Case: A 32-year-old primigravida woman first presented to endocrinology outpatient clinic following an abnormal oral glucose tolerance test at 18-weeks’ gestation and was noted to have coarse facial features and splaying of teeth. Further history revealed enlargement of hands and feet and broadening of nose, and weight gain over several years with current body mass index of 39kg/m2. Furthermore, ovulation induction and assisted reproduction was required to achieve pregnancy in the presence of oligomenorrhoea. Biochemistry was consistent with acromegaly demonstrating elevations in serum growth hormone of 18.9mU/L (range 1.0-13.0mU/L), IGF-1 of 70.6nmol/L (range 9.6-31.8nmol/L), IGFBP-3 223.9nmol/L (range 89.5-201.9nmol/L) and prolactin 3774mIU/L (range 64-395mIU/L); with an associated suppression in thyroid axis with TSH of 3.02mIU/L (range 0.13-4.55mIU/L), FT4 of 5.8pmol/L (range 7.4-16.7pmol/L) and FT3 of 2.9pmol/L (range 3.0-5.9pmol/L). At 30-weeks’ gestation, she developed pre-eclampsia and HELLP requiring emergency caesarean. She gave birth to a male weighing 1644g with 1- and 5-minute APGAR scores of 4 and 8 respectively, with baby requiring non-invasive ventilation for respiratory distress and intravenous dextrose to treat neonatal hypoglycaemia. MRI pituitary is currently pending.
Discussion: We report a case of acromegaly following presentation with diabetes in pregnancy. The risk of gestational diabetes and diabetes in pregnancy is higher is women with acromegaly, however the precise incidence is still largely unknown. Acromegaly is typically associated with infertility due to associated hyperprolactinaemia or hypogonadotropic hypogonadism, with presentation during pregnancy extremely rare. Biochemical confirmation of acromegaly is difficult in pregnancy due to production of placental variant growth hormone, a major stimulus to secretion of IGF-1 in pregnancy. Currently, gestation specific reference ranges for growth hormone, IGF-1 and IGFBP-3 are yet to be established, adding to the complexity in diagnosis.