Pituitary Apoplexy: An Uncommon Cause of Postpartum Headache

When a postpartum headache follows a dural puncture, the diagnosis of post-dural puncture headache (PDPH) is usually considered; however, anesthesiologists must also recognize findings that warrant urgent specialized evaluation. Pituitary apoplexy (PA) is a rare but potentially life-threatening complication, and pregnancy itself is a recognized risk factor. The diagnosis should be suspected in the presence of a sudden-onset, severe headache, usually retro-orbital and worsening with time, visual disturbances, and cranial nerve palsy, especially in patients with additional risk factors such as a known pituitary neuroendocrine tumor. We report a case of postpartum PA in a woman with a pre-existing pituitary macroadenoma, who initially presented with severe headache attributed to PDPH. The headache progressively worsened despite therapy directed at PDPH, and she subsequently developed bradycardia and left oculomotor palsy. Imaging confirmed PA, and she was managed with intravenous hydrocortisone and transsphenoidal sellar decompression, followed by long-term endocrine replacement therapy. This case highlights the importance of considering this uncommon but critical condition in the differential diagnosis of postpartum headache in anesthetic practice. It also emphasizes the need to recognize red flags, such as a change in the nature or severity of a headache or the onset of focal neurological deficits, which should prompt urgent multidisciplinary evaluation and appropriate neuroimaging.