Octreotide partially controlled insulinoma-induced hypoglycemia in a pregnant woman, highlighting diagnostic and therapeutic challenges
Background
Insulinoma during pregnancy is an exceedingly rare endocrine tumor, with fewer than 30 cases reported globally. Its diagnosis is often significantly delayed due to the physiological changes of gestation, which can mask or mimic symptoms of hypoglycemia. This delay poses substantial risks, including neuroglycopenic damage to the mother and adverse outcomes like fetal growth restriction. Current standard-of-care for insulinoma often involves surgical resection, but this is complicated by the risks of anesthesia and invasive procedures during pregnancy, necessitating alternative management strategies.
Study Design
This case report details a 36-year-old gravida 4 para 2+1 woman who presented at 7 weeks' gestation with recurrent symptomatic hypoglycemia. She re-presented at 12 weeks' gestation with persistent neuroglycopenic symptoms and weight loss. Biochemical evaluation revealed inappropriately non-suppressed insulin and C-peptide levels during hypoglycemic episodes. Initial ultrasound was non-diagnostic, but magnetic resonance imaging (MRI) identified a 2.3 x 2.5 cm pancreatic lesion consistent with insulinoma. A multidisciplinary team (MDT) involving Endocrinology, Obstetrics & Gynecology, Hepatobiliary Surgery, and Radiology guided management. Due to tumor size and procedural risks, definitive intervention was deferred, and medical therapy with octreotide was initiated.
Results
Biochemical evaluation confirmed endogenous hyperinsulinaemia with inappropriately non-suppressed insulin and C-peptide levels during hypoglycemia. MRI successfully identified a 2.3 x 2.5 cm pancreatic lesion, confirming the diagnosis of insulinoma. Medical therapy with octreotide achieved only partial glycemic control, indicating its limitations in this context. The pregnancy was subsequently complicated by fetal growth restriction, necessitating an early delivery at 34 weeks. Postpartum, the patient underwent endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA). This required two sessions before achieving sustained glycemic stabilization, underscoring the challenges of non-surgical management for tumors of this size. The case highlights the significant impact on both maternal and fetal outcomes.
Octreotide provided only partial glycemic control for the 2.3 x 2.5 cm insulinoma, leading to fetal growth restriction and requiring two sessions of postpartum
EUS-RFAfor stabilization.
Key Findings
- Insulinoma diagnosis in pregnancy is challenging due to symptom overlap, leading to significant delays.
- MRI identified a 2.3 x 2.5 cm pancreatic insulinoma in a pregnant woman with recurrent hypoglycemia.
- Medical therapy with octreotide achieved only partial glycemic control during pregnancy.
- The pregnancy was complicated by fetal growth restriction, necessitating delivery at 34 weeks.
- Postpartum, two sessions of
EUS-RFAwere required for glycemic stabilization.
Why It Matters
This case underscores that MDT-guided individualized management is critical for rare and complex conditions like insulinoma in pregnancy. Clinicians must maintain a high index of suspicion for endogenous hyperinsulinaemia in pregnant women with recurrent hypoglycemia, even with overlapping gestational symptoms, to avoid diagnostic delays. The partial efficacy of octreotide and the need for two sessions of EUS-RFA postpartum suggest that current medical and minimally invasive therapies may have limitations, especially for larger tumors. This highlights the ongoing need for safer and more effective therapeutic options during pregnancy that can achieve better glycemic control and improve fetal outcomes, potentially influencing future protocol development for similar cases.
insulinoma
pregnancy
hypoglycemia
octreotide
case-report
endocrinology