AND pregnancy" and "insulinoma" for a second request of ClinicalTrials.gov. All publications concerning pregnant or post-partum women with insulinoma were included. Thirty-six cases could be identified for analysis. Each publication was reviewed for demographic, diagnostic and therapeutic data. The most frequent clinical signs were unconsciousness and neurological symptoms. 64.9% were diagnosed during early pregnancy and 35.1% post-partum. 91.9% underwent surgery with a third resected during pregnancy without severe influence on fetal or maternal outcome. Three patients died of metastatic disease or misdiagnosing, two of them miscarried. Insulinoma in pregnancy is rare but should be considered in case of unclear hyperinsulinemic hypoglycemia. Surgery can be performed during the second trimester or post-partum with promising outcome.

Imaging zebrafish neural circuitry from whole brain to synapse

Recent advances in imaging tools are inspiring zebrafish researchers to tackle ever more ambitious questions in the neurosciences. Behaviorally fundamental conserved neural networks can now be potentially studied using zebrafish from a brain-wide scale to molecular resolution. In this perspective, we offer a roadmap by which a zebrafish researcher can navigate the course from collecting neural activities across the brain associated with a behavior, to unraveling molecular identities and testing the functional relevance of active neurons. In doing so, important insights will be gained as to how neural networks generate behaviors and assimilate changes in synaptic connectivity.

Insulinoma diagnosed in the postpartum: clinical and immunohistochemical features

Insulinomas are rare pancreatic β-cell tumors with an estimated incidence of 1:250.000 persons/year. We present a novel case of insulinoma manifesting immediately after childbirth. Eight days after delivery, a 21-year-old, previously healthy woman presented paresthesia in hands, upper and lower limbs muscle weakness with difficult walking, which worsened during breastfeeding sessions. Laboratory tests showed blood glucose levels between 37 and 55 mg/dL with inappropriately normal insulin levels (7.78 μUI/mL; normal range: 5-29). An abdominal computed tomography showed a nodular lesion measuring 2 cm at the head of the pancreas. Tumor enucleation resulted in complete resolution of hypoglycemia. Histopathological and immunohistochemical analysis were consistent with an insulinoma. About 27 cases of insulinoma associated with pregnancy have been reported to date, mostly diagnosed before the 16th week. The beginning of symptoms soon after delivery is less common. Understanding the interactions between pancreatic β-cell function and all the physiological metabolic and hormonal adaptations associated with gestation is essential for the adequate management of hypoglycemic disorders in pregnant women.

Insulinoma in a third-trimester pregnant woman combined with pre-eclampsia: a case report and review of the diagnostic strategies

Insulinomas are rare neuroendocrine tumors with an incidence of 4 per 1,000,000 person-years, being even rarer during pregnancy. During pregnancy most cases are recognized or become symptomatic during the first trimester. A 29-year-old woman, primigravida, was hospitalized in the 38th gestational week due to slurred speech, weakness and slow reaction patterns. An electroencephalogram and computed tomography scan of the brain and blood samples were normal. Blood pressure was 170-145/110-95 mmHg, albuminuria was moderate and there was moderate edema of the ankles. Labor started spontaneously the third day, 62 h after of hospitalization, and the patient gave birth to a healthy girl with no neonatal problems. Fourteen hours after delivery, the patient became comatose and developed universal clonic seizures. At the same time plasma glucose was <1.1 mmol/l and the patient responded immediately to intravenous glucose. The patient was managed with frequent small meals and continuous intravenous glucose. Postpartum testing was consistent with insulinoma and diazoxide treatment was initiated. Endoscopic ultrasound with biopsy showed an insulinoma in the head of the pancreas. During surgical exploration, four separate insulinomas were removed from the head of the pancreas. The hypoglycemic episodes resolved and the glucose levels normalized. Following biochemical diagnosis of insulinoma, diagnostic imaging procedures encountered include endoscopic ultrasonography, magnetic resonance imaging and digital subtraction angiography. Of isotopic procedures, somatostatin receptor scintigraphy (Octreoscan) and newer receptor binding ligands can be used in non-pregnant women. Intraoperative ultrasonography seems mandatory. The present case demonstrates that seizure disorders in non-diabetic pregnant women may be caused by hyperinsulinemia-induced hypoglycemia due to insulinoma.

The hypothalamic-pituitary-adrenal axis in pregnancy: challenges in disease detection and treatment

Pregnancy dramatically affects the hypothalamic-pituitary-adrenal axis leading to increased circulating cortisol and ACTH levels during gestation, reaching values in the range seen in Cushing's syndrome (CS). The cause(s) of increased ACTH may include placental synthesis and release of biologically active CRH and ACTH, pituitary desensitization to cortisol feedback, or enhanced pituitary responses to corticotropin-releasing factors. In this context, challenges in diagnosis and management of disorders of the hypothalamic-pituitary-adrenal axis in pregnancy are discussed. CS in pregnancy is uncommon and is associated with fetal morbidity and mortality. The diagnosis may be missed because of overlapping clinical and biochemical features in pregnancy. The proportion of patients with primary adrenal causes of CS is increased in pregnancy. CRH stimulation testing and inferior petrosal sinus sampling can identify patients with Cushing's disease. Surgery is a safe option for treatment in the second trimester; otherwise medical therapy may be used. Women with known adrenal insufficiency that is appropriately treated can expect to have uneventful pregnancies. Whereas a fetal/placental source of cortisol may mitigate crisis during gestation, unrecognized adrenal insufficiency may lead to maternal or fetal demise either during gestation or in the puerperium. Appropriate treatment and management of labor are reviewed.