Insulinoma in a third-trimester pregnant woman combined with pre-eclampsia: a case report and review of the diagnostic strategies.

Insulinomas are rare neuroendocrine tumors with an incidence of 4 per 1,000,000 person-years, being even rarer during pregnancy. During pregnancy most cases are recognized or become symptomatic during the first trimester. A 29-year-old woman, primigravida, was hospitalized in the 38th gestational week due to slurred speech, weakness and slow reaction patterns. An electroencephalogram and computed tomography scan of the brain and blood samples were normal. Blood pressure was 170-145/110-95 mmHg, albuminuria was moderate and there was moderate edema of the ankles. Labor started spontaneously the third day, 62 h after of hospitalization, and the patient gave birth to a healthy girl with no neonatal problems. Fourteen hours after delivery, the patient became comatose and developed universal clonic seizures. At the same time plasma glucose was <1.1 mmol/l and the patient responded immediately to intravenous glucose. The patient was managed with frequent small meals and continuous intravenous glucose. Postpartum testing was consistent with insulinoma and diazoxide treatment was initiated. Endoscopic ultrasound with biopsy showed an insulinoma in the head of the pancreas. During surgical exploration, four separate insulinomas were removed from the head of the pancreas. The hypoglycemic episodes resolved and the glucose levels normalized. Following biochemical diagnosis of insulinoma, diagnostic imaging procedures encountered include endoscopic ultrasonography, magnetic resonance imaging and digital subtraction angiography. Of isotopic procedures, somatostatin receptor scintigraphy (Octreoscan) and newer receptor binding ligands can be used in non-pregnant women. Intraoperative ultrasonography seems mandatory. The present case demonstrates that seizure disorders in non-diabetic pregnant women may be caused by hyperinsulinemia-induced hypoglycemia due to insulinoma.