Endocrine Abstracts

Case history: A 31-year-old-lady was referred to the antenatal clinic at 6 weeks gestation. She had a background of a Craniopharyngioma and underwent transsphenoidal surgery (TSS) at age 9 years. She subsequently developed post-operative hypopituitarism which required supplementation with Growth hormone (GH), Levothyroxine and hormone replacement therapy (HRT). She also developed cranial diabetes insipidus (CDI) requiring supplementation with desmopressin. She had never been steroid deficient and only transiently required hydrocortisone following TSS. Over the years, there were multiple alterations of her hormonal therapy. She had primary amenorrhea as TSS had been done prior to puberty. Using ovulation induction treatment and a HCG trigger, she conceived. On review, she was on subcutaneous GH 1 mg daily, 125 mg OD Levothyroxine and Desmopressin 0.2 mg PO in the morning, 0.1 mg PO in the afternoon and 0.3 mg PO in the evening. She was however advised to cease the GH injections. Her dose of Levothyroxine had been empirically increased to 125 mg PO OD post conception. She was experiencing increased osmotic symptoms thus Desmopressin dose was increased. She continued to be monitored on a 4-weekly basis, with her Levothyroxine dose being increased further, aiming for her FT4 to be in the upper third of the normal range. This case highlights the challenges of complexities and challenges of managing hypopituitarism and CDI in pregnancy.

Discussion: Fertility can be subnormal in women with hypopituitarism with affliction of the reproductive hormone axis, but also when other pituitary hormones are affected. Women often require assisted reproduction techniques to conceive. However there are reported cases of spontaneous conception. Simple regression analysis for hypopituitarism in pregnancy identified only maternal age and depression as predictors of pregnancy outcomes whereas multiple regression analysis found a trend, albeit non-statistically significant for worse pregnancy outcomes in women with childhood onset disease. DI is associated with increased complications of pregnancy that include including preeclampsia. With pulsatile GnRH treatment, the pregnancy rates are comparable to the normal population. The supplementation of GH in pregnancy is controversial as the placenta is known to produce GH, thereby suppressing pituitary GH production. Keeping this in mind, we omitted the GH supplementation in our patient. Owing to altered water homeostasis, and the effect of placental vasopressinase, the dose of Desmopressin may need to be increase, as was seen with our patient