Presentation, management and outcomes in acute pituitary apoplexy: a large single-centre experience from the United Kingdom.

OBJECTIVE: To study the presentation, management and outcomes and to apply retrospectively the Pituitary Apoplexy Score (PAS) (United Kingdom (UK) guidelines for management of apoplexy) to a large, single-centre series of patients with acute pituitary apoplexy. DESIGN: Retrospective analysis of casenotes at a single neurosurgical centre in Liverpool, UK. RESULTS: Fifty-five patients [mean age, 52·4 years; median duration of follow-up, 7 years] were identified; 45 of 55 (81%) had nonfunctioning adenomas, four acromegaly and six prolactinomas. Commonest presenting features were acute headache (87%), diplopia (47·2%) and visual field (VF) defects (36%). The most frequent ocular palsy involved the 3rd nerve (81%), followed by 6th nerve (34·6%) and multiple palsies (19%). Twenty-three patients were treated conservatively, and the rest had surgery either within 7 days of presentation or delayed elective surgery. Indications for surgery were deteriorating visual acuity and persistent field defects. Patients presenting with VF defects (n = 20) were more likely to undergo surgery (75%) than to be managed expectantly (25%). There was no difference in the rates of complete/near-complete resolution of VF deficits and cranial nerve palsies between those treated conservatively and those who underwent surgery. Endocrine outcomes were also similar. We were able to calculate the PAS for 46 patients: for the group treated with early surgery mean, PAS was 3·8 and for those managed conservatively or with delayed surgery was 1·8. CONCLUSIONS: Patients without VF deficits or whose visual deficits are stable or improving can be managed expectantly without negative impact on outcomes. Clinical severity based on a PAS ≥ 4 appeared to influence management towards emergency surgical intervention.

Obstetric performance of women who have previously delivered a baby of low birthweight.

OBJECTIVES: To investigate pregnancy outcomes in women who have previously given birth to a baby weighing less than 2500 grams in a population in which the low birthweight rate is high. METHODS: We compared the obstetric performance of 100 women who had delivered a low birthweight baby (<2500g) at term in a previous pregnancy (cases) with those of 100 women who were matched for age, height, body mass index at booking, parity and medical disorders, who had previously delivered a baby above that threshold (controls). RESULTS: We found the following significant differences between cases and controls (p<0.001 for all). Gestation at delivery (mean±SD = 38.0±1.9 vs. 39.1 ± 1.2 weeks); risk of delivery before completion of 37 weeks (19.0% vs. 3.0%); birthweight (mean±SD = 2.553 ± 0.444 vs. 3.015 ± 0.413 Kg); risk of delivery of a low birthweight (LBW) baby in the current pregnancy (27.0% vs. 4.0%). The stillbirth rate was also significantly higher among cases (4 vs. 0; p<0.05). CONCLUSIONS: Birth of a LBW baby points to adverse events in future pregnancies even where its prevalence is high. It is a useful criterion for assessment of risk in antenatal care and for directed interventions.

Hypogonadism secondary to hyperprolactinaemia: successful treatment but adverse consequences.

It is accepted that care must be taken in initiating testosterone replacement in hypogonadal individuals with historically low androgen levels. However less is reported about the influence of restoration of normal endogenous testosterone production on behaviour.Here we report how the adverse sequelae of successful treatment of hypogonadism secondary to hyperprolactinaemia, manifesting as irritability and low threshold to aggression, were managed through a joint approach between psychiatrist and physician.

Low investigation rate for adrenal incidentalomas.

The prevalence of adrenal incidentaloma has increased with the increasing use of imaging techniques. While majority are benign adenoma, a small but significant minority may be primary adrenal carcinoma or have endocrine hyper secretion. Existing guidance suggests that excess catecholamine and cortisol secretion should be ruled out in all cases and excess aldosterone secretion should be ruled out in hypertensive patients. Repeat evaluation after a period of time is also suggested. We have reviewed the management of adrenal incidentaloma in a large district general hospital in the North West of England.

Detection of the "small for gestational age" fetus: comparison of a teaching hospital with field clinics.

INTRODUCTION: Low birthweight babies make a disproportionate contribution to perinatal morbidity and mortality. Antenatally they manifest as "small for gestational age" fetuses. Their detection is an important aspect of antenatal care. OBJECTIVES: To compare the effectiveness of antenatal detection of "small for gestational age", fetuses by a clinic in a teaching hospital and field clinics. DESIGN: Comparative descriptive study. SETTING: Professorial Obstetric Unit of De Soysa Maternity Hospital, Colombo. METHODS: Antenatal records of 67 consecutive women who delivered low birthweight babies at term were reviewed. Entries in the teaching hospital clinic records and the pregnancy record of the field clinics were studied. A deviation corresponding to more than two weeks' growth was considered significant. The period of gestation at which the deviation was first detected and any follow up action taken were noted. RESULTS: Of the total sample of 67 women 56 had also attended a field clinic. A significantly greater percentage of small for dates fetuses were detected by the primary care staff (71.4 vs 53.7%; p < 0.05). They also detected them earlier in pregnancy (26.4 vs 30.7 weeks; p < 0.05). However, referral for specialised care was arranged only in 32% by the field clinics. CONCLUSION: The detection rate of small for gestational age fetuses by staff of field clinics was close to the higher rates quoted in the literature. Only a minority of these fetuses were assessed further in both settings indicating a deficiency in antenatal care.