Intrasellar meningioma versus pituitary apoplexy in the setting of postpartum hemorrhage: a case report

Headache in the postpartum period can indicate serious underlying pathology, such as a meningioma or a pituitary apoplexy event. These conditions can present similarly but are managed differently, indicating the need for careful diagnostic consideration. A 39-year-old G7P2042 female delivered a healthy male neonate by urgent repeat cesarean delivery secondary to premature rupture of membranes at 35 weeks 1 day gestation. She sustained blood loss of approximately 1000 mL during delivery. One week postpartum, she developed new-onset persistent non-positional headache with diplopia. Laboratory findings did not support the diagnosis of preeclampsia. Brain MRI revealed a complex intrasellar and cavernous sinus mass. Removal was initially deferred due to normal endocrine function and to preserve breastfeeding ability; however, serial imaging revealed interval growth and symptom progression over several months. Resection of the mass was performed at seven months postpartum, revealing a grade I meningioma with no gross evidence of apoplexy. Repeat brain MRI at one year postpartum revealed continual tumor growth, for which the patient pursued fractionated radiosurgery given ongoing deficits and concern for worsening cranial nerve neuropathies. While both intrasellar meningiomas and pituitary apoplexy events are rare, they can have serious implications during pregnancy and the postpartum period. A diligent neurologic exam, serial imaging, and pituitary hormone levels can aid in diagnostic differentiation and prompt intervention to avoid the potential sequelae of adrenal insufficiency or tumor expansion.