Endocrine Abstracts

33-year-old female presented at 35 weeks of pregnancy with black spots in the peripheral vision and headaches to Ophthalmology department. No other relevant clinical symptoms of note and no past medical history. On examination she had bitemporal hemianopia confirmed on perimetry hence was referred to Endocrine department. The MRI showed pituitary macroadenoma (1.8 cm x 2 cm x 1.2 cm), with extension into suprasellar and parasellar regions and displacement of the optic chiasm. Biochemical profile showed a Prolactin of 2420 ng/ml, secondary hypothyroidism - TSH (0.04 mU/l), T4 (9.1 mg/dl) and 9AM cortisol (164 mg/dl). Discussions with Oxford MDT advised early C-section and Trans-sphenoidal surgery following delivery with weekly visual field monitoring. She was delivered successfully 3 weeks after presentation with no post op complications. She was started on steroid replacement peri-operatively as empirical therapy, followed by levothyroxine. Post-delivery her SST was normal and hence she was weaned off steroids gradually (as she remained on them for 12 weeks post-partum due to nonattendance at some appointments). Following delivery, her vision improved and so did her visual fields. Her MRI post-partum showed reduction in size of the pituitary lesion (reduced from 1.8 to 1.0 cm in maximal craniocaudal diameter and no longer compressing optic chiasm). She was re-discussed at Oxford Pituitary MDT. Given that her visual fields normalised and she desired to have more children, it was felt Trans-sphenoidal surgery would have a risk of infertility hence they recommended 6 month follow up scans and debulking surgery only if a significant adenoma was still present prior to next pregnancy. Her latest pituitary MRI shows further spontaneous reduction in size of pituitary tumour from 1 cm to 0.7 cm in craniocaudal dimension. She is keeping well with no clinical symptoms and normal visual fields; she is breastfeeding, and her cycles restarted postpartum. She managed to conceive second time, 8 months after delivery but had a miscarriage unfortunately.

Discussion: • How to investigate a young pregnant female with late presentation and vision threatening pathology with no baseline hormone profile or brain scans. MDT and patient involvement in decisions remains crucial centre point.

• Interpreting pituitary biochemical profile in pregnancy. Safety of serial contrast MRIs during pregnancy.

• Management options – Surgery vs conservative approach in 3rd trimester with patient being on board with risks of each.

• Changes in pituitary tumours (functioning and non-functioning) during and after pregnancy.