Endocrine Abstracts

We report a 29-year old primiparous woman, presenting 3-days post vaginal delivery with a severe frontal headache of gradual onset but particularly severe whenever she tried breastfeeding and accompanied by vomiting. She was conscious, mildly dehydrated and apyrexial. Reflexes were globally brisk and besides for neck stiffness the rest of her central nervous system and major systemic examination was normal. FBC and clotting were normal, C-reactive protein 35 (normal <5). Glucose, urea, electrolytes, LFT, serum/urinary osmolality were normal. Despite an earlier epidural, the onset of her symptoms and that it got worse in the supine position made dural headache unlikely.

CT-scan showed a hyperdensity of the pituitary that was thought to be either normal puerperal appearance or possible pituitary haemorrhage. MRI confirmed haemorrhage into a probable pituitary microadenoma. Goldman perimetry was normal. Thyroid function tests were normal, LH&FSH undetectable, Oestradiol 670 pmol/L, Prolactin 2485 mU/L-consistent with postpartum levels. Symptoms resolved with rehydration. She stopped breast-feeding. Short synacthen test 8-weeks after onset was normal. MRI scan 4 months later showed resolution of the haemorrhage with no obvious residual abnormality. Menstruation recommenced 4 months later and pituitary function has returned to normal with no recurrence of headache 10 months on.

Spontaneous pituitary haemorrhage can occur into a pre-existing macro- or microadenoma presenting as pituitary apoplexy and can complicate pregnancy wherein the anterior pituitary increases in size due to lactotroph hyperplasia. This is the first known case of spontaneous post-partum pituitary haemorrhage into an otherwise ‘normal’ pituitary and consequently unaffecting its function. Headache accompanying pituitary tumours have been shown to be associated with an increased mean intrasellar pressure. The mechanism of headache worsened by lactation in our patient is thought to be due to a rise in intrasellar pressure presumably due to an oxytocin-mediated localised vasomotor response accompanying the milk-ejection reflex.