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Gheorghe AM, Trandafir AI, Stanciu M, Popa FL, Nistor C, Carsote M. Challenges of Pituitary Apoplexy in Pregnancy. J Clin Med 2023; 12:jcm12103416. [PMID: 37240522 DOI: 10.3390/jcm12103416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/02/2023] [Accepted: 05/07/2023] [Indexed: 05/28/2023] Open
Abstract
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.
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Affiliation(s)
- Ana-Maria Gheorghe
- Department of Endocrinology, "C.I. Parhon" National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Alexandra-Ioana Trandafir
- Department of Endocrinology, Doctoral School of "Carol Davila" University of Medicine and Pharmacy, "C.I. Parhon" National Institute of Endocrinology, 011683 Bucharest, Romania
| | - Mihaela Stanciu
- Department of Endocrinology, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 50169 Sibiu, Romania
| | - Florina Ligia Popa
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, "Lucian Blaga" University of Sibiu, 550169 Sibiu, Romania
| | - Claudiu Nistor
- Department 4-Cardio-Thoracic Pathology, Thoracic Surgery II Discipline, Faculty of Medicine, "Carol Davila" University of Medicine and Pharmacy & Thoracic Surgery Department, "Dr. Carol Davila" Central Emergency University Military Hospital, 013058 Bucharest, Romania
| | - Mara Carsote
- Department of Endocrinology, "Carol Davila" University of Medicine and Pharmacy & "C.I. Parhon" National Institute of Endocrinology, 011683 Bucharest, Romania
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Fischer J, Gerresheim G, Schwemmer U. Internistische Notfälle bei der schwangeren Patientin. Med Klin Intensivmed Notfmed 2022; 117:239-252. [PMID: 35312817 PMCID: PMC8935102 DOI: 10.1007/s00063-022-00910-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Peripartale Notfälle, die intensivmedizinisch behandelt werden müssen, stellen eine große Herausausforderung an das interdisziplinäre Behandlungsteam dar. Aufgrund physiologischer Veränderungen der Schwangeren können Symptome maskiert und eine Therapieeinleitung verzögert werden. Die peripartale Sepsis weist eine relativ hohe Inzidenz auf. Die antiinfektive Therapie richtet sich nach dem zu erwartenden Keimspektrum. Endokrinologische Notfälle sind selten, können jedoch fulminant und tödlich sein. Die Entstehung einer Ketoacidose wird durch erniedrigte Bikarbonatpuffer und Plazentahormone begünstigt. Im Rahmen einer Thyreotoxikose stehen zur Therapie Propylthiouracil und Thiamazol in Abhängigkeit vom Gestationszeitpunkt zur Verfügung. Das Sheehan-Syndrom ist eine Infarzierung des Hypophysenvorderlappens im Rahmen einer Hämorrhagie. Durch Produktionsausfall lebenswichtiger Hormone kann dieses letal enden. Ebenso akut ist die Entstehung eines Lungenödems. Dieses wird durch physiologische Veränderungen während der Schwangerschaft begünstigt. Kausal ist für die Therapie die Unterscheidung eines hyper- oder hypotensiven Lungenödems von Bedeutung.
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Affiliation(s)
| | | | - U Schwemmer
- Klinik für Anästhesiologie und Intensivmedizin, Klinikum Neumarkt i.d.OPf., Neumarkt i.d.OPf., Deutschland.
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Fischer J, Gerresheim G, Schwemmer U. [Internal medical emergencies in the pregnant patient : Peripartum sepsis, metabolic derailment, endocrinological emergencies and pulmonary edema]. Anaesthesist 2021; 70:795-808. [PMID: 34143232 PMCID: PMC8212281 DOI: 10.1007/s00101-021-00944-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 11/28/2022]
Abstract
Peripartale Notfälle, die intensivmedizinisch behandelt werden müssen, stellen eine große Herausausforderung an das interdisziplinäre Behandlungsteam dar. Aufgrund physiologischer Veränderungen der Schwangeren können Symptome maskiert und eine Therapieeinleitung verzögert werden. Die peripartale Sepsis weist eine relativ hohe Inzidenz auf. Die antiinfektive Therapie richtet sich nach dem zu erwartenden Keimspektrum. Endokrinologische Notfälle sind selten, können jedoch fulminant und tödlich sein. Die Entstehung einer Ketoacidose wird durch erniedrigte Bikarbonatpuffer und Plazentahormone begünstigt. Im Rahmen einer Thyreotoxikose stehen zur Therapie Propylthiouracil und Thiamazol in Abhängigkeit vom Gestationszeitpunkt zur Verfügung. Das Sheehan-Syndrom ist eine Infarzierung des Hypophysenvorderlappens im Rahmen einer Hämorrhagie. Durch Produktionsausfall lebenswichtiger Hormone kann dieses letal enden. Ebenso akut ist die Entstehung eines Lungenödems. Dieses wird durch physiologische Veränderungen während der Schwangerschaft begünstigt. Kausal ist für die Therapie die Unterscheidung eines hyper- oder hypotensiven Lungenödems von Bedeutung.
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Affiliation(s)
| | | | - U Schwemmer
- Klinik für Anästhesiologie und Intensivmedizin, Klinikum Neumarkt i.d.OPf., Neumarkt i.d.OPf., Deutschland.
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Gede Utara Hartawan IGA, Agung Senapathi T, Ryalino C, Pradhana A, Irawan A, Imannudin R. Thyroid storm in pregnancy. BALI JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.4103/bjoa.bjoa_219_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Jemel M, Kandara H, Riahi M, Gharbi R, Nagi S, Kamoun I. Gestational pituitary apoplexy: Case series and review of the literature. J Gynecol Obstet Hum Reprod 2019; 48:873-881. [PMID: 31059861 DOI: 10.1016/j.jogoh.2019.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 04/24/2019] [Accepted: 05/02/2019] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Manel Jemel
- National Institute of Nutrition and Food Technology Department of Endocrinology, Manar University Tunis, Tunisia.
| | - Hajer Kandara
- National Institute of Nutrition and Food Technology Department of Endocrinology, Manar University Tunis, Tunisia.
| | - Mariem Riahi
- National Institute of Nutrition and Food Technology Department of Endocrinology, Manar University Tunis, Tunisia.
| | - Radhouane Gharbi
- National Institute of Nutrition and Food Technology Department of Endocrinology, Manar University Tunis, Tunisia.
| | - Sonia Nagi
- National Institute Of Neurology Department of Neuroradiology, Manar University Tunis, Tunisia.
| | - Ines Kamoun
- National Institute of Nutrition and Food Technology Department of Endocrinology, Manar University Tunis, Tunisia.
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Calina D, Docea AO, Golokhvast KS, Sifakis S, Tsatsakis A, Makrigiannakis A. Management of Endocrinopathies in Pregnancy: A Review of Current Evidence. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16050781. [PMID: 30836653 PMCID: PMC6427139 DOI: 10.3390/ijerph16050781] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 02/27/2019] [Accepted: 02/27/2019] [Indexed: 12/29/2022]
Abstract
Pregnancy in women with associated endocrine conditions is a therapeutic challenge for clinicians. These disorders may be common, such us thyroid disorders and diabetes, or rare, including adrenal and parathyroid disease and pituitary dysfunction. With the development of assisted reproductive techniques, the number of pregnancies with these conditions has increased. It is necessary to recognize symptoms and correct diagnosis for a proper pharmacotherapeutic management in order to avoid adverse side effects both in mother and fetus. This review summarizes the pharmacotherapy of these clinical situations in order to reduce maternal and fetal morbidity.
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Affiliation(s)
- Daniela Calina
- Department of Clinical Pharmacy, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania.
| | - Anca Oana Docea
- Department of Toxicology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania.
| | | | - Stavros Sifakis
- Department of Obstetrics and Gynecology, Mitera Maternity Hospital, 71110 Heraklion, Crete, Greece.
| | - Aristides Tsatsakis
- Department of Forensic Sciences and Toxicology, Faculty of Medicine, University of Crete, 71110 Heraklion, Crete, Greece.
| | - Antonis Makrigiannakis
- Department of Obstetrics and Gynecology, Medical School, University of Crete, 71110 Heraklion, Crete, Greece.
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Harbeck B, Rahvar AH, Danneberg S, Schütt M, Sayk F. Life-threatening endocrine emergencies during pregnancy - management and therapeutic features. Gynecol Endocrinol 2017; 33:510-514. [PMID: 28361555 DOI: 10.1080/09513590.2017.1307959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Endocrine emergencies during pregnancy may be life-threatening events for both mother and fetus. Besides pregnancy-associated endocrine disorders, several pre-existing endocrinopathies such as type-1 diabetes and Grave's disease or adrenal failure may acutely deteriorate during pregnancy. Since "classical" signs are often modified by pregnancy, early diagnosis and management may be hampered. In addition, laboratory tests show altered physiologic ranges and pharmacologic options are limited while therapeutic goals are mostly tighter than in the non-pregnant patient. Though subclinical endocrinopathies are more frequent and worth consideration due to their related adverse sequelae, this article focuses on endocrine emergencies complicating pregnancy.
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Affiliation(s)
- Birgit Harbeck
- a Department of Medicine I , University of Lübeck , Lübeck , Germany and
| | | | - Sven Danneberg
- a Department of Medicine I , University of Lübeck , Lübeck , Germany and
| | - Morten Schütt
- a Department of Medicine I , University of Lübeck , Lübeck , Germany and
| | - Friedhelm Sayk
- b Department of Medicine II , University of Lübeck , Lübeck , Germany
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Annamalai AK, Jeyachitra G, Jeyamithra A, Ganeshkumar M, Srinivasan KG, Gurnell M. Gestational Pituitary Apoplexy. Indian J Endocrinol Metab 2017; 21:484-485. [PMID: 28553611 PMCID: PMC5434739 DOI: 10.4103/ijem.ijem_8_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Anand K. Annamalai
- Department of Endocrinology, Ashwin Speciality Hospital, Madurai, Tamil Nadu, India
| | - Gopalakrishnan Jeyachitra
- Department of Obstetrics and Fertility Medicine, Nithilaa Multispeciality Hospital, Madurai, Tamil Nadu, India
| | - Anandkumar Jeyamithra
- Department of Fertility Medicine, Ashwin Speciality Hospital, Madurai, Tamil Nadu, India
| | | | | | - Mark Gurnell
- NIHR Cambridge Biomedical Research Centre, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Tingi E, Syed AA, Kyriacou A, Mastorakos G, Kyriacou A. Benign thyroid disease in pregnancy: A state of the art review. J Clin Transl Endocrinol 2016; 6:37-49. [PMID: 29067240 PMCID: PMC5644429 DOI: 10.1016/j.jcte.2016.11.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 11/08/2016] [Accepted: 11/10/2016] [Indexed: 12/20/2022] Open
Abstract
Thyroid dysfunction is the commonest endocrine disorder in pregnancy apart from diabetes. Thyroid hormones are essential for fetal brain development in the embryonic phase. Maternal thyroid dysfunction during pregnancy may have significant adverse maternal and fetal outcomes such as preterm delivery, preeclampsia, miscarriage and low birth weight. In this review we discuss the effect of thyroid disease on pregnancy and the current evidence on the management of different thyroid conditions in pregnancy and postpartum to improve fetal and neonatal outcomes, with special reference to existing guidelines on the topic which we dissect, critique and compare with each other. Overt hypothyroidism and hyperthyroidism should be treated appropriately in pregnancy, aiming to maintain euthyroidism. Subclinical hypothyroidism is often pragmatically treated with levothyroxine, although it has not been definitively proven whether this alters maternal or fetal outcomes. Subclinical hyperthyroidism does not usually require treatment and the possibility of non-thyroidal illness or gestational thyrotoxicosis should be considered. Autoimmune thyroid diseases tend to improve during pregnancy but commonly flare-up or emerge in the post-partum period. Accordingly, thyroid auto-antibodies tend to decrease with pregnancy progression. Postpartum thyroiditis should be managed based on the clinical symptoms rather than abnormal biochemical results.
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Affiliation(s)
- Efterpi Tingi
- Obstetrics and Gynaecology, St Mary’s Hospital, Manchester, UK
| | - Akheel A. Syed
- Endocrinology and Diabetes, Salford Royal NHS Foundation Trust, Salford, Greater Manchester, UK
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Alexis Kyriacou
- School of Health Sciences, University of Stirling, Stirling, UK
- CEDM Centre of Endocrinology, Diabetes & Metabolism, Limassol, Cyprus
| | | | - Angelos Kyriacou
- Endocrinology and Diabetes, Salford Royal NHS Foundation Trust, Salford, Greater Manchester, UK
- CEDM Centre of Endocrinology, Diabetes & Metabolism, Limassol, Cyprus
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Rosival V. Endocrine emergencies in pregnancy. Best Pract Res Clin Obstet Gynaecol 2014; 28:e1. [PMID: 24560893 DOI: 10.1016/j.bpobgyn.2014.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 01/13/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Viktor Rosival
- SYNLAB Department of Laboratory Medicine, Dérer's Hospital, Limbová 5, SK-833 05 Bratislava, Slovakia.
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