Endocrine Abstracts

Case history: A 39 year old female presented reporting a 5-year history of swollen face, hands and feet, with associated joint pain. She was initially investigated for rheumatoid arthritis. She had no significant past medical history except for a previous miscarriage in 2014 and treatment for hypertension in a subsequent successful pregnancy. Post-partum she breastfed with no difficulty for 18-months but remained amenorrhoeic during this time. During 2016 she noticed increase in shoe and ring size, snoring and sweating. She felt increasingly tired, with a reduction in libido and experienced recurrent headaches with deterioration in her peripheral vision.

Investigations: Investigations demonstrated elevated IGF-1 level of 71 nmol/l (8.5–30.7 nmol/l) with growth hormone of 15.3 mcg/l. Her prolactin was 1717 MU/l. An MRI scan in August 2016 confirmed a large pituitary macroadenoma compressing the optic chiasm and eroding the fossa with right cavernous sinus invasion. She was advised to stop breast feeding, commenced on Lanretoide and Carbergoline, and referred to our centre for Transphenoidal surgery.

Results and treatment: She underwent transphenoidal adenomectomy in December 2016. Post operatively there were no significant complications. Histology showed a somatotroph pituitary adenoma with a mixed densely and sparsely granulated pattern, no evidence of atypia, and a MIBI index < 1%. Lanretoide was continued post-operatively in view of the known residual tumour within the cavernous sinus. This was then confirmed on the post-operative MRI at 3 months. Biochemistry (on Lanretoide) showed IGF-1 of 24.3 nmol/l (6.4–31.0 nmol/l), growth hormone 1.2 mcg/l, LH 2.3 IU/l, FSH 5.9 IU/l and prolactin of 129 MU/l. In April 2017 her IGF-1 level was 20 nmol/l and random growth hormone was 2.3 IU/l. Prior to a complete biochemical post op assessment, she was keen to extend her family. Following discussion around the evidence of Lanreotide in pregnancy she and her husband chose to stop treatment. She conceived in May 2017 and the pregnancy is progressing without complication. She has expressed the wish to complete the pregnancy and breast feed off somatostatin analogue therapy.

Conclusion: This case highlights the potential challenges in monitoring and treatment of acromegaly during pregnancy and the post-partum period. There is limited evidence on the use of somatostatin analogues in pregnancy, largely based upon anecdotal evidence and case reports. This case highlights the importance of pre-natal discussion and tailoring treatment to the individual.