A multidisciplinary approach to management of a non-traumatic subdural hematoma in the third trimester of pregnancy: A case report and review of literature.

Key Message: Although non-traumatic SDHs are uncommon during and immediately following pregnancy, management of these cases should be carried out by a multidisciplinary team, including obstetricians, pediatricians, neurosurgeons, and anesthesiologists. Abstract: Intracranial hemorrhage represents an uncommon but serious complication of pregnancy. Non-traumatic subdural hematomas (SDH) are uncommon during the prenatal period with limited literature about etiology and management. In this case report, the authors report on a patient with non-traumatic SDH in the third trimester of pregnancy. The patient is a 40-year-old G6P5L5 female at gestational age of 34 weeks and 5 days presenting with frontal headache, nausea, vomiting, and blurry vision. CT scan revealed an acute on chronic right subdural hematoma with midline shift and multiple herniations. An emergency cesarean section and right burr hole SDH evacuation were performed. Etiology of the SDH remains unknown. Although non-traumatic SDHs are uncommon during and immediately following pregnancy, health care providers should always consider this possibility if a patient presents with typical symptoms and signs. Management of these cases should be carried out by a multidisciplinary team, including obstetricians, pediatricians, neurosurgeons, and anesthesiologists to optimize maternal and fetal outcomes.

Status epilepticus and diabetes ketoacidosis: uncommon clinical presentations of acromegaly.

SUMMARY: Acromegaly is a rare disease caused by hypersecretion of the growth hormone (GH). Most cases are caused by either pituitary microadenoma or macroadenoma. The GH producing tumors present with clinical manifestations of acromegaly due to excessive GH secretion or symptoms resulting from mass effects of the enlarging tumor. The physical changes are usually slow and, therefore, recognition of the disease is delayed. These adenomas are never malignant but can have significant morbidity and mortality. A subgroup of patients with acromegaly present with severe hyperglycemia resulting in diabetic ketoacidosis (DKA) which requires insulin. Rarely are pituitary tumors responsible for generalized convulsions except when they are too large. We hereby present two cases, the first is that of a 26-year-old female who presented with new onset status epilepticus, DKA with a 1-year history of diabetes mellitus (DM). On examination, she had clinical features of acromegaly. The second case is that of a 34-year-old female who presented with new onset status epilepticus, hyperglycemia with a history of recently diagnosed DM, and features of gigantism. In both cases, their diagnosis was confirmed by elevated serum GH and later by elevated insulin-like growth factor type 1 levels, and CT of the head demonstrating large pituitary macroadenoma. The importance of clinical history and examination, as well as investigations is vital in the recognition of acromegaly. The prognosis of acromegalic patients depends on early clinical recognition and tumor size reduction by either medical or surgical therapy. LEARNING POINTS: Conditions such as status epilepticus and DKA may be clinical presentations in patients presenting with acromegaly. Seizures are rare in people with pituitary adenoma and typically occur when the tumor invades the suprasellar area due to mass effect on the brain. This article shows how best we were able to manage the acromegaly complications in a low resource setting. Hyperprolactinemia in acromegaly may be due to disruption of the normal dopaminergic inhibition of prolactin secretion due to mass effect of the macroadenoma, and around 25% of GH-secreting adenomas co-secrete prolactin.