A 35-year-old lady was admitted at 24 weeks gestation with a 34 weeks history of persistent severe, left sided headaches associated with vomiting but not with visual disturbance. She had a prior history of migraines. However, her current headaches were very different in character. On examination her Glasgow Coma score was 15. There was no neck stiffness or photophobia. Visual fields and fundoscopy was normal. She was haemodynamically stable. Magnetic resonance imaging (MRI) and venogram (MRV) of her brain were performed to exclude a venous sinus thrombosis. MRI revealed an enlarged sella turcica containing a macroadenoma with a fluid-fluid level, with signal characteristics consistent with subacute haemorrhage within the pituitary gland. She was reviewed by the endocrinology team and baseline pituitary function tests were performed: TSH 0.50 mIU/l (0.354.10), free T4 10.26 pmol/l (9.6317.0), ACTH 20.7 ng/l, 0900 h cortisol 214 nmol/l, random GH 0.118 μg/l (00.8), and IGF1 19 nmol/l (16.139.8). Oestradiol was 26 963 pmol/l. In view of her low 0900 h cortisol she was commenced on hydrocortisone replacement. Formal Humphreys perimetry was normal. Her case was discussed at the regional pituitary MDT. She did not require neurosurgical intervention but was transferred over to a tertiary care centre and jointly managed by the endocrinologists and obstetric team. She had an uneventful pregnancy and a healthy baby was delivered at 39 weeks gestation by caesarean section. She has ongoing endocrinology follow up and remains on hydrocortisone. Pituitary apoplexy is a medical emergency caused by haemorrhage and/or infarction of the pituitary gland. Pregnancy is a risk factor so this diagnosis should be considered in any pregnant woman presenting with acute severe headache or significant change in headache phenotype. Corticosteroid replacement may be life-saving. Neurosurgical intervention should be considered in cases with persistent visual field defects or deteriorating conscious level.
02 Nov 2015 - 04 Nov 2015