1
|
Gamito MAPDO, Amaral NYB, Rodrigues CF, Ribeiro JM, Guerra S. Pituitary Apoplexy in Pregnancy: What do We Know? REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:273-280. [PMID: 37339647 PMCID: PMC10442903 DOI: 10.1055/s-0043-1770128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/21/2023] [Indexed: 06/22/2023] Open
Abstract
Pituitary apoplexy refers to a rare clinical syndrome consisting of signs and symptoms that occur due to rapid expansion of the contents of the sella turcica. It can occur spontaneously or associated with pituitary tumors. It can have a broad clinical spectrum, but usually presents with severe headache, visual impairment and hypopituitarism. Sudden onset of symptoms associated to imagiologic confirmation makes the diagnosis. Surgical treatment is advised when there is important compression of the optic tract. We present a case report and a review of the literature on pituitary apoplexy in pregnancy. The cases were reviewed to obtain information on maternal characteristics, clinical presentation, diagnostic studies, therapeutic modalities and maternal and fetal outcomes. Our review found 36 cases of pituitary apoplexy in pregnancy. Most of the cases occurred in the second trimester of pregnancy and headache was the most frequent symptom at presentation. Surgical therapy was required in more than half of the patients. In what respect maternal and fetal outcomes, there were 3 cases of preterm delivery and one case of maternal death. Our clinical case and literature review reinforces the importance of an early diagnosis to avoid potential adverse consequences.
Collapse
|
2
|
Luzardo-Ocampo I, Dena-Beltrán JL, Ruiz-Herrera X, Ocampo-Ruiz AL, Martínez de la Escalera G, Clapp C, Macotela Y. Obesity-derived alterations in the lactating mammary gland: Focus on prolactin. Mol Cell Endocrinol 2023; 559:111810. [PMID: 36374835 DOI: 10.1016/j.mce.2022.111810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 10/18/2022] [Accepted: 10/21/2022] [Indexed: 11/07/2022]
Abstract
Obesity is a modern pandemic with negative consequences in women's reproductive health. Women with overweight and obesity can develop mammary gland alterations that unable exclusive breastfeeding. Obesity associates with a disturbed lactating mammary gland endocrine environment including a decreased action of the hormone prolactin (PRL), the master regulator of lactation. The PRL receptor and the action of PRL are reduced in the mammary gland of lactating rodents fed an obesogenic diet and are contributing factors to impaired lactation in obesity. Also, treatment with PRL improves milk yield in women with lactation insufficiency. This review focuses on the impact of diet-induced obesity in the lactating mammary gland and how obesity impairs the lactogenic action of PRL. Although obesity alters lactation performance in humans and rodents, the responsible mechanisms have been mainly addressed in rodents.
Collapse
Affiliation(s)
- Ivan Luzardo-Ocampo
- Instituto de Neurobiología, Universidad Nacional Autónoma de México (UNAM), Campus UNAM-Juriquilla, 76230, Querétaro, Mexico
| | - José L Dena-Beltrán
- Instituto de Neurobiología, Universidad Nacional Autónoma de México (UNAM), Campus UNAM-Juriquilla, 76230, Querétaro, Mexico
| | - Xarubet Ruiz-Herrera
- Instituto de Neurobiología, Universidad Nacional Autónoma de México (UNAM), Campus UNAM-Juriquilla, 76230, Querétaro, Mexico
| | - Ana Luisa Ocampo-Ruiz
- Instituto de Neurobiología, Universidad Nacional Autónoma de México (UNAM), Campus UNAM-Juriquilla, 76230, Querétaro, Mexico
| | - Gonzalo Martínez de la Escalera
- Instituto de Neurobiología, Universidad Nacional Autónoma de México (UNAM), Campus UNAM-Juriquilla, 76230, Querétaro, Mexico
| | - Carmen Clapp
- Instituto de Neurobiología, Universidad Nacional Autónoma de México (UNAM), Campus UNAM-Juriquilla, 76230, Querétaro, Mexico
| | - Yazmín Macotela
- Instituto de Neurobiología, Universidad Nacional Autónoma de México (UNAM), Campus UNAM-Juriquilla, 76230, Querétaro, Mexico.
| |
Collapse
|
3
|
Karbhari N, Thomas AA. Clinical management of brain tumors in pregnancy. Curr Opin Oncol 2022; 34:691-697. [PMID: 36170169 DOI: 10.1097/cco.0000000000000894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW We review the diagnostic tools, treatment options, and clinical management for brain tumors diagnosed in pregnancy with consideration for management approaches that are best suited to preserve maternal and fetal health. RECENT FINDINGS Women of child-bearing age are at risk of developing brain tumors and are at increased risk compared with male counterparts for tumors that are hormonally driven. Brain tumors are rare neoplasms, and diagnosis of brain tumors in pregnancy is uncommon, such that management guidelines and treatment recommendations are lacking for most tumor types. We discuss the standard treatment options for brain tumors and the relative risks and safety when these treatments are considered during pregnancy. We review the neoplasms most commonly affecting pregnant women and the existing literature and guidelines. SUMMARY Pregnancy is a unique phase of life in which hormonal, immunologic, and vascular changes may impact tumor growth and presentation. Treatment decisions should consider the symptoms and stability of the pregnant patients, the gestational age and health of the fetus, and the location and behavior of the neoplasm.
Collapse
Affiliation(s)
- Nishika Karbhari
- Department of Neurology, Dartmouth Hitchcock Medical Center, Hanover, NH
| | - Alissa A Thomas
- Department of Neurological Sciences, University of Vermont Larner College of Medicine, Burlington, VT, USA
| |
Collapse
|
4
|
Inder WJ, Jang C. Treatment of Prolactinoma. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1095. [PMID: 36013562 PMCID: PMC9413135 DOI: 10.3390/medicina58081095] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 05/14/2023]
Abstract
Prolactinomas are the commonest form of pituitary neuroendocrine tumor (PitNET), representing approximately half of such tumors. Dopamine agonists (DAs) have traditionally been the primary treatment for the majority of prolactinomas, with surgery considered the second line. The aim of this review is to examine the historical and modern management of prolactinomas, including medical therapy with DAs, transsphenoidal surgery, and multimodality therapy for the treatment of aggressive prolactinomas and metastatic PitNETs, with an emphasis on the efficacy, safety, and future directions of current therapeutic modalities. DAs have been the mainstay of prolactinoma management since the 1970s, initially with bromocriptine and more recently with cabergoline. Cabergoline normalizes prolactin in up to 85% of patients and causes tumor shrinkage in up to 80%. Primary surgical resection of microprolactinomas and enclosed macroprolactinomas performed by experienced pituitary neurosurgeons have similar remission rates to cabergoline. Aggressive prolactinomas and metastatic PitNETS should receive multimodality therapy including high dose cabergoline, surgery, radiation therapy (preferably using stereotactic radiosurgery where suitable), and temozolomide. DAs remain a reliable mode of therapy for most prolactinomas but results from transsphenoidal surgery in expert hands have improved considerably over the last one to two decades. Surgery should be strongly considered as primary therapy, particularly in the setting of microprolactinomas, non-invasive macroprolactinomas, or prior to attempting pregnancy, and has an important role in the management of DA resistant and aggressive prolactinomas.
Collapse
Affiliation(s)
- Warrick J. Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Woolloongabba 4102, Australia
- Academy for Medical Education, Faculty of Medicine, The University of Queensland, Herston 4029, Australia
| | - Christina Jang
- Department of Endocrinology and Diabetes, Royal Brisbane and Women’s Hospital, Herston 4029, Australia
- Faculty of Medicine, The University of Queensland, Herston 4029, Australia
| |
Collapse
|
5
|
Laway BA, Baba MS, Bansiwal SK, Choh NA. Prolactinoma Outcome After Pregnancy and Lactation: A Cohort Study. Indian J Endocrinol Metab 2021; 25:559-562. [PMID: 35355922 PMCID: PMC8959201 DOI: 10.4103/ijem.ijem_372_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/10/2021] [Accepted: 12/12/2021] [Indexed: 11/20/2022] Open
Abstract
CONTEXT Prolactinoma is the most frequent pituitary tumor among women of childbearing age. Fewer studies have addressed the outcome of prolactinomas after gestation. OBJECTIVE The aim was to study the spontaneous remission rate and change in tumor size after pregnancy and/or lactation in women with prolactinomas. PATIENTS AND METHODS Retrospective study conducted at a tertiary care center of north India. Records of 25 women with 31 pregnancies (20 microprolactinomas and 11 macroprolactinomas), who conceived on dopamine agonist (cabergoline) were studied. Cabergoline was stopped at conception in 24 pregnancies and continued in 7. Serum prolactin was noted 3 months after delivery and/or lactation. Magnetic resonance imaging available at last visit after delivery and/or lactation was also noted. Remission was defined as normal serum prolactin after pregnancy and/or lactation without use of cabergoline. RESULTS Among patients in whom cabergoline was stopped during pregnancy (n = 24), 41.6% (n = 10) had prolactin in normal range (achieved remission) after pregnancy and/or lactation. In 25% (n = 6) of women, adenoma size decreased by more than 50%, in 33%(n = 8), there was no change in adenoma size, and in 42% (n = 10), decrease in adenoma size was less than 50% after pregnancy and/or lactation. The median duration of cabergoline treatment before pregnancy among patients who achieved remission was 60 months against 24 months in those who did not achieve remission. The median pre-pregnancy adenoma size was 5.5 mm in women with remission against 8 mm in women who did not achieve remission. CONCLUSION Pregnancy-induced remission of hyperprolactinemia was seen in 41.6% prolactinomas. Longer duration of dopamine agonist treatment before pregnancy, small pre-pregnancy adenoma size, and lower baseline prolactin were associated with high likelihood of remission, though not statistically significant.
Collapse
Affiliation(s)
- Bashir A. Laway
- Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Mohammad S. Baba
- Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Sailesh K. Bansiwal
- Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Naseer A. Choh
- Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| |
Collapse
|
6
|
Sridharan K, Sahoo J, Palui R, Patil M, Kamalanathan S, Ramesh AS, Kubera NS. Diagnosis and treatment outcomes of Cushing's disease during pregnancy. Pituitary 2021; 24:670-680. [PMID: 33779937 DOI: 10.1007/s11102-021-01142-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/14/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE We report a case of a pregnant woman with Cushing's disease (CD) and performed a systematic review of literature on diagnosis, treatment, maternal and fetal outcomes of CD in pregnancy. METHODS A PubMed search was performed for manuscripts in English language from inception till June 2020. Cases of CD with hypercortisolism during pregnancy were included and categorized into three groups based on treatment received. Data on diagnostic modalities, CD remission, materno-fetal outcomes were analysed. RESULTS Fifty-five patients of CD with 62 pregnancies were analysed. 24-h urinary free cortisol(UFC) was elevated by a mean of 5.4 ± 4.2 fold upper limit of normal non-pregnant level. 12/19 (63.1%) CD patients had more than threefold elevation of UFC measured during pregnancy. Mean midnight serum cortisol was 753.7 ± 270.5 nmol/l. At a midnight serum cortisol cut off of 440 nmol/l, 15/16 patients were correctly identified as CD. 23.2% underwent trans-sphenoidal surgery (group 1), 16.1% received only medical treatment (group 2) while 60.7% received no treatment (group 3) during pregnancy. Remission rates for CD in groups 1 and 2 were 76.9% and 77.8%, respectively. Adverse maternal and fetal outcomes were seen in 53.9% and 59.3% of the patients, respectively and were not significantly different between groups, although, lesser live births and greater pregnancy losses were seen in group 3. CONCLUSION Midnight serum cortisol had better sensitivity than UFC for diagnosing hypercortisolism due to CD during pregnancy. In general, CD should be treated during pregnancy in order to optimize maternal and fetal outcomes as a trend towards increased live births is seen in treated subjects.
Collapse
Affiliation(s)
- Kalyani Sridharan
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India.
| | - Jayaprakash Sahoo
- Department of Endocrinology and Metabolism, Jawaharlal Institute of Post Graduate Medical Education and Research, Dhanvanthri Nagar, Puducherry, India
| | - Rajan Palui
- Consultant Endocrinologist, The Mission Hospital, Durgapur, West Bengal, India
| | - Milind Patil
- Consultant Endocrinologist, Inlaks Budhrani Hospital, Pune, India
| | - Sadishkumar Kamalanathan
- Department of Endocrinology and Metabolism, Jawaharlal Institute of Post Graduate Medical Education and Research, Dhanvanthri Nagar, Puducherry, India
| | - A S Ramesh
- Department of Neurosurgery, Jawaharlal Institute of Post Graduate Medical Education and Research, Dhanvanthri Nagar, Puducherry, India
| | - N S Kubera
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Post Graduate Medical Education and Research, Dhanvanthri Nagar, Puducherry, India
| |
Collapse
|
7
|
Rosmino J, Tkatch J, Di Paolo MV, Berner S, Lescano S, Guitelman M. Non-functioning pituitary adenomas and pregnancy: one-center experience and review of the literature. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 64:614-622. [PMID: 34033303 PMCID: PMC10118964 DOI: 10.20945/2359-3997000000232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The usual clinical presentation of non-functioning pituitary adenoma (NFPA) consists of symptoms of mass effect and hypopituitarism. NFPA is a rare condition in young women and an uncommon complication during pregnancy. We present the outcome of three patients with NFPA during pregnancy. Case 1: a 38-year-old woman was referred at 32nd week of spontaneous pregnancy because of diagnosis of a pituitary macroadenoma discovered in the context of progressive visual loss. Hormonal deficiency and hypersecretion were ruled out. Prolactin levels were high as expected. She developed diplopia and severe headache despite the use of dopamine agonists and corticosteroids, so pregnancy was interrupted at 34th week. After an uncomplicated delivery of a healthy newborn, transsphenoidal surgery was performed. The pathology was consistent with a gonadotroph adenoma. She recovered visual field, and remained with normal pituitary function. Postsurgical tumor remnant increased in size during the follow-up. Case 2: a 34-year-old woman was referred due to secondary amenorrhea and galactorrhea. A macroadenoma with suprasellar extension was discovered. Transsphenoidal surgery confirmed a gonadotroph adenoma. Two years after surgery she had a normal pregnancy. Six years after surgery a small tumor recurrence occurred. Case 3: a 23-year-old woman was referred due to a microincidental pituitary adenoma. Laboratory testing was normal. No findings on physical examination. A wait and see approach was decided. Two years after diagnosis, the patient got pregnant without complications. Image remained stable. This article may contribute new cases and provides an extensive review of NFPA during pregnancy.
Collapse
Affiliation(s)
- Josefina Rosmino
- División Endocrinología, Hospital General de Agudos Dr. Carlos G. Durand, Buenos Aires, Argentina,
| | - Julieta Tkatch
- División Endocrinología, Hospital General de Agudos Dr. Carlos G. Durand, Buenos Aires, Argentina
| | - Maria Victoria Di Paolo
- División Endocrinología, Hospital General de Agudos Dr. Carlos G. Durand, Buenos Aires, Argentina
| | - Silvia Berner
- Unidad de Neurocirugía, Hospital Santa Lucía, Buenos Aires, Argentina
| | - Sebastián Lescano
- Departamento de Neuroradiología, División de Resonancia Magnética, Hospital Juan A. Fernández - ARGUS, Buenos Aires, Argentina
| | - Mirtha Guitelman
- División Endocrinología, Hospital General de Agudos Dr. Carlos G. Durand, Buenos Aires, Argentina
| |
Collapse
|
8
|
Bichard LK, Torpy DJ. Diabetes insipidus complicating apoplexy during pregnancy: the potential use of copeptin. Intern Med J 2021; 50:877-879. [PMID: 32656971 DOI: 10.1111/imj.14918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 01/09/2020] [Accepted: 01/14/2020] [Indexed: 11/30/2022]
Abstract
Pituitary apoplexy during pregnancy is rare but important to recognise, particularly in the hyperoestrogenaemic state when known lactotroph hyperplasia occurs. Untreated, the complication rates from pituitary adenomas depend upon the size of the adenoma before pregnancy. A history of thirst plus polydipsia during pregnancy raises suspicion for diabetes insipidus and a 24-h urine collection quantifying polyuria with an inappropriately low urine osmolality confirms the diagnosis. Further evaluation for assessing diabetes insipidus in pregnancy may be facilitated by the use of a copeptin.
Collapse
Affiliation(s)
- Lisa K Bichard
- Adult Endocrinology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - David J Torpy
- Adult Endocrinology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| |
Collapse
|
9
|
Kazma JM, van den Anker J, Allegaert K, Dallmann A, Ahmadzia HK. Anatomical and physiological alterations of pregnancy. J Pharmacokinet Pharmacodyn 2020; 47:271-285. [PMID: 32026239 PMCID: PMC7416543 DOI: 10.1007/s10928-020-09677-1] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/28/2020] [Indexed: 02/07/2023]
Abstract
The extensive metabolic demands of pregnancy require specific physiological and anatomical changes. These changes affect almost all organ systems, including the cardiovascular, respiratory, renal, gastrointestinal, and hematologic system. The placenta adds another layer of complexity. These changes make it challenging for clinicians to understand presenting signs and symptoms, or to interpret laboratory and radiological tests. Furthermore, these physiological alterations can affect the pharmacokinetics and pharmacodynamics of drugs. Drug safety in lactation is only supported by limited evidence. In addition, the teratogenic effects of medications are often extrapolated from animals, which further adds uncertainties. Unfortunately, pregnant women are only rarely included in clinical drug trials, while doses, regimens, and side effects are often extrapolated from studies conducted in non-pregnant populations. In this comprehensive review, we present the changes occurring in each system with its effects on the pharmacokinetic variables. Understanding these physiological changes throughout normal pregnancy helps clinicians to optimize the health of pregnant women and their fetuses. Furthermore, the information on pregnancy-related physiology is also critical to guide study design in this vulnerable 'orphan' population, and provides a framework to explore pregnancy-related pathophysiology such as pre-eclampsia.
Collapse
Affiliation(s)
- Jamil M Kazma
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, USA
- Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital, Basel, Switzerland
| | - Karel Allegaert
- Department of Development and Regeneration, and Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
- Department of Clinical Pharmacy, Erasmus MC, Rotterdam, The Netherlands
| | - André Dallmann
- Clinical Pharmacometrics, Research & Development, Pharmaceuticals, Bayer AG, Leverkusen, Germany
| | - Homa K Ahmadzia
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| |
Collapse
|
10
|
Phenotype and resistance patterns of 10 resistant prolactinomas. ENDOCRINOL DIAB NUTR 2020; 67:194-204. [DOI: 10.1016/j.endinu.2019.04.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 04/24/2019] [Accepted: 04/26/2019] [Indexed: 11/17/2022]
|
11
|
Abstract
Pituitary adenomas are common. The impact of pituitary tumors on fertility are mainly caused by oversecretion and/or undersecretion of pituitary hormones or compression of pituitary stalk and normal pituitary tissue by the tumor. Diagnosing and managing pituitary tumors during pregnancy involve many challenges, including the effect of hormone excess or deficiency on pregnancy outcome, changes in the pituitary or pituitary-related hormones, changes in tumor size, and the impact of various treatments of pituitary tumors on maternal and fetal outcomes. This article discusses the diagnosis and treatment of patients with prolactinomas, acromegaly, Cushing disease, and other pituitary tumors during pregnancy.
Collapse
Affiliation(s)
- Wenyu Huang
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 North Michigan Avenue, Suite 530, Chicago, IL 60611, USA
| | - Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 North Michigan Avenue, Suite 530, Chicago, IL 60611, USA.
| |
Collapse
|
12
|
Hu Y, Ding Y, Yang M, Xiang Z. Serum prolactin levels across pregnancy and the establishment of reference intervals. Clin Chem Lab Med 2019; 56:838-842. [PMID: 29194037 DOI: 10.1515/cclm-2017-0644] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 11/01/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Reference intervals (RIs) play key roles in clinical diagnosis, treatment and prognosis. However, RIs for clinical testing tend to be confined to the general population, and RIs for pregnant women are not very comprehensive. In this study, we establish RIs for prolactin (PRL) in healthy pregnant and postpartum women in the Chinese population. METHODS Healthy pregnant women (n=378) were divided into groups according to whether they were in the first, second or third trimester of pregnancy. Healthy postpartum women (n=493) were separated into four groups according to mode of delivery as follows: postvaginal (24 and 48 h) or postcesarean (24 and 48 h). Healthy, non-pregnant women (n=123) were enrolled as a control group. Serum PRL levels were measured by electrochemiluminescence immunoassay, and RIs were established for each group. RESULTS The RIs for PRL were as follows: healthy non-pregnant women, 178.89-757.52 μIU/mL; first trimester, 621.20-3584.00 μIU/mL; second trimester, 1432.00-5349.68 μIU/mL; third trimester, 4087.33-9733.65 μIU/mL; 24 and 48 h postvaginal delivery (combined), 7865.36-10998.86 μIU/mL; and 24 and 48 h postcesarean delivery, 4556.41-7675.99 and 6578.45-9980.45 μIU/mL, respectively. CONCLUSIONS PRL RIs for pregnant women were established according to trimester, days postpartum and mode of delivery, thus providing a clinical reference for medical staff.
Collapse
Affiliation(s)
- Yun Hu
- Department of Obstetrics and Gynecology, Second Xiangya Hospital, Central South University, Hunan, P.R. China
| | - Yiling Ding
- Department of Obstetrics and Gynecology, Second Xiangya Hospital, Central South University, Hunan, P.R. China
| | - Mengyuan Yang
- Department of Obstetrics and Gynecology, Second Xiangya Hospital, Central South University, Hunan, P.R. China
| | - Zhongyuan Xiang
- Department of Laboratory Medicine, Second Xiangya Hospital, Central South University, Hunan, P.R. China
| |
Collapse
|
13
|
Hannon AM, O'Shea T, Thompson CA, Hannon MJ, Dineen R, Khattak A, Gibney J, O'Halloran DJ, Hunter S, Thompson CJ, Sherlock M. Pregnancy in acromegaly is safe and is associated with improvements in IGF-1 concentrations. Eur J Endocrinol 2019; 180:K21-K29. [PMID: 30620709 DOI: 10.1530/eje-18-0688] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 01/08/2019] [Indexed: 01/15/2023]
Abstract
Pregnancy is rarely reported in acromegaly. Many patients are diagnosed in later life and younger patients may have subfertility due to hypopituitarism. We present a case series of 17 pregnancies in 12 women with acromegaly. Twelve women with acromegaly who completed pregnancy were identified from centres involved in the Irish Pituitary Study. Eleven women had pituitary macroadenomas and one woman had a microadenoma. Only 5/17 pregnancies had optimal biochemical control of acromegaly preconception, as defined by IGF-1 concentration in the age-related reference level and plasma GH concentration of <2 μg/L. In 6/17 pregnancies, dopamine agonist treatment was continued during pregnancy; all other acromegaly treatments were discontinued during pregnancy. Effect of pregnancy on acromegaly: No patient developed new visual field abnormalities, or symptoms suggestive of tumour expansion during pregnancy. In 9/12 patients, plasma IGF-1 concentrations that were elevated preconception normalised during pregnancy. There was a reduction in plasma IGF-1 concentrations, though not into the normal range, in a further two pregnancies. Effect of acromegaly on pregnancy: 15 healthy babies were born at term; one patient underwent emergency C-section at 32 weeks for pre-eclampsia, and one twin pregnancy had an elective C-section at 35 weeks' gestation. Blood pressure remained within normal limits in the remainder of the pregnancies. Gestational diabetes did not develop in any pregnancy. Our data suggests that pregnancy in women with acromegaly is generally safe, from a maternal and foetal perspective. Furthermore, biochemical control tends to improve despite the withdrawal of somatostatin analogue therapy during pregnancy.
Collapse
Affiliation(s)
- Anne Marie Hannon
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland
| | - Triona O'Shea
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | | | - Mark J Hannon
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
| | - Rosemary Dineen
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland
- Department of Endocrinology, Adelaide and Meath Hospital, Tallaght, Dublin, Ireland
| | - Aftab Khattak
- Department of Endocrinology and Diabetes, Cork University Hospital, Cork, Ireland
| | - James Gibney
- Department of Endocrinology, Adelaide and Meath Hospital, Tallaght, Dublin, Ireland
| | | | - Steven Hunter
- Department of Endocrinology and Diabetes, Royal Victoria Hospital, Belfast, Ireland
| | - Christopher J Thompson
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland
| | - Mark Sherlock
- Department of Endocrinology, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland
| |
Collapse
|
14
|
Duan Y, Liu X, Hou W, Deng M, Gao J, Zhou C, Xu Y. No impact of treated hyperprolactinemia on cumulative live birth rate and perinatal outcomes in in vitro fertilization-embryo transfer. J Obstet Gynaecol Res 2019; 45:1236-1244. [PMID: 30932283 DOI: 10.1111/jog.13957] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 03/01/2019] [Indexed: 12/14/2022]
Abstract
AIM To investigate whether treated hyperprolactinemia has an impact on pregnancy outcomes in in vitro fertilization/intracytoplasmic sperm injection-embryo transfer (IVF/ICSI-ET). METHODS A retrospective cohort study was conducted on 535 women who underwent IVF/ICSI-ET between January 2012 and December 2016, of which 123 had treated hyperprolactinemia (case group), 369 were matched controls. Besides, 43 remained hyperprolactinemic after treatment consisted of abnormal group. Cumulative live birth rate (CLBR) after one oocyte retrieval cycle was taken as the primary outcome. A time-to-event analysis using Fine and Gray's test was used to compare CLBR between case and control groups. RESULTS The median prolactin level was 80.00 ng/mL before dopamine agonist treatment in case group, and it reduced to 14.80 ng/mL after the treatment, similar to the level of control group (15.17 ng/mL, P = 0.316). No significant differences in baseline characteristics were found between case and control groups. The CLBR after one oocyte retrieval cycle were 69.1% (85/123) and 66.4% (245/369) in the case group and control group, respectively (P = 0.580). No significant differences were found between case and control groups in perinatal outcomes. Pregnancy and perinatal outcomes of abnormal group were similar to those of case and control groups. CONCLUSION Impact of treated hyperprolactinemia on CLBR and perinatal outcomes in IVF-ET was not evident.
Collapse
Affiliation(s)
- Yuwei Duan
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xinyan Liu
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wenhui Hou
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Mingfen Deng
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jun Gao
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Canquan Zhou
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanwen Xu
- Reproductive Medicine Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Guangdong Provincial Key Laboratory of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| |
Collapse
|
15
|
Calina D, Docea AO, Golokhvast KS, Sifakis S, Tsatsakis A, Makrigiannakis A. Management of Endocrinopathies in Pregnancy: A Review of Current Evidence. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16050781. [PMID: 30836653 PMCID: PMC6427139 DOI: 10.3390/ijerph16050781] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 02/27/2019] [Accepted: 02/27/2019] [Indexed: 12/29/2022]
Abstract
Pregnancy in women with associated endocrine conditions is a therapeutic challenge for clinicians. These disorders may be common, such us thyroid disorders and diabetes, or rare, including adrenal and parathyroid disease and pituitary dysfunction. With the development of assisted reproductive techniques, the number of pregnancies with these conditions has increased. It is necessary to recognize symptoms and correct diagnosis for a proper pharmacotherapeutic management in order to avoid adverse side effects both in mother and fetus. This review summarizes the pharmacotherapy of these clinical situations in order to reduce maternal and fetal morbidity.
Collapse
Affiliation(s)
- Daniela Calina
- Department of Clinical Pharmacy, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania.
| | - Anca Oana Docea
- Department of Toxicology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania.
| | | | - Stavros Sifakis
- Department of Obstetrics and Gynecology, Mitera Maternity Hospital, 71110 Heraklion, Crete, Greece.
| | - Aristides Tsatsakis
- Department of Forensic Sciences and Toxicology, Faculty of Medicine, University of Crete, 71110 Heraklion, Crete, Greece.
| | - Antonis Makrigiannakis
- Department of Obstetrics and Gynecology, Medical School, University of Crete, 71110 Heraklion, Crete, Greece.
| |
Collapse
|
16
|
|
17
|
Vroonen L, Daly AF, Beckers A. Epidemiology and Management Challenges in Prolactinomas. Neuroendocrinology 2019; 109:20-27. [PMID: 30731464 DOI: 10.1159/000497746] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/06/2019] [Indexed: 11/19/2022]
Abstract
Clinically relevant pituitary adenomas are present in about 1 per 1,000 of the general population and prolactinomas are by far the most common clinical subtype of pituitary adenomas. Usually prolactinomas affect premenopausal women and present with typical symptoms of menstrual disturbance and/or galactorrhea. They are generally managed with dopamine agonists to restore fertility and to control symptoms and tumor size. In a subset of prolactinomas, however, management remains challenging. Studies in recent years have identified the factors related to dopamine agonist resistance, such as male sex, genetic features, and aggressive tumor behavior. Certain other patient groups represent particular challenges for management, such as pediatric patients and pregnant women. Treatment with dopamine agonists is usually safe and effective, and adverse effects such as clinically relevant cardiac valvular complications and impulse control disorders may occur in isolated instances. A number of important disease characteristics of prolactinomas remain to be explained, such as the difference in sex prevalence before and after menopause, the higher prevalence of macroadenomas in older males, and the biochemical mechanisms of resistance to dopaminergic agonists.
Collapse
Affiliation(s)
- Laurent Vroonen
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Liège Université, Liège, Belgium
| | - Adrian F Daly
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Liège Université, Liège, Belgium
| | - Albert Beckers
- Department of Endocrinology, Centre Hospitalier Universitaire de Liège, Liège Université, Liège, Belgium,
| |
Collapse
|
18
|
Huang X, Zhang R, Wu Y, Sheng L, Xu J, Zha B, Liu J. Association of High Prolactin Level on Postoperative Day 1 and Tumor Invasion with Female Gonadal Dysfunction After Trans-Sphenoidal Surgery of Pituitary Adenomas. Med Sci Monit 2018; 24:9265-9271. [PMID: 30569911 PMCID: PMC6320648 DOI: 10.12659/msm.910348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background The aim of this study was to evaluate the risk factors of gonadal dysfunction among Chinese women of reproductive age with pituitary adenomas (PAs) after trans-sphenoidal surgery. Material/Methods We retrospectively evaluated 317 women (16–44 years old) who underwent gonadal function and hormone testing before and after trans-sphenoidal surgery for PAs during 2003–2012. Gonadal function was assessed on the basis of menstrual status. Results Three women were excluded because of pre-existing gynecological diseases. Before trans-sphenoidal surgery, 34 (10.7%) women were eugonadal and 283 (89.3%) women had gonadal dysfunction. After trans-sphenoidal surgery, 130/189 (68.7%) women with follow-up menstruation data were eugonadal, and 59/189 (31.2%) women exhibited gonadal dysfunction. In addition, 67.4% women of reproductive age with PAs and gonadal dysfunction were restored by trans-sphenoidal surgery (P<0.01). Postoperative gonadal dysfunction was independently associated with high prolactin level at day 1 after trans-sphenoidal surgery (odds ratio (OR)=1.024; 95% confidence interval (CI)=1.005–1.043; P=0.012) and tumor invasion (OR=5.752; 95%CI=1.618–20.447; P<0.01). Based on the receiver operating characteristic (ROC) curve, prediction of gonadal dysfunction in women of reproductive age after trans-sphenoidal surgery for PAs using prolactin >46.82 μg/L on postoperative day 1 had sensitivity of 88%, specificity of 95%, positive predictive value of 98%, and negative predictive value of 76%, and an area under the ROC curve of 0.701. Conclusions Gonadal dysfunction is very common in Chinese women of reproductive age with PAs and can be effectively restored by trans-sphenoidal surgery. Prolactin >46.82 μg/L at 1 day after trans-sphenoidal surgery and tumor invasion can predict postoperative gonadal dysfunction in these patients.
Collapse
Affiliation(s)
- Xinmei Huang
- Department of Endocrinology, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China (mainland)
| | - Rui Zhang
- Department of Endocrinology, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China (mainland)
| | - Yueyue Wu
- Department of Endocrinology, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China (mainland)
| | - Li Sheng
- Department of Endocrinology, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China (mainland)
| | - Jiong Xu
- Department of Endocrinology, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China (mainland)
| | - Bingbing Zha
- Department of Endocrinology, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China (mainland)
| | - Jun Liu
- Department of Endocrinology, The Fifth People's Hospital of Shanghai, Fudan University, Shanghai, China (mainland)
| |
Collapse
|
19
|
Almistehi WM, Almalki MH. Beat the giant: case of a giant prolactinoma during pregnancy on cabergoline. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM180099. [PMID: 30159146 PMCID: PMC6109208 DOI: 10.1530/edm-18-0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 07/31/2018] [Indexed: 11/28/2022] Open
Abstract
Giant prolactinomas are a rare entity; during pregnancy, the risk for complications associated with these tumors is higher. Here, we report a case of a young woman who had an invasive, giant prolactinoma post resection with residual disease who became pregnant. This patient was treated with cabergoline to prevent tumor expansion in pregnancy, resulting in the uneventful delivery of a healthy baby boy.
Collapse
Affiliation(s)
- Wael M Almistehi
- 1Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mussa H Almalki
- 1Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
- 2King Fahad Medical City, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| |
Collapse
|
20
|
|
21
|
Roof AK, Jirawatnotai S, Trudeau T, Kuzyk C, Wierman ME, Kiyokawa H, Gutierrez-Hartmann A. The Balance of PI3K and ERK Signaling Is Dysregulated in Prolactinoma and Modulated by Dopamine. Endocrinology 2018; 159:2421-2434. [PMID: 29726995 PMCID: PMC6172703 DOI: 10.1210/en.2017-03135] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 04/25/2018] [Indexed: 12/13/2022]
Abstract
Prolactin-secreting adenomas, or prolactinomas, cause hypogonadism, osteoporosis, and infertility. Although dopamine agonists (DAs) are used clinically to treat prolactinoma and reduce prolactin secretion via cAMP inhibition, the precise mechanism by which DAs inhibit lactotrope proliferation has not been defined. In this study, we report that phosphatidylinositol 3-kinase (PI3K) signals through AKT and mTOR to drive proliferation of pituitary somatolactotrope GH4T2 cells. We demonstrate that the DA cabergoline reduces activity of the mTOR effector s6K and diminishes GH4T2 cell proliferation primarily via activation of the long isoform of the dopamine D2 receptor (D2R). Dysfunctional D2R-mediated signaling and/or downregulated D2R expression is thought be the primary mechanism of DA resistance, which is observed in 10% to 20% of prolactinoma tumors. Dopamine-mediated D2R activation results in ERK stimulation and PI3K inhibition, suggesting that these two pathways act in an inverse manner to maintain lactotrope homeostasis. In this study, we found that ERK1/2-mediated prolactin transcription is inhibited by PI3K/CDK4-driven cell cycle progression, emphasizing that the ERK and PI3K signaling pathways oppose one another in lactotrope cells under homeostatic conditions. Lastly, we show that both ERK1/2 and AKT are activated in prolactinoma, demonstrating that the balance of ERK and AKT is dysregulated in human prolactinoma. Our findings reveal a potential use for dual pharmacological inhibitors of ERK and AKT as an alternative treatment strategy for DA-resistant prolactinomas.
Collapse
Affiliation(s)
- Allyson K Roof
- Program in Integrated Physiology and Reproductive Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Siwanon Jirawatnotai
- Laboratory for Systems Pharmacology, Department of Pharmacology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Biochemistry and Molecular Genetics, University of Illinois College of Medicine, Chicago, Illinois
| | - Tammy Trudeau
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Biochemistry and Molecular Genetics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Crystal Kuzyk
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Biochemistry and Molecular Genetics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Margaret E Wierman
- Program in Integrated Physiology and Reproductive Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Research Service Veterans Affairs Medical Center, Denver, Colorado
| | - Hiroaki Kiyokawa
- Department of Biochemistry and Molecular Genetics, University of Illinois College of Medicine, Chicago, Illinois
- Department of Molecular Pharmacology and Biological Chemistry, University of Illinois College of Medicine, Chicago, Illinois
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Arthur Gutierrez-Hartmann
- Program in Integrated Physiology and Reproductive Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Department of Biochemistry and Molecular Genetics, University of Colorado Anschutz Medical Campus, Aurora, Colorado
- Correspondence: Arthur Gutierrez-Hartmann, MD, Departments of Medicine and Biochemistry and Molecular Genetics, University of Colorado, Anschutz Medical Campus, 12801 East 17th Avenue, Mail Stop 8106, Aurora, Colorado 80045. E-mail:
| |
Collapse
|
22
|
Cocks Eschler D, Javanmard P, Cox K, Geer EB. Prolactinoma through the female life cycle. Endocrine 2018; 59:16-29. [PMID: 29177641 DOI: 10.1007/s12020-017-1438-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 09/22/2017] [Indexed: 12/27/2022]
Abstract
Prolactinomas are the most common secretory pituitary adenoma. They typically occur in women in the 3rd-6th decade of life and rarely in the pediatric population or after menopause. Most women present with irregular menses and/or infertility. Dopamine (DA) agonists, used in their treatment, are safe during pregnancy, but in most cases are discontinued at conception with close monitoring for signs or symptoms of tumor growth. Breastfeeding is safe postpartum, provided there was no significant growth during pregnancy. Some women will experience normalization of prolactin levels postpartum. Menopause may also decrease prolactin levels and even those with macroprolactinomas may consider discontinuing their DA agonist with close follow-up. Prolactinomas may be associated with decreased quality of life scores in women, and play a role in bone health and cardiovascular risk factors. This review discusses the current literature and clinical understanding of prolactinomas throughout the entirety of the female life cycle.
Collapse
Affiliation(s)
- Deirdre Cocks Eschler
- Department of Medicine, Division of Endocrinology and Metabolism, SUNY Stony Brook School of Medicine, 26 Research Way, East Setauket, New York, NY, 11733, USA
| | - Pedram Javanmard
- Department of Medicine, Division of Endocrine, Diabetes, and Bone Disease, Icahn School of Medicine at The Mount Sinai Hospital, 1 Gustave L Levy Place box 1055, New York, NY, 10029, USA
| | - Katherine Cox
- Department of Medicine, Division of Endocrine, Diabetes, and Bone Disease, Icahn School of Medicine at The Mount Sinai Hospital, 1 Gustave L Levy Place box 1055, New York, NY, 10029, USA
| | - Eliza B Geer
- Multidisciplinary Pituitary and Skull Base Tumor Center, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 419, New York, NY, 10065, USA.
| |
Collapse
|
23
|
Rastogi A, Bhadada SK, Bhansali A. Pregnancy and tumor outcomes in infertile women with macroprolactinoma on cabergoline therapy. Gynecol Endocrinol 2017; 33:270-273. [PMID: 27908214 DOI: 10.1080/09513590.2016.1254177] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Hyperprolactinemia and prolactinomas cause infertility in significant number of women. But, pregnancy may lead to post-partum remission of hyperprolactinemia. The data on pregnancy and tumor outcome in women with macroprolactinoma conceiving on Cabergoline (CAB) therapy is increasing but still less than with Bromocriptine. We studied the incidence of fetal malformations, hyperprolactinemia and tumor course after gestation in infertile women harboring macroprolactinoma, who conceived on CAB therapy during the year 2005-2015. The cohort was divided into two groups based on the continuation of CAB therapy during gestation (Group A) or not (Group B). Forty-eight pregnancies in 33 women were recorded. CAB was continued throughout gestation in 25 pregnancies (Group A). The incidence of missed abortion (8.3%), still birth (4.2%) and low birth weight (7.7%) were not different in two groups. Neural tube defects were observed in 3 pregnancies (all in Group A). Post-partum, recurrence of hyperprolactinemia was observed in 64.6% and 60.9% (p = 0.8) of women in group A and B, respectively. Cabergoline was restarted after 60% and 60.9% (p = 0.9) pregnancies in the two groups in view of symptomatic hyperprolactinemia and/or persistence of macroadenoma. Post-partum, recurrence of hyperprolactinemia is common in spite of significant tumor reduction in infertile women with macroprolactinoma. Continuation of CAB during gestation does not influence the post-pregnancy recurrence of hyperprolactinemia or tumor remission.
Collapse
Affiliation(s)
- Ashu Rastogi
- a Department of Endocrinology , Post Graduate Institute of Medical education and Research (PGIMER) , Chandigarh, 160012 , India
| | - Sanjay K Bhadada
- a Department of Endocrinology , Post Graduate Institute of Medical education and Research (PGIMER) , Chandigarh, 160012 , India
| | - Anil Bhansali
- a Department of Endocrinology , Post Graduate Institute of Medical education and Research (PGIMER) , Chandigarh, 160012 , India
| |
Collapse
|
24
|
The risks of overlooking the diagnosis of secreting pituitary adenomas. Orphanet J Rare Dis 2016; 11:135. [PMID: 27716353 PMCID: PMC5052978 DOI: 10.1186/s13023-016-0516-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 09/16/2016] [Indexed: 01/06/2023] Open
Abstract
Secreting pituitary adenomas that cause acromegaly and Cushing’s disease, as well as prolactinomas and thyrotroph adenomas, are uncommon, usually benign, slow-growing tumours. The rarity of these conditions means that their diagnosis is not familiar to most non-specialist physicians. Consequently, pituitary adenomas may be overlooked and remain untreated, and affected individuals may develop serious comorbidities that reduce their quality of life and life expectancy. Because many signs and symptoms of pituitary adenomas overlap with those of other, more common disorders, general practitioners and non-endocrinology specialists need to be aware of the “red flags” suggestive of these conditions. A long duration of active disease in patients with secreting pituitary adenomas is associated with an increased risk of comorbidities and reduced quality of life. Appropriate treatment can lead to disease remission, and, although some symptoms may persist in some patients, treatment usually reduces the incidence and severity of comorbidities and improves quality of life. Therefore, correct, early diagnosis and characterization of a pituitary adenoma is crucial for patients, to trigger timely, appropriate treatment and to optimize outcome. This article provides an overview of the epidemiology of hormonal syndromes associated with pituitary adenomas, discusses the difficulties of and considerations for their diagnosis, and reviews the comorbidities that may develop, but can be prevented, by accurate diagnosis and appropriate treatment. We hope this review will help general practitioners and non-endocrinology specialists to suspect secreting pituitary adenomas and refer patients to an endocrinologist for confirmation of the diagnosis and treatment.
Collapse
|
25
|
Update on prolactinomas. Part 1: Clinical manifestations and diagnostic challenges. J Clin Neurosci 2016; 22:1562-7. [PMID: 26256063 DOI: 10.1016/j.jocn.2015.03.058] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/18/2015] [Indexed: 11/20/2022]
Abstract
The authors provide an update on the clinical manifestations and diagnostic challenges of prolactinomas. Prolactinomas are the most common pituitary adenoma seen in clinical practice. Secondary causes of hyperprolactinemia should be ruled out by assessment of the clinical history, including current medications, physical examination, pregnancy test, routine biochemical analysis with a thyroid function test, and neuroimaging, before a confirmatory diagnosis of prolactinoma is made. Prolactinomas are associated with endocrine dysfunction, affecting gonadal function and causing neurological deficits due to mass effect. The progress in elucidating the pathogenesis of prolactinomas and advances in diagnostic methods, including more sensitive diagnostic hormone assays and neuroimaging, have enriched the current diagnostic approach and management. Making the correct diagnosis is crucial to implementing the appropriate therapy. Dopamine agonist therapy remains the first line of treatment for prolactinomas, as it is effective in normalizing serum prolactin levels and reducing tumor size. Surgery is typically indicated for patients who are resistant to medical therapy or intolerant of its adverse side effects, or for those experiencing progressive neurological deficits. Nevertheless, curative surgical resection as a primary mode of treatment for smaller prolactinomas has recently gained attention as an alternative to lifelong dopamine agonist treatment.
Collapse
|
26
|
Maiter D. Prolactinoma and pregnancy: From the wish of conception to lactation. ANNALES D'ENDOCRINOLOGIE 2016; 77:128-34. [PMID: 27130071 DOI: 10.1016/j.ando.2016.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 04/04/2016] [Indexed: 10/21/2022]
Abstract
Prolactinoma is a common cause of infertility in young women and treatment with dopamine agonists (DA) allows restoration of fertility in over 90% of the cases. Both bromocriptine and cabergoline have shown a good safety profile when administered during early pregnancy. In particular, data on exposure of the fetus or embryo to cabergoline during the first weeks of pregnancy have now been reported in more than 900 cases, and do indicate that cabergoline is safe in this context. There is no increase in the frequency of spontaneous miscarriage, premature delivery, multiple births or neonatal malformations, and follow-up studies of the children for up to 12years after fetal exposure to cabergoline did not show any physical or developmental abnormalities. These women should therefore continue DA treatment until pregnancy has been initiated. Treatment discontinuation is recommended at that time in women with microprolactinoma or non-compressive macroprolactinoma. For microprolactinomas, the risk of symptomatic tumour enlargement during pregnancy is very low (2-3%). It is higher for macroprolactinomas (20-30%) and careful follow-up is advised, including MRI without contrast injection if symptoms or visual disturbances develop. If a symptomatic tumour enlargement does occur, reinitiation of the dopamine agonist (BRC or CAB) is indicated rather than surgery. Breast-feeding has no harmful effect on tumour growth and DA treatment, if still needed, may be postponed as long as breast-feeding is desired. Finally, about 40% of women with a microprolactinoma or an intermediate size macroprolactinoma may be in prolonged remission after one or more pregnancies.
Collapse
Affiliation(s)
- Dominique Maiter
- Service d'endocrinologie et nutrition, cliniques universitaires Saint-Luc, avenue Hippocrate, UCL 54.74, 1200 Bruxelles, Belgium.
| |
Collapse
|
27
|
De Ycaza AE, Chang AY, Jensen JR, Khan Z, Erickson D. Approach to the management of rare clinical presentations of macroprolactinomas in reproductive-aged women. Case Rep Womens Health 2015; 8:9-12. [PMID: 27668187 PMCID: PMC5033506 DOI: 10.1016/j.crwh.2015.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To describe 2 cases of macroprolactinomas with atypical presentation in women desiring pregnancy that illustrate important considerations in the management approach for macroprolactinomas in reproductive-aged women. Patient(s) Case 1 was a 26-year-old woman referred to our institution for possible tumor resection after pituitary apoplexy during her first pregnancy. Instead, she underwent treatment with cabergoline for a year with goals of normalization of prolactin and decrease in tumor size to < 1 cm before trying to conceive. Case 2 was an 18-year-old woman with a macroprolactinoma intolerant to dopamine agonists. She underwent stereotactic radiosurgery, with marked reduction in tumor size and normalization of prolactin levels. She conceived and delivered a healthy infant 3 years after radiosurgery. Conclusion Management of macroprolactinomas in women desiring pregnancy requires careful consideration of alternatives to surgery which could impair pituitary function and fertility and awareness of treatment goals that can minimize the risks for pituitary apoplexy and vision loss during pregnancy. It is important to increase awareness of these options prior to initiation of treatment and conception. Pituitary apoplexy is a rare complication of prolactinomas in pregnancy. A successful pregnancy can be achieved after pituitary apoplexy of a prolactinoma Radiosurgery is a treatment option for prolactinomas in selected cases
Collapse
Affiliation(s)
- Ana Espinosa De Ycaza
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, 200 First Street SW, Mayo Clinic, Rochester, MN, 55905, United States
| | - Alice Y Chang
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, 200 First Street SW, Mayo Clinic, Rochester, MN, 55905 United States
| | - Jani R Jensen
- Division of Reproductive Endocrinology and Infertility, 200 First Street SW, Mayo Clinic, Rochester, MN, 55905, United States
| | - Zaraq Khan
- Division of Reproductive Endocrinology and Infertility, 200 First Street SW, Mayo Clinic, Rochester, MN, 55905, United States
| | - Dana Erickson
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, 200 First Street SW, Mayo Clinic, Rochester, MN, 55905, United States
| |
Collapse
|
28
|
Wong A, Eloy JA, Couldwell WT, Liu JK. Update on prolactinomas. Part 2: Treatment and management strategies. J Clin Neurosci 2015; 22:1568-74. [PMID: 26243714 DOI: 10.1016/j.jocn.2015.03.059] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 03/18/2015] [Indexed: 11/25/2022]
Abstract
The authors present an update on the various treatment modalities and discuss management strategies for prolactinomas. Prolactinomas are the most common type of functional pituitary tumor. Effective hyperprolactinemia treatment is of great importance, due to its potential deleterious effects including infertility, gonadal dysfunction and osteoporosis. Dopamine agonist therapy is the first line of treatment for prolactinomas because of its effectiveness in normalizing serum prolactin levels and shrinking tumor size. Though withdrawal of dopamine agonist treatment is safe and may be implemented following certain recommendations, recurrence of disease after cessation of the drug occurs in a substantial proportion of patients. Concerns regarding the safety of dopamine agonists have been raised, but its safety profile remains high, allowing its use during pregnancy. Surgery is typically indicated for patients who are resistant to medical therapy or intolerant of its adverse side effects, or are experiencing progressive tumor growth. Surgical resection can also be considered as a primary treatment for those with smaller focal tumors where a biochemical cure can be expected as an alternative to lifelong dopamine agonist treatment. Stereotactic radiosurgery also serves as an option for those refractory to medical and surgical therapy.
Collapse
Affiliation(s)
- Anni Wong
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers University, New Jersey Medical School, Suite 8100, 90 Bergen Street, Newark, NJ 07103, USA; Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Jean Anderson Eloy
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers University, New Jersey Medical School, Suite 8100, 90 Bergen Street, Newark, NJ 07103, USA; Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA; Department of Otolaryngology, Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - James K Liu
- Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers University, New Jersey Medical School, Suite 8100, 90 Bergen Street, Newark, NJ 07103, USA; Department of Neurological Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA; Department of Otolaryngology, Head and Neck Surgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA.
| |
Collapse
|
29
|
Abstract
A woman with a prolactinoma is usually infertile. Dopamine agonists usually restore ovulation and fertility and such treatment generally is preferred over transsphenoidal surgery because of higher efficacy and safety. Cabergoline is usually preferred over bromocriptine because of its better efficacy with fewer adverse effects. Either drug increases the rates of spontaneous abortions, preterm deliveries, multiple births, or congenital malformations over what may be expected. However, the number of pregnancies reporting such experience is about sevenfold greater for bromocriptine. Tumor growth causing significant symptoms and requiring intervention has been reported to occur in 2.4% of those with microadenomas, 21% in those with macroadenomas without prior surgery or irradiation, and 4.7% of those with macroadenomas with prior surgery or irradiation. Visual fields should be assessed periodically during gestation in women with macroadenomas. If significant tumor growth occurs, most patients respond well to reinstitution of the dopamine agonist. Delivery of the baby and placenta can also be considered if the pregnancy is sufficiently advanced. Transsphenoidal debulking of the tumor is rarely necessary.
Collapse
Affiliation(s)
- Mark E Molitch
- Division of EndocrinologyMetabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 North Michigan Avenue, Suite 530, Chicago, Illinois 60611, USA
| |
Collapse
|
30
|
Abstract
The improved management of pituitary adenomas has led to an increasing number of pregnancies in patients harboring pituitary adenomas. Therefore, adequate management of pregnant women with pituitary adenomas is of growing importance. Because pregnancy produces several physiologic changes to the endocrine system, especially to the pituitary gland, endocrinologists must be knowledgeable and skilled to effectively manage pregnant women with pituitary adenomas and to guarantee the wellbeing of the fetus.
Collapse
Affiliation(s)
- Paula Bruna Araujo
- Endocrinology Section, Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ 21941-913, Brazil
| | - Leonardo Vieira Neto
- Endocrinology Section, Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ 21941-913, Brazil; Department of Endocrinology, Hospital Federal da Lagoa - Rua Jardim Botãnico, 501 Jardim Botãnico, Rio de Janeiro, RJ 22470-050, Brazil
| | - Mônica R Gadelha
- Endocrinology Section, Neuroendocrinology Research Center, Medical School and Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ 21941-913, Brazil; Neuroendocrinology Unit, Instituto Estadual do Cérebro - Rua do Rezende, 156 Centro, Rio de Janeiro, RJ 20231-092, Brazil.
| |
Collapse
|
31
|
Almalki MH, Alzahrani S, Alshahrani F, Alsherbeni S, Almoharib O, Aljohani N, Almagamsi A. Managing Prolactinomas during Pregnancy. Front Endocrinol (Lausanne) 2015; 6:85. [PMID: 26074878 PMCID: PMC4443771 DOI: 10.3389/fendo.2015.00085] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 05/10/2015] [Indexed: 01/14/2023] Open
Abstract
Prolactinomas are the most prevalent functional benign pituitary tumors due to a pituitary micro- or macroadenoma. The majority of patients presents with infertility and gonadal dysfunction. A dopamine agonist (DA) (bromocriptine or cabergoline) is the treatment of choice that can normalize prolactin levels, reduce tumor size, and restore ovulation and fertility. Cabergoline generally preferred over bromocriptine because of its higher efficacy and tolerability. Managing prolactinomas during pregnancy may be challenging. During pregnancy, the pituitary gland undergoes global hyperplasia due to a progressive increase in serum estrogens level that may lead to increase of the tumor volume with potential mass effect and visual loss. The risk of tumor enlargement may occur in 3% of those with microadenomas, 32% in those with macroadenomas that were not previously operated on, and 4.8% of those with macroadenomas with prior ablative treatment. Though both drugs appear to be safe during pregnancy, the data on fetal exposure to DAs during pregnancy have been reported with bromocriptine far exceeds that of cabergoline with no association of increased risk of pregnancy loss and premature delivery. It is advisable to stop the use of DAs immediately once pregnancy is confirmed, except in the case of women with invasive macroprolactinomas or pressure symptoms. This review outlines the therapeutic approach to prolactinoma during pregnancy, with emphasis on the safety of available DA therapy.
Collapse
Affiliation(s)
- Mussa Hussain Almalki
- Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
- College of Medicine, King Fahad Medical City, King Saud bin Abdulaziz University for Health Science, Riyadh, Saudi Arabia
- *Correspondence: Mussa Hussain Almalki, Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, 7062, Ajman street, Riyadh 13314-3397, Saudi Arabia,
| | - Saad Alzahrani
- Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
- College of Medicine, King Fahad Medical City, King Saud bin Abdulaziz University for Health Science, Riyadh, Saudi Arabia
| | - Fahad Alshahrani
- College of Medicine, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Science, Riyadh, Saudi Arabia
| | - Safia Alsherbeni
- Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ohoud Almoharib
- Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Naji Aljohani
- Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
- College of Medicine, King Fahad Medical City, King Saud bin Abdulaziz University for Health Science, Riyadh, Saudi Arabia
| | - Abdurahman Almagamsi
- Obesity, Endocrine, and Metabolism Center, King Fahad Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
32
|
Abstract
Prolactinomas account for approximately 40 % of all pituitary adenomas. Over 95 % of prolactinomas are microadenomas (< 10 mm diameter). Treatment is indicated to correct hypogonadism, restore other hormonal deficits, and alleviate local mass effects. Dopamine agonists (DA) are highly effective in achieving these goals and are well-tolerated. The vast majority of prolactinomas will respond to conventional doses of cabergoline (≤2 mg/week) that do not carry an increased risk of cardiac valvular abnormalities. DA therapy may be successful withdrawn in a subset of patients and thus is not necessarily a lifelong commitment. Although transsphenoidal surgery (TSS) is an option for prolactinoma treatment, it is less effective than medical management, carries considerably more risk, and is more expensive. The benefit/risk ratio for DA therapy compared to TSS actually becomes increasingly more favorable as tumor size increases. Therefore DA should remain the clear treatment of choice for essentially all patients with prolactinomas, reserving TSS as a second-line option for the very small number of patients that do not tolerate or are completely resistant to DA therapy.
Collapse
Affiliation(s)
- Eve Bloomgarden
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, 645 N. Michigan Ave., Suite 530, Chicago, IL, 60611, USA
| | | |
Collapse
|
33
|
Abstract
Recent studies have reported a higher prevalence of pituitary tumors than previously thought. Among these tumors, prolactinomas occur in up to 66% of cases. Since the mid-1980s, the widespread use of dopamine agonists has facilitated the management of the majority of prolactinomas, allowing biological and tumoral control in most cases. The less frequent cases of resistant prolactinomas remain challenging despite a multimodal therapy approach. The understanding of genetic alterations in familial and aggressive pituitary tumors provides new perspectives in the management of some prolactinomas. Genetic screening should be considered, particularly in familial cases but also in young patients with macroprolactinomas, as some mutations can predict potential aggressiveness.
Collapse
Affiliation(s)
- Laurent Vroonen
- a Department of Endocrinology, CHU de Liège, University of Liège, 4000 Liège, Belgium
| | - Adrian F Daly
- a Department of Endocrinology, CHU de Liège, University of Liège, 4000 Liège, Belgium
| | | |
Collapse
|
34
|
Abstract
Hyperprolactinemia, frequently caused by a prolactinoma, is an important cause of infertility among young women. Dopamine agonists (DA) are the treatment of choice. Although cabergoline (CAB) is currently considered the gold standard DA, bromocriptine (BRC) remains the drug of choice for women desiring pregnancy, as it was proven to be safe in more than 6,000 pregnancies. The purpose of this review is to perform a critical evaluation of CAB safety in pregnancy, as it is used by most patients harboring prolactinomas. Although the number of CAB-induced pregnancies (about 800) is still reduced as compared with those under BRC treatment, data in the literature do not point to increase risk of preterm delivery or fetal malformations, comparing to pregnancies induced by BRC and those in the general population. Moreover, CAB use throughout pregnancy was reported in about ten cases, without evidence of any harm to fetal development. Therefore, even though BRC still remains the recommended DA drug for pregnancy induction or use during pregnancy in women with prolactinomas, increasing evidences point to the safety of CAB for this purpose.
Collapse
Affiliation(s)
- Andrea Glezer
- Neuroendocrine Unit, Division of Endocrinology and Metabolism Hospital das Clinicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | |
Collapse
|
35
|
Piantanida E, Gallo D, Lombardi V, Tanda ML, Lai A, Ghezzi F, Minotto R, Tabano A, Cerati M, Azzolini C, Balbi S, Baruzzi F, Sessa F, Bartalena L. Pituitary apoplexy during pregnancy: a rare, but dangerous headache. J Endocrinol Invest 2014; 37:789-97. [PMID: 24916564 DOI: 10.1007/s40618-014-0095-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 05/12/2014] [Indexed: 11/30/2022]
Abstract
Pituitary apoplexy is a rare endocrine emergency that occurs in a small number of patients with a pituitary tumor. It is a clinical syndrome characterized by the sudden onset of headache, nausea, vomiting, visual impairment, and decreased consciousness, caused by hemorrhage and/or infarction of the pituitary gland. Pituitary apoplexy has very rarely been described during pregnancy, when it is potentially life-threatening to both the mother and the fetus, if unrecognized. Only a few cases have been published to date. The review of the existing literature underlines that pituitary apoplexy, although rare, should be borne in mind when a pregnant woman presents with severe headache and visual defects of sudden onset. After initial management, which includes intravenous glucocorticoid therapy, fluid and electrolyte replacement, the final selection of medical or surgical treatment should result from a multidisciplinary approach involving expert specialists, keeping into account both severity of clinical presentation and gestational week.
Collapse
Affiliation(s)
- E Piantanida
- Section of Endocrinology, Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, Ospedale di Circolo, viale L. Borri, 57, 21100, Varese, Italy,
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Mistry M, Gupta M, Kaler M. Pregnancy in multiple endocrine neoplasia type 1 equals multiple complications. Obstet Med 2014; 7:123-5. [PMID: 27512437 DOI: 10.1177/1753495x14532634] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Multiple endocrine neoplasia type 1 (MEN 1) is a rare inherited disorder caused by mutations in the tumour suppressor gene MEN 1. It is characterised by a predisposition towards the development of parathyroid, anterior pituitary and entero-pancreatic tumours. Clinically, MEN 1 is defined following development of two out of these three tumours. There have been no published cases of the management of MEN 1 in pregnancy. We report the first case of a 31-year-old primigravida with a confirmed diagnosis of MEN 1 prior to conception. Due to the rare nature of MEN 1, there are no guidelines on how such women should be managed. The main issues were to assess and manage potential complications, such as hypercalcaemia, diabetes mellitus and the symptoms from a pituitary tumour as well the issues around a gastrinoma and monitor fetal well-being. A Caesarean section was performed at 35 weeks gestation for a growth-restricted fetus with raised umbilical artery Dopplers. The neonate was treated with intravenous calcium secondary to hypocalcaemia. The patient and neonate recovered well. We have demonstrated successful management of a woman with MEN 1 who completed her pregnancy with few complications and a healthy neonate. It is vital for such women to be managed in the context of a multidisciplinary team setting to optimise maternal and fetal outcomes.
Collapse
Affiliation(s)
- Megha Mistry
- Department of Obstetrics and Gynaecology, Barts Health, Whipps Cross University Hospital, London, UK
| | - Manish Gupta
- Department of Obstetrics and Gynaecology, Barts Health, Whipps Cross University Hospital, London, UK
| | - Mandeep Kaler
- Department of Obstetrics and Gynaecology, Barts Health, Whipps Cross University Hospital, London, UK
| |
Collapse
|
37
|
Domingue ME, Devuyst F, Alexopoulou O, Corvilain B, Maiter D. Outcome of prolactinoma after pregnancy and lactation: a study on 73 patients. Clin Endocrinol (Oxf) 2014; 80:642-8. [PMID: 24256562 DOI: 10.1111/cen.12370] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 08/19/2013] [Accepted: 10/23/2013] [Indexed: 11/28/2022]
Abstract
CONTEXT Prolactinoma is the most frequent pituitary tumour among women of child-bearing age. Only a few studies have addressed the outcome of prolactinoma after pregnancy. OBJECTIVE To study remission, defined as prolactin normalization without medical treatment, after pregnancy and lactation in women with prolactinoma. PATIENTS AND METHODS A retrospective study conducted in 2 Belgian academic centres including 73 patients (54 microprolactinomas and 19 macroprolactinomas) with 104 pregnancies continuing beyond first trimester. Dopamine agonists were stopped in early pregnancy in all treated cases. Prolactin level and adenoma size at pituitary magnetic resonance imaging (MRI) were recorded before pregnancy and throughout follow-up. RESULTS Thirty of 73 women (41%) were in remission after a median follow-up of 22 months after delivery or cessation of lactation. Adenoma size at diagnosis was smaller in women in remission (5 vs 8 mm). There was a nonsignificant higher rate of remission for microprolactinomas than for macroprolactinoma (46% vs 26%). The first pituitary MRI after pregnancy and lactation showed no tumour and a decreased adenoma size in 23% and 39% of women, respectively. MRI normalization was associated with remission. The number of pregnancies per woman as well as breastfeeding and its duration did not influence remission rate. CONCLUSION More than 40% of women with previous diagnosis of prolactinoma have normal PRL level without medical treatment for a median follow-up of 22 months after pregnancy and lactation. The likelihood of remission is associated with a smaller initial adenoma size and normalization of pituitary MRI after pregnancy.
Collapse
Affiliation(s)
- Marie-Eve Domingue
- Department of Endocrinology and Nutrition, Cliniques Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | | | | | | | | |
Collapse
|
38
|
Pivonello R, De Martino MC, Auriemma RS, Alviggi C, Grasso LFS, Cozzolino A, De Leo M, De Placido G, Colao A, Lombardi G. Pituitary tumors and pregnancy: the interplay between a pathologic condition and a physiologic status. J Endocrinol Invest 2014; 37:99-112. [PMID: 24497208 DOI: 10.1007/s40618-013-0019-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 11/17/2013] [Indexed: 11/29/2022]
Abstract
Pregnancy is becoming a relatively common event in patients with pituitary tumors (PT), due to the increasing availability of medical treatments, which control pituitary diseases associated with the development of PT. However, the presence of PT and its treatment may be a disturbing factor for pregnancy, and pregnancy significantly influences the course and the management of PT. This review summarizes the knowledge about the management of PT during pregnancy and the occurrence of pregnancy in patients with pre-existent PT, focusing on secreting PT characterized by hormonal excess and on clinically non-functioning PT often associated to hormone deficiency, which configure the hypopituitaric syndrome.
Collapse
Affiliation(s)
- Rosario Pivonello
- Section of Endocrinology, Department of Clinical Medicine and Surgery, "Federico II" University, Naples, Italy,
| | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Abstract
Pregnancy is associated with normal physiological changes in endocrine system that assists fetal survival as well as preparation of labor. The pituitary gland is one of the most affected organs in which major changes in anatomy and physiology take place. Due to overlapping clinical and biochemical features of pregnancy, sometimes the diagnosis of pituitary disorders may be challenging. It is important to know what normal parameters of changes occur in endocrine system in order to diagnose and manage complex endocrine problems in pregnancy. In our present review, we will focus on pituitary disorders that occur exclusively during pregnancy like Sheehan's syndrome and lymphocytic hypophysitis and pre-existing pituitary disorders (like prolactinoma, Cushing's disease and acromegaly), which poses significant challenge to endocrinologists.
Collapse
Affiliation(s)
- Bashir A. Laway
- Department of Endocrinology, Sher I Kashmir Institute of Medical Sciences, Soura Srinagar, Jammu and Kashmir, India
| | - Shahnaz A. Mir
- Department of Endocrinology, Sher I Kashmir Institute of Medical Sciences, Soura Srinagar, Jammu and Kashmir, India
| |
Collapse
|
40
|
Molitch ME. Management of medically refractory prolactinoma. J Neurooncol 2013; 117:421-8. [PMID: 24146188 DOI: 10.1007/s11060-013-1270-8] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 10/09/2013] [Indexed: 11/24/2022]
Abstract
Resistance to dopamine agonists is defined here as failure to normalize prolactin levels and failure to decrease macroprolactinoma size by ≥50 %. Failure to normalize prolactin levels is found in about 25 % of patients treated with bromocriptine and 10-15 % of those treated with cabergoline. Failure to achieve at least a 50 % reduction in tumor size occurs in about one-third of those treated with bromocriptine and 10-15 % of those treated with cabergoline. Treatment approaches for patients resistant to dopamine agonists include changing to another dopamine agonist and increasing the dose of the drug as long as there is continued response to the dose increases and no adverse effects with higher doses. Transsphenoidal surgery is also an option. Clomiphene, gonadotropins, and GnRH can be used if fertility is desired. For those not desiring fertility, estrogen replacement may be used unless there is a macroadenoma, in which case control of tumor growth is also an issue and dopamine agonists are generally necessary. In many patients modest or even no reduction in tumor size may be acceptable as long as there is not tumor growth. Hormone replacement [estrogen or testosterone] may cause a decrease in efficacy of the dopamine agonist. Reduction of endogenous estrogen, use of selective estrogen receptor modulators, and aromatase inhibitors are potential experimental approaches. Temozolomide may be useful as a last resort for aggressive, invasive tumors refractory to other medical and ablative therapies.
Collapse
Affiliation(s)
- Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Avenue, Suite 530, Chicago, IL, 60611, USA,
| |
Collapse
|
41
|
Saraiva J, Gomes L, Paiva S, Ruas L, Carvalheiro M. Giant macroprolactinoma and pregnancy. ACTA ACUST UNITED AC 2013; 57:558-61. [DOI: 10.1590/s0004-27302013000700010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2012] [Accepted: 11/12/2012] [Indexed: 11/21/2022]
Abstract
Prolactinomas are a common cause of gonadal dysfunction and infertility. We present the case of a 38-year-old woman with history of amenorrhea and infertility. At seven weeks of pregnancy she presented neuro-ophthalmologic complaints of headaches, diplopia, and right ptosis. The work-up study revealed an invasive pituitary macroadenoma with a maximum diameter of 9 cm and serum prolactin of 25,800 ng/mL (3-20). At 12 weeks, she was referred to the Endocrinology Department of the Coimbra University Hospital and started therapy with bromocriptine, initially 5 mg/day and then at crescent doses. Hyperprolactinemia was rapidly and drastically reduced to 254 ng/mL three weeks after taking bromocriptine 15 mg/day. Tumoral volume was reduced and there was improvement of III pair paresis. At 38 weeks, a male healthy baby was born. This is a relevant clinical case that illustrates the efficacy and safety of bromocriptine therapy during pregnancy, even in severe cases like this one.
Collapse
|
42
|
Al-Sharafi BA, Nassar OH. Successful pregnancy in a female with a large prolactinoma after pituitary tumor apoplexy. Case Rep Obstet Gynecol 2013; 2013:817603. [PMID: 24194992 PMCID: PMC3806158 DOI: 10.1155/2013/817603] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 08/29/2013] [Indexed: 11/17/2022] Open
Abstract
Pituitary apoplexy is a rare condition which may cause death of the patient in severe cases and many times leads to hypopituitarism. We report a case of apoplexy in a large prolactinoma resulting in empty sella syndrome followed by a successful pregnancy. Our patient is a 32-year-old female with a history of a macroprolactinoma for approximately 17 years who presented to our hospital with a history of severe headache, decreased level of consciousness, fever, nausea, vomiting, and diplopia of 12 hours duration. Magnetic resonance imaging done on admission showed an increase in the size of the pituitary adenoma with a subtle hemorrhage. The patient was admitted to the intensive care unit and treated conservatively. The condition of the patient improved within a few days. A few months later, she started having regular menstrual periods. A magnetic resonance imaging of the pituitary 1.5 years later was reported as empty sella syndrome, and approximately one year later she became pregnant. With the pituitary adenoma being resolved after developing pituitary apoplexy and continuing on cabergoline, the patient had a successful pregnancy with no recurrence of the adenoma after delivery and breastfeeding.
Collapse
Affiliation(s)
- Butheinah A. Al-Sharafi
- Department of Medicine, School of Medicine and Health Sciences, Sana'a University, P.O Box 12268, Sana'a, Yemen
| | - Omar H. Nassar
- Department of Radiology, University of Science and Technology Hospital, P.O. Box 13061, Sana'a, Yemen
| |
Collapse
|
43
|
|
44
|
Abstract
Prolactinomas are the most common type of pituitary adenomas. Macroprolactinomas are the name used for these tumors when their size is ≥ 1 cm. These tumors commonly cause symptoms due to the excessive production of prolactin as well as complaints caused by tumor mass and compression of neural adjacent structures. Clinical diagnosis and assessment of macroprolactinoma are based on the measurement of serum prolactin concentrations and the morphological evaluation of the pituitary gland by magnetic resonance imaging. Dopamine agonists are the first-line treatment modality, with cabergoline being preferred to bromocriptine, because of its better tolerance and feasibility of administration. Cabergoline therapy has been reported to achieve normalization of prolactin levels and gonadal function and reduction of tumor volume in >50% of patients with macroprolactinoma. Resistance or intolerance to dopamine agonists are the main indications for transsphenoidal adenomectomy in patients with macroprolactinoma. External radiation therapy has been used in patients with poor response to medical and surgical procedures. Clinically significant tumor growth may occur during pregnancy in women with macroprolactinomas, especially if they have not received prior surgical or radiation therapy. Visual fields should be assessed periodically during pregnancy and therapy with dopamine agonists is indicated if symptomatic tumor growth occurs. Cystic and giant prolactinomas as well as the rare cases of malignant prolactinomas have special peculiarities and entail a therapeutic challenge.
Collapse
Affiliation(s)
- P Iglesias
- Department of Endocrinology, Hospital Ramón y Cajal, Ctra. de Colmenar, Km 9, 28034 Madrid, Spain.
| | | |
Collapse
|
45
|
Abstract
PURPOSE Elevated prolactin levels may have several etiologies, one of which is a prolactinoma. Prolactinomas, the most prevalent pituitary tumors, may be more common than once described. These tumors can result in ocular complications such as vision loss and visual field defects. Prolactinomas are easily treated but need to be identified early in order to prevent more serious systemic complications. CASE REPORT A 24-year-old Pacific Islander male presented with sudden blurred vision and an associated visual field defect in the right eye for 4 to 6 months. After performing a magnetic resonance imaging and consultation with an endocrinologist, the patient was diagnosed with a prolactinoma. The patient was treated and demonstrated a complete recovery of visual acuity and visual field defect. CONCLUSIONS Prolactinomas are a common pituitary tumor characterized by an increase in prolactin levels. This review describes how prolactinomas are classified, their etiology, subsequent complications, and treatments.
Collapse
|
46
|
Radl D, De Mei C, Chen E, Lee H, Borrelli E. Each individual isoform of the dopamine D2 receptor protects from lactotroph hyperplasia. Mol Endocrinol 2013; 27:953-65. [PMID: 23608643 DOI: 10.1210/me.2013-1008] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Dopamine acting through D2 receptors (D2Rs) controls lactotroph proliferation and prolactin (PRL) levels. Ablation of this receptor in mice results in lactotroph hyperplasia and prolactinomas in aged females. Alternative splicing of the Drd2 gene generates 2 independent isoforms, a long (D2L) and a short (D2S) isoform, which are present in all D2R-expressing cells. Here, we addressed the role of D2L and D2S on lactotroph physiology through the generation and analysis of D2S-null mice and their comparison with D2L-null animals. These mice represent a valuable tool with which to investigate dopamine-dependent isoform-specific signaling in the pituitary gland. We sought to assess the existence of a more prominent role of D2L or D2S in controlling PRL expression and lactotroph hyperplasia. Importantly, we found that D2L and D2S are specifically linked to independent transduction pathways in the pituitary. D2L-mediated signaling inhibits the AKT/protein kinase B kinase activity whereas D2S, in contrast, is required for the activation of the ERK 1/2 pathway. Under normal conditions, presence of only 1 of the 2 D2R isoforms in vivo prevents hyperprolactinemia, formation of lactotroph's hyperplasia, and tumorigenesis that is observed when both isoforms are deleted as in D2R-/- mice. However, the protective function of the single D2R isoforms is overridden when single isoform-knockout mice are challenged by chronic estrogen treatments as they show increased PRL production and lactotroph hyperplasia. Our study indicates that signaling from each of the D2R isoforms is sufficient to maintain lactotroph homeostasis in physiologic conditions; however, signaling from both is necessary in conditions simulating pathologic states.
Collapse
Affiliation(s)
- Daniela Radl
- Department of Microbiology and Molecular Genetics, Institut National de la Santé et de la Recherche Médicale INSERM/UCI U904, France
| | | | | | | | | |
Collapse
|
47
|
Couture N, Aris-Jilwan N, Serri O. Apoplexy of A Microprolactinoma During Pregnancy: Case Report and Review of Literature. Endocr Pract 2012; 18:e147-50. [PMID: 22982795 DOI: 10.4158/ep12106.cr] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Nathalie Couture
- Division of Endocrinology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | | | | |
Collapse
|