7405 A Case of Pituitary Apoplexy in Pregnancy

Abstract Disclosure: Y. Esaki: None. G.E. Vates: None. I. Shafiq: None. Pituitary apoplexy is a rare cause of headache during pregnancy. The prevalence of pituitary apoplexy during gestation and the peripartum period is estimated to be 1 in 10,000 term pregnancies. Approximately 42-47% of these patients were known to have a pituitary lesion especially history of prolactinoma. Here we report a pregnant female developing pituitary apoplexy after discontinuation of dopamine agonist. A 27-year-old female was initially diagnosed with prolactinoma with elevated prolactin of 158.1 ng/ml (3.0-300 ng/ml). MRI revealed a 1.3 cm x 1.5 cm x 1.4 cm pituitary mass with solid and cystic components. Treatment with cabergoline 0.25 mg twice weekly was started. After 2 years of treatment, prolactin was 74.2 ng/ml and the size of the adenoma decreased to 1.0 cm x 1.2 cm x 1.3 cm. One year later, she became pregnant at age 30 and discontinued cabergoline after 7 weeks of gestation. At 12 weeks of gestation, she presented to the Emergency Department for 3 days of severe headaches associated with emesis. The ED work up includes prolactin > 2,000 ng/ml. MRI head without contrast demonstrated an interval increase in size to 1.5 cm x 1.7 cm with hemorrhagic component. Urgent evaluation by a Neuro-ophthalmologist revealed no clinical evidence of optic neuropathy. Blood work showed AM cortisol 2.3 mcg/dl (4.0-22.0 mcg/dl), TSH 0.5 mIU/L (0.4-0.5 mIU/L), FT4 0.6 ng/dl (0.8-1.8 ng/dl). Cabergoline 0.25 mg twice weekly was restarted to control the size of the tumor as well as hydrocortisone and levothyroxine for central adrenal insufficiency and hypothyroidism respectively. Four weeks later, she was 17 weeks pregnant. MRI showed a further increase in the size of the adenoma, now measuring 1.8 cm x 2.0 cm x 1.3 cm. The lesion now extended into the suprasellar cistern, affecting the optic chiasm. She underwent the transsphenoidal resection of the pituitary adenoma at 18 weeks of gestation due to the increase in size of the tumor. The final pathology was consistent with pituitary adenoma, lactotroph cell type, WHO grade 1. MRI obtained 3 months post-operation showed no residual T1 hyperintense tumor signal. There was a cyst-like expansion of the sella turcica with a decreased mass effect on the optic chiasm. She delivered her healthy baby at 40 weeks and 5 days via vaginal delivery. She received stress dose steroid during labor, then was discharged home with hydrocortisone 10 mg twice daily. She is doing well following the delivery and breastfeeding the baby. This case illustrates a rare case of pituitary apoplexy during pregnancy in a patient with prolactinoma. Pituitary apoplexy should be considered as a differential diagnosis when pregnant patients develop an acute, severe headache, especially those with an underlying pituitary adenoma. It is critical to assess and treat the hormonal deficiencies. For prolactinoma, pharmacological therapy can be initiated. Surgery is considered if the medical therapy fails. Presentation: 6/3/2024