Introduction: Intracranial haemorrhage, predominantly subdural haematoma, is an uncommon complication of dural puncture. Pituitary haemorrhage (pituitary apoplexy) is rare.
Case presentation: A 23 year old G5P4 Australian Indigenous woman presented in spontaneous labour at uncertain gestation having had no antenatal care. Three attempts at epidural anaesthesia were unsuccessful, and the woman proceeded to vaginal delivery of a 3574g male with estimated blood less during delivery of 150mls, the lowest recorded maternal blood pressure of 110/68mmHg. Seven hours post-delivery the woman complained of a postural headache typical for post-dural puncture headache (PDPH). Transient relief was obtained following epidural blood patch however headache recurred with increasing intensity. Magnetic resonance imaging disclosed pituitary haemorrhage with bulging into the suprasellar cistern and elevation of the optic chiasm without an underlying pituitary adenoma, with pachymeningeal thickening, distension of the intracranial and intercavernous venous sinuses and drooping of the brainstem consistent with intracranial hypotension. Serum cortisol and computer visual fields were normal.
Discussion : Twenty-one (81%) of the 26 reported cases of post-partum acute pituitary haemorrhage were associated with significant maternal blood loss or anaemia. Of the remaining 5 reports, one was associated with severe hypotension at the time of epidural anaesthesia, and another with a PDPH with an underlying pituitary macroadenoma. No obvious precipitant for pituitary haemorrhage occurred in 3 cases other than PDPH.
The pituitary is more vulnerable to injury during pregnancy as a result of the 20-36% increase in volume, which reaches its maximum in the first 3 postpartum days. The importance lies in the potential for life threatening hypothalamic-pituitary-adrenal axis insufficiency, visual compromise, and cranial nerve injury. The possibility of pituitary haemorrhage should be considered in any woman with PDPH which is severe and unrelieved by EBP, or where agalactia, hypotension or visual symptoms are present.