Approach to the management of rare clinical presentations of macroprolactinomas in reproductive-aged women

Challenges of Pituitary Apoplexy in Pregnancy

Our purpose is to provide new insights concerning the challenges of pituitary apoplexy in pregnancy (PAP) and the postpartum period (PAPP). This is a narrative review of the English literature using a PubMed search. The inclusion criteria were clinically relevant original studies (January 2012-December 2022). Overall, we included 35 original studies: 7 observational studies (selected cases on PA) and 28 case reports, including 4 case series (N = 49; PAP/PAPP = 43/6). The characteristics of PAP patients (N = 43) are as follows: maternal age between 21 and 41 (mean of 27.76) years; 21/43 subjects with a presentation during the third trimester (only one case during first trimester); average weak of gestation of 26.38; most females were prim gravidae; 19 (out of 30 patients with available data on delivery) underwent a cesarean section. Headache remains the main clinical feature and is potentially associated with a heterogeneous panel (including visual anomalies, nausea, vomiting, cranial nerve palsies, diabetes insipidus, photophobia, and neck stiffness). Pre-pregnancy medication included dopamine agonists (15/43) and terguride (1/43) in addition to subsequent insulin therapy for gestational diabetes (N = 2) and type 1 diabetes mellitus (N = 1). Overall, 29/43 females received the conservative approach, and 22/43 women had trans-sphenoidal surgery (TSS) (and 10/22 had the initial approach). Furthermore, 18/43 patients had a pituitary adenoma undiagnosed before pregnancy. Most PA-associated tumors were prolactinomas (N = 26/43), with the majority of them (N = 16/26) being larger than 1 cm. A maternal-fetal deadly outcome is reported in a single case. The characteristics of PAPP patients (N = 6) are as follows: mean age at diagnosis of 33 years; 3/6 subjects had PA during their second pregnancy; the timing of PA varied between 5 min and 12 days after delivery; headache was the main clinical element; 5/6 had no underlying pituitary adenoma; 5/6 patients were managed conservatively and 1/6 underwent TSS; pituitary function recovered (N = 3) or led to persistent hypopituitarism (N = 3). In conclusion, PAP represents a rare, life-threatening condition. Headache is the most frequent presentation, and its prompt distinction from other conditions associated with headache, such as preeclampsia and meningitis, is essential. The index of suspicion should be high, especially in patients with additional risk factors such as pre-gestation treatment with dopamine agonists, diabetes mellitus, anticoagulation therapy, or large pituitary tumors. The management is conservative in most cases, and it mainly includes corticosteroid substitution and dopamine agonists. The most frequent surgical indication is neuro-ophthalmological deterioration, although the actual risk of pituitary surgery during pregnancy remains unknown. PAPP is exceptionally reported. To our knowledge, this sample-case series study is the largest of its kind that is meant to increase the awareness to the benefit of the maternal-fetal outcomes from multidisciplinary insights.

Pituitary adenoma apoplexy in pregnancy: Case report and literature review

Gestational pituitary apoplexy is an extremely rare condition. It is characterised by an unexpected headache, vomiting, nausea, and visual disturbances. Pituitary apoplexy in pregnancy and postpartum is a challenging diagnosis with symptoms overlapping multiple conditions. There is a limited number of articles presenting cases or case series of gestational pituitary apoplexy. This is a potentially life-threatening emergency which requires a high index of suspicion for its diagnosis. This article presents a case of postpartum pituitary apoplexy and outlines the current stage of clinical, imagistic diagnosis and management options. A 26-year-old primipara was submitted to a Caesarean section, with no perioperative incidents. Forty-eight hours later she reported the apparition of frontal and temporal throbbing headaches, nausea, photophobia, and she was diagnosed with a pituitary tumor measuring 33x10.5x15.5 mm. Although initially conservative treatment was proposed, the clinical outcome was not favourable, thus the patient was submitted to endoscopic transsphenoidal resection. The histopathological studies demonstrated the presence of a pituitary macroadenoma. At the 2-year follow-up, the patient is free of disease. Although it represents an extremely rare condition, gestational pituitary apoplexy should be suspected whenever headache and neurological disorders such as nausea and photophobia are reported during the postpartum period.

Fertility issues in aggressive pituitary tumors

The management of aggressive pituitary adenomas represents a special clinical challenge, and usually involves a combination of surgery, radiotherapy and pharmacological agents to control tumor growth and hormone abnormalities. Fertility is commonly affected in these patients due to compressive effects of the tumor, pituitary hormone dysfunction or as a result of the multiple therapies. The initial approach to restore fertility involves the reduction of tumor volume by the use of dopamine agonists in prolactinomas and by surgery in other pituitary adenomas. Somatostatin analogues are alternative options for GH, ACTH and TSH-secreting tumors. When present, pituitary deficiencies should be appropriately treated, particularly GH deficiency that has been associated with poor pregnancy rates in hypopituitary patients. Other therapies for aggressive pituitary tumors, such as invasive surgery, radiotherapy and temozolamide, may lead to infertility. In such cases, fertility preservation strategies might be considered and discussed with the patient desiring conception before or during treatment. In men and women with hypogonadotropic hypogonadism, administration of gonadotropins or pulse GnRH has resulted in satisfactory pregnancy rates. If spontaneous gestation is not achieved, assisted reproduction techniques can be employed as the last line of treatment. In any context, pre-conception counseling and care are essential as pregnancies in women with aggressive pituitary tumors should always be considered high risk.

A case of atypical macroprolactinoma presenting with pituitary apoplexy during pregnancy and review of the literature

Pituitary apoplexy (PA) during pregnancy is a rare acute clinical situation which could have life-threatening consequences. Here we reported a case of 26-year-old nulliparous woman presenting with PA at the second trimester of her pregnancy. We also have reviewed reported cases of PA during pregnancy and conducted a detailed discussion on presenting symptoms, underlying pituitary pathology, management of apoplexy during pregnancy and outcomes.

Prolactinomas in pregnancy: considerations before conception and during pregnancy

Prolactinomas are the most common pituitary tumors and pathological hyperprolactinemia. Therefore, women harboring prolactinomas frequently present infertility due to the gonadal axis impairment. The gold-standard treatment is dopamine agonist (DA) which can reverse hyperprolactinemia and hypogonadism, and promote tumor shrinkage in the majority of cases. Therefore, reports of pregnancy in such cohort become more common. In this scenario, bromocriptine is still the DA of choice due to its shorter half-life and larger experience as compared to cabergoline. In DA resistant cases, transsphenoidal pituitary surgery is indicated. However, potential risks of DA-induced pregnancies include fetal exposition and symptomatic tumor growth. Dopamine agonist should be discontinued as soon as pregnancy is confirmed in microprolactinomas and intrasellar macroprolactinomas (MAC). Concerning expansive/invasive MAC, DA maintenance should be considered. Periodically clinical evaluation should be performed during pregnancy, being sellar imaging indicated if tumor symptomatic growth is suspected. In such cases, if DA treatment fails, neurosurgery is indicated.