Headache, pituitary lesion and panhypopituitarism in a pregnant woman: tumor, apoplexy or hypophysitis?

Pituitary dysfunction during pregnancy and its differential diagnosis and treatment can be challenging, as illustrated by the following case. A 22-year-old woman underwent a C-section at 32 weeks of gestation because of preterm labor. She had headache, vision disturbance, polyuria, polydipsia, hypernatremia, diabetes insipidus and a pituitary lesion with findings compatible with apoplexy. Hormonal testing revealed panhypopituitarism. The peripartum presentation, magnetic resonance imaging findings, autoimmunity and global pituitary dysfunction led to the clinical diagnosis of autoimmune lymphocytic hypophysitis. The patient was begun on appropriate hormone replacement therapy. A follow-up magnetic resonance imaging 6 weeks later showed spontaneous regression of the abnormality and a normal-appearing pituitary gland. Thus, acute presentations of pituitary-based pathology during gestation can include previously unrecognized but enlarging tumors, apoplectic hemorrhage and necrosis, and the entity of lymphocytic hypophysitis. A careful evaluation of the clinical, biochemical and radiological characteristics is imperative for accurate diagnosis and proper management to ensure optimal obstetrical outcome.