Endocrine Abstracts

Introduction: Insulinomas are the most common cause of hypoglycemia due to endogenous hyperinsulinism. Almost all insulinomas are benign, and long-term recovery with complete disappearance of preoperative symptoms can be expected after complete resection.

Case report: A 33-year-old woman, who developed gestational diabetes during her second pregnancy, which persisted post-partum, stopped insulin due to recurrent severe hypoglycemia, but which persisted even after stopping insulin, which is why she presented in our department where the suspicion of insulinoma was raised because plasma glucose was 27 mg/dl, concomitant to a high insulinemia of 50.1 μIU/ml. The imaging investigations were normal. Nuclear imaging investigations were also normal. In dynamics, plasma glucose values remained low (13 mg/dl) and insulinemia increased (169.8 μIU/ml), which motivates the initiation of somatostatin analog (SSA). However, the hypoglycemic status was maintained, so the dose of SSA was increased. Although there was no clear imaging localization following the high suspicion of insulinoma it was decided to perform distal pancreatectomy. Post-operative, the patient’s condition was good, so the somatostatin analog was stopped. At 8 months follow-up after the surgery, the patient had a normal plasma glucose level and a normal insulinemia level but later hypoglycemic episodes appeared again, which was why the administration of the SSA was restarted but the patient voluntarily stopped the treatment. At the next follow-up, the pregnant patient at that time presented with increasing insulinemia, thus deciding to continue the treatment with SSA with the patient’s consent, although there are relative contraindications for administration during pregnancy. The patient was monitored throughout the pregnancy, hypoglycemia prophylaxis was performed but the fetus was small for gestational age (SGA) according to ultrasound evaluations. Due to an obstetrical complication, premature induction of labor was performed at 28 weeks of pregnancy. Post-partum, the patient’s status was reevaluated, the imaging and nuclear investigations results showing no pathological images. During the last visit it was decided to increase the frequency of administration of the SSA.

Conclusion: The SGA new-born can be explained both by the mother’s persistent hypoglycemic status and by the administration of the SSA which has been proven to lead to intrauterine growth restriction. With a continuous persistence of hypoglycemia despite the distal pancreatectomy, although without imaging evidence of the localization of the insulinoma, the final step of treatment would be cephalic pancreatectomy, a difficult surgery, with multiple complications and with the need for post-operative replacement of the pancreatic exocrine and endocrine function.