We report the case of a 21 year old primigravida who presented at 36 weeks gestation with a sudden onset of headache and blurred vision. She was normotensive with no proteinuria. Formal examination revealed a bitemporal hemianopia and subsequent MRI indicated a large pituitary mass with suprasellar extension and chiasmal compression. Hormone profile was unremarkable, aside from an elevated prolactin level.
The working diagnosis was pituitary macroadenoma and she was commenced on brompcriptine. Although her vision improved this was poorly tolerated. Labour was therefore induced, and she delivered a healthy female infant.
Postnatally her visual field defect worsened and, following endocrine and neurosurgical input, she underwent transphenoidal hypophysectomy. Post operative evaluation indicated partial cortisol deficiency necessitating steroid replacement. Subsequent histology reported hypophysitis.
She retained a regular menstrual cycle and conceived spontaneously one year later. She continued on hydrocortisone throughout the pregnancy which progressed to a spontaneous vaginal delivery (with additional steroid cover) of a male infant.
Autoimmune hypophysitis is a rare disease with an annual incidence of only 1 in 7-9 million. Subsequent pregnancy after such extensive pituitary surgery is even rarer and, has, to date, not been reported. It must be considered in the differential diagnosis of any pituitary mass, especially in pregnancy and/or the puerperium. A high index of suspicion and consideration of contrast CT/biopsy is required as conservative management would eliminate the need for aggressive surgery which subsequently renders the patient steroid dependant and/or subfertile.
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