38-Year-Old at 26 Weeks Gestation with Pituitary Macroadenoma

Purpose: To report a rare case of pituitary macroadenoma in pregnancy. Pituitary macroadenomas are benign tumors of the pituitary gland. Routine presentation may include endocrine abnormalities or visual field defects. The prevalence of pituitary macroadenomas in the general population is approximately 40.67 per 100,000 individuals. In pregnancy, the occurrence is even more rare, and diagnosis and management require a multidisciplinary approach to minimize potential complications. This case highlights the diagnostic process, management considerations, and potential impact on pregnancy outcomes. Method: Case Report Results: A 38-year-old G8P3043 female at 26+2 weeks of gestation presented with intractable headache. The patient stated she choked while drinking juice the night before, which led to a coughing spell. She reported that the headache began soon after the coughing spell. The headache was persistent, dull, and diffuse in nature and associated with photophobia, phonophobia, and two episodes of vomiting. She denied visual changes, dizziness, or weakness. The patient was administered a pain cocktail with minimal relief. Computed tomography (CT) and magnetic resonance imaging (MRI) of the head showed a 2.6 x 1.3 x 1.8 cm expansile mass in the sella with suprasellar extension, elevating and compressing the optic chiasm. The primary diagnosis was a pituitary macroadenoma. Neurology was consulted, and the patient was evaluated. Neurological physical exam was unremarkable, including cranial nerves, motor, sensation, coordination, and higher integrative functions. Neurology concluded there was no need for further neurological workup at this time and to follow up with the neurologist in 2 months. Her pregnancy has been complicated by fetal growth restriction (FGR), abnormal non-invasive prenatal testing (NIPT) with high suspicion for Trisomy 21, chronic hypertension, and advanced maternal age. Past medical history includes chronic hypertension on labetalol 100 mg twice a day and occasional migraines. She was never evaluated by a neurologist for the migraines because she reported only a few episodes a year. The patient was receiving twice weekly fetal testing for FGR with follow up ultrasounds every 3 weeks to assess fetal growth in the setting of highly suspected Trisomy 21. The patient remained asymptomatic throughout this time and did not require pain medication. The patient expressed a desire for a vaginal delivery. Due to the findings of pituitary adenoma and concerns for labor, an anesthesia referral was requested to determine if she was an appropriate candidate for regional anesthesia. She was evaluated by anesthesia, and they deemed her an appropriate candidate. At her 2 month follow-up visit with neurology, she denied any complaints, including headache or visual changes. Neurology referred her to neurosurgery for further evaluation. Neurology plans to follow up with her in 6 months. The team plans for delivery at 38 weeks pending continued normal antenatal testing. Conclusion: Pregnancy is a physiological state that induces significant changes in the endocrine system, particularly affecting the pituitary gland. These anatomical and functional changes make the management of pituitary disease more complex compared to the non-pregnant state. Due to hyperplasia and hypertrophy of lactotroph cells, the pituitary gland may increase in size by up to 40% in the second trimester and up to 70% in the third trimester, reaching two to three times its normal size. A pituitary adenoma greater than 10 mm in diameter, classified as a macroadenoma, has a 15-36 % chance of increasing in size during pregnancy. This growth risk necessitates close monitoring for symptoms such as headaches or visual disturbances, which may indicate tumor progression and could require neurosurgical evaluation. The treatment and surveillance of macroadenomas during pregnancy should be individualized. Patients should undergo close clinical follow-up with visual field testing during each trimester. In cases of non-functioning adenomas or hormone-secreting adenomas, surgery may be considered when there is significant visual impairment or life-threatening endocrine dysfunction. The second trimester is typically considered the safest period for surgical intervention, as it is associated with lower risks of congenital anomalies and preterm birth. The majority of women with macroprolactinomas or non-functioning adenomas experience favorable pregnancy outcomes. The primary goal of management is to ensure maternal and fetal safety while effectively controlling the tumor. Although rare, pituitary apoplexy, which involves infarction or hemorrhage within the pituitary gland often in the context of a pre-existing adenoma, can occur and may require emergency intervention. A collaborative, multidisciplinary approach involving obstetrics, endocrinology, neurology, neurosurgery, and maternal-fetal medicine is essential to optimize outcomes for both the mother and the fetus.