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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.
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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
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2
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Dourado MLBF, Costa TPD, Carvalho MSD, Moura CGGD. Dilated Cardiomyopathy Reversibility in Sheehan's Syndrome: A Case Report. Arq Bras Cardiol 2021; 116:17-20. [PMID: 33566997 PMCID: PMC8118631 DOI: 10.36660/abc.20190547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 03/09/2020] [Indexed: 11/30/2022] Open
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3
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Haber MA, Nunez D. Imaging neurological emergencies in pregnancy and puerperium. Emerg Radiol 2018; 25:673-684. [PMID: 30030690 DOI: 10.1007/s10140-018-1625-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 07/06/2018] [Indexed: 12/13/2022]
Abstract
The altered physiologic state of female patients during and just after pregnancy places them at an increased risk for several potentially life-threatening neurologic disorders. Swift diagnosis of such pathology and related complications is critical in order to reduce risk of morbidity and mortality to both the mother and the fetus. Neuroimaging plays an important role in the emergent diagnosis of pathology associated with pregnancy and puerperium, and it is critical for the radiologist to be cognizant of correlative imaging findings. Furthermore, given concerns regarding risks of neuroimaging to the fetus, it is important for the radiologist to act as an informed consultant regarding balancing fetal risks and the mother's health. The purpose of this review is to elucidate the underlying pathophysiology and neuroimaging findings associated with diagnoses that are unique to or highly associated with pregnancy and puerperium, as well as to understand the role that CT and MR play in diagnosis during and just after pregnancy, and their respective risks to the fetus.
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Affiliation(s)
- Matthew A Haber
- Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Diego Nunez
- Department of Radiology, Division of Neuroradiology, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, PBB RAD, 3rd Floor, Room 357, Boston, MA, 02115, USA.
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4
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Ennaifer H, Jemel M, Kandar H, Grira W, Kammoun I, Salem LB. Developed diplopia due to a pituitary macroadenoma during pregnancy. Pan Afr Med J 2018; 29:39. [PMID: 29875921 PMCID: PMC5987105 DOI: 10.11604/pamj.2018.29.39.12706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 09/04/2017] [Indexed: 11/11/2022] Open
Abstract
Physiologic pituitary enlargement is common during normal pregnancy. However, symptoms such as diplopia, blurred vision and headache resulting from physiologic pituitary enlargement are very rare during pregnancy. A 43-year-old woman complained of sudden headache and left eye ptosis at 36th weeks of gestation. An magnetic resonance imaging (MRI) demonstrated the pituitary enlargement and a macroadenoma without a compressing of the optic chiasm, but with an extension to the left cavernous sinus. 48 hours after the prescription of the bromocriptine, we had a spectacular evolution with disappearance of the headache and a total regression of the ptosis. We report a case of visual loss due to the physiologic pituitary enlargement or to the macroadenoma during pregnancy, which regressed after the prescription of bromocroptine.
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Affiliation(s)
- Houda Ennaifer
- Department of Endocrinology, National Institute of Nutrition, Tunis, Tunisia
| | - Manel Jemel
- Department of Endocrinology, National Institute of Nutrition, Tunis, Tunisia
| | - Hejer Kandar
- Department of Endocrinology, National Institute of Nutrition, Tunis, Tunisia
| | - Wafa Grira
- Department of Endocrinology, National Institute of Nutrition, Tunis, Tunisia
| | - Ines Kammoun
- Department of Endocrinology, National Institute of Nutrition, Tunis, Tunisia
| | - Leila Ben Salem
- Department of Endocrinology, National Institute of Nutrition, Tunis, Tunisia
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5
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Marques P, Gunawardana K, Grossman A. Transient diabetes insipidus in pregnancy. Endocrinol Diabetes Metab Case Rep 2015; 2015:150078. [PMID: 26524979 PMCID: PMC4626653 DOI: 10.1530/edm-15-0078] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 09/23/2015] [Indexed: 11/28/2022] Open
Abstract
Gestational diabetes insipidus (DI) is a rare complication of pregnancy, usually developing in the third trimester and remitting spontaneously 4–6 weeks post-partum. It is mainly caused by excessive vasopressinase activity, an enzyme expressed by placental trophoblasts which metabolises arginine vasopressin (AVP). Its diagnosis is challenging, and the treatment requires desmopressin. A 38-year-old Chinese woman was referred in the 37th week of her first single-gestation due to polyuria, nocturia and polydipsia. She was known to have gestational diabetes mellitus diagnosed in the second trimester, well-controlled with diet. Her medical history was unremarkable. Physical examination demonstrated decreased skin turgor; her blood pressure was 102/63 mmHg, heart rate 78 beats/min and weight 53 kg (BMI 22.6 kg/m2). Laboratory data revealed low urine osmolality 89 mOsmol/kg (350–1000), serum osmolality 293 mOsmol/kg (278–295), serum sodium 144 mmol/l (135–145), potassium 4.1 mmol/l (3.5–5.0), urea 2.2 mmol/l (2.5–6.7), glucose 3.5 mmol/l and HbA1c 5.3%. Bilirubin, alanine transaminase, alkaline phosphatase and full blood count were normal. The patient was started on desmopressin with improvement in her symptoms, and normalisation of serum and urine osmolality (280 and 310 mOsmol/kg respectively). A fetus was delivered at the 39th week without major problems. After delivery, desmopressin was stopped and she had no further evidence of polyuria, polydipsia or nocturia. Her sodium, serum/urine osmolality at 12-weeks post-partum were normal. A pituitary magnetic resonance imaging (MRI) revealed the neurohypophyseal T1-bright spot situated ectopically, with a normal adenohypophysis and infundibulum. She remains clinically well, currently breastfeeding, and off all medication. This case illustrates some challenges in the diagnosis and management of transient gestational DI.
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Affiliation(s)
- Pedro Marques
- Endocrinology Department , Instituto Português de Oncologia de Lisboa , Francisco Gentil, Rua Professor Lima Basto1099-023, Lisboa , Portugal ; Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford , Oxford , UK
| | - Kavinga Gunawardana
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford , Oxford , UK
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford , Oxford , UK
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6
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Bellastella G, Bizzarro A, Aitella E, Barrasso M, Cozzolino D, Di Martino S, Esposito K, De Bellis A. Pregnancy may favour the development of severe autoimmune central diabetes insipidus in women with vasopressin cell antibodies: description of two cases. Eur J Endocrinol 2015; 172:K11-7. [PMID: 25501964 DOI: 10.1530/eje-14-0762] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Recently, an increased incidence of central diabetes insipidus (CDI) in pregnancy, and less frequently in the post partum period, has been reported, most probably favoured by some conditions occurring in pregnancy. This study was aimed at investigating the influence of pregnancy on a pre-existing potential/subclinical hypothalamic autoimmunity. We studied the longitudinal behaviour of arginine-vasopressin cell antibodies (AVPcAbs) and post-pituitary function in two young women with a positive history of autoimmune disease and presence of AVPcAbs, but without clinical CDI, and who became pregnant 5 and 7 months after our first observation. The behaviour of post-pituitary function and AVPcAbs (by immunofluorescence) was evaluated at baseline, during pregnancy and for 2 years after delivery. AVPcAbs, present at low/middle titres at baseline in both patients, showed a titre increase during pregnancy in one patient and after delivery in the other patient, with development of clinically overt CDI. Therapy with 1-deamino-8-d-arginine vasopressin (DDAVP) caused a prompt clinical remission. After a first unsuccessful attempt of withdrawal, the therapy was definitively stopped at the 6th and the 7th month of post partum period respectively, when AVPcAbs disappeared, accompanied by post-pituitary function recovery, persisting until the end of the follow-up. The determination of AVPcAbs is advisable in patients with autoimmune diseases planning their pregnancy, because they could be considered good predictive markers of gestational or post partum autoimmune CDI. The monitoring of AVPcAb titres and post-pituitary function during pregnancy in these patients may allow for an early diagnosis and an early replacement therapy, which could induce the disappearance of these antibodies with consequent complete remission of CDI.
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Affiliation(s)
- Giuseppe Bellastella
- Departments of Medical, Surgical, Neurological, Metabolic and Geriatric SciencesClinical and Experimental MedicineCardiothoracic and Respiratory SciencesSecond University of Naples, Piazza L. Miraglia 2, 80131 Napoli, Italy
| | - Antonio Bizzarro
- Departments of Medical, Surgical, Neurological, Metabolic and Geriatric SciencesClinical and Experimental MedicineCardiothoracic and Respiratory SciencesSecond University of Naples, Piazza L. Miraglia 2, 80131 Napoli, Italy
| | - Ernesto Aitella
- Departments of Medical, Surgical, Neurological, Metabolic and Geriatric SciencesClinical and Experimental MedicineCardiothoracic and Respiratory SciencesSecond University of Naples, Piazza L. Miraglia 2, 80131 Napoli, Italy
| | - Mariluce Barrasso
- Departments of Medical, Surgical, Neurological, Metabolic and Geriatric SciencesClinical and Experimental MedicineCardiothoracic and Respiratory SciencesSecond University of Naples, Piazza L. Miraglia 2, 80131 Napoli, Italy
| | - Domenico Cozzolino
- Departments of Medical, Surgical, Neurological, Metabolic and Geriatric SciencesClinical and Experimental MedicineCardiothoracic and Respiratory SciencesSecond University of Naples, Piazza L. Miraglia 2, 80131 Napoli, Italy
| | - Sergio Di Martino
- Departments of Medical, Surgical, Neurological, Metabolic and Geriatric SciencesClinical and Experimental MedicineCardiothoracic and Respiratory SciencesSecond University of Naples, Piazza L. Miraglia 2, 80131 Napoli, Italy
| | - Katherine Esposito
- Departments of Medical, Surgical, Neurological, Metabolic and Geriatric SciencesClinical and Experimental MedicineCardiothoracic and Respiratory SciencesSecond University of Naples, Piazza L. Miraglia 2, 80131 Napoli, Italy
| | - Annamaria De Bellis
- Departments of Medical, Surgical, Neurological, Metabolic and Geriatric SciencesClinical and Experimental MedicineCardiothoracic and Respiratory SciencesSecond University of Naples, Piazza L. Miraglia 2, 80131 Napoli, Italy
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7
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Hale B, Habib AS. Sheehan syndrome: acute presentation with severe headache. Int J Obstet Anesth 2014; 23:383-6. [PMID: 25223643 DOI: 10.1016/j.ijoa.2014.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/30/2014] [Accepted: 04/28/2014] [Indexed: 10/25/2022]
Abstract
Postpartum headache is a common occurrence with a broad differential diagnosis. Sheehan syndrome, or postpartum pituitary necrosis, is not typically recognized as a cause of postpartum headache. We present a case of Sheehan syndrome that initially presented as severe headache after vaginal delivery complicated by retained placenta and postpartum hemorrhage. The patient was discharged home on postpartum day three but continued to have headaches and returned to hospital on postpartum day six with severe headache, failure to lactate, edema, dizziness, fatigue, nausea and vomiting. Cranial magnetic resonance imaging revealed pituitary infarction consistent with Sheehan syndrome. We discuss the differential diagnosis for postpartum headache, the pathophysiological features of Sheehan syndrome and headache as an atypical acute presentation.
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Affiliation(s)
- B Hale
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - A S Habib
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.
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8
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Developed diplopia and ptosis due to a nonfunctioning pituitary macroadenoma during pregnancy. Obstet Gynecol Sci 2014; 57:66-9. [PMID: 24596820 PMCID: PMC3924742 DOI: 10.5468/ogs.2014.57.1.66] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 07/17/2013] [Accepted: 08/05/2013] [Indexed: 11/08/2022] Open
Abstract
Physiologic pituitary enlargement is common during normal pregnancy. However, symptoms such as diplopia, blurred vision and headache resulting from physiologic pituitary enlargement are very rare during pregnancy. A 39-year-old woman complained of sudden diplopia and left eye ptosis at 33th weeks of gestation. An magnetic resonance imaging (MRI) demonstrated the pituitary enlargement compressing the optic chiasm. Notwithstanding the medication of bromocriptine, her symptoms did not regress during pregnancy. At 5 months after delivery, her symptoms dramatically resolved without any surgery, and her visual acuity was normalized. Her MRI scan also revealed more decreased size of pituitary gland compared to antenatal MRI. We report a case of visual loss due to the physiologic pituitary enlargement of nonfunctioning adenoma during pregnancy, which regressed spontaneously after delivery without any surgery.
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9
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10
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Khoo CM, Lee KO. Endocrine emergencies in pregnancy. Best Pract Res Clin Obstet Gynaecol 2013; 27:885-91. [PMID: 24016619 DOI: 10.1016/j.bpobgyn.2013.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 08/08/2013] [Accepted: 08/09/2013] [Indexed: 12/20/2022]
Abstract
Endocrine emergencies in pregnancy are rare and are more likely to occur in the absence of good obstetric care. Serious thyroid and diabetes related events in pregnancy are more common because of their higher prevalence in the normal population. Pituitary complications in pregnancy are now relatively rare. A high index of suspicion is needed for early diagnosis, and medical treatment is directed primarily at maintaining maternal hemodynamic stability. A close liaison between an endocrinologist, maternal-fetal specialist and intensivist is critical in optimising both maternal and fetal outcomes.
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Affiliation(s)
- Chin Meng Khoo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Rd NUHS Tower Blk L10, Singapore 119228, Singapore
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11
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Bellastella A, Bizzarro A, Colella C, Bellastella G, Sinisi AA, De Bellis A. Subclinical diabetes insipidus. Best Pract Res Clin Endocrinol Metab 2012; 26:471-83. [PMID: 22863389 DOI: 10.1016/j.beem.2011.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Subclinical central diabetes insipidus (CDI) can be the outcome of a number of diseases that affect the hypothalamus-infundibulum-post hypophysis axis. One of the most common forms of subclinical CDI is linked to an autoimmune pathogenesis even if other causes may be also responsible. Among these, pregnancy, traumatic and surgical brain injury and some infiltrative, vascular, infectious and neoplastic diseases have been reported with increasing frequency. The natural history of autoimmune CDI seems to evolve through 4 functional stages according to the presence of antibodies to vasopressin-secreting cells (AVPcAb) and the relationship between their behavior overtime, the variations of posterior pituitary function and the characteristics of hypothalamic-hypophyseal region on magnetic resonance imaging. This staging is of crucial importance for the therapeutic strategy, taking into account that some stages could be still reversible. Several medical treatments have been suggested to interrupt the progression toward clinical CDI but the results are still discussed.
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Affiliation(s)
- Antonio Bellastella
- Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, Via Leonardo Bianchi, Monaldi Hospital, 80131 Naples, Italy
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12
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Irreversibel coma na hypoglykemie bij het syndroom van Sheehan met bijnierschorsinsufficiëntie. Crit Care 2011. [DOI: 10.1007/s12426-011-0073-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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13
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Díaz-Gómez JL, Seigel T, Schmidt U, Pino RM, Bittner EA. Acute hypopituitarism in a pregnant patient after cardiac gunshot injury. J Clin Anesth 2011; 23:414-7. [PMID: 21741812 DOI: 10.1016/j.jclinane.2010.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Revised: 08/26/2010] [Accepted: 09/07/2010] [Indexed: 11/18/2022]
Abstract
Sheehan's syndrome is a well described entity that refers to hypopituitarism with pituitary infarction secondary to postpartum shock or hemorrhage. Antepartum pituitary infarction is a very rare condition that has been reported only in patients with longstanding type 1 diabetes mellitus or uncontrolled gestational diabetes. A case of severe, acute hypopituitarism in the setting of hemorrhagic shock from a gunshot wound is presented. Our case report highlights the importance of including hypopituitarism in the differential diagnosis of a critically ill parturient.
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Affiliation(s)
- José L Díaz-Gómez
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
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14
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Ertek S, Erdogan G. Postpartum thyroiditis and hypothalamo-hypophysial insufficiency in the same woman with successive pregnancies: a case report. Gynecol Endocrinol 2010; 26:105-8. [PMID: 19718560 DOI: 10.3109/09513590903215532] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Although the incidence of postpartum autoimmune disorders of endocrine glands are not rare, the presence of two different entities in the same patient with two different pregnancies is uncommon. METHODS We present a 35-year-old woman whose story starts with her first pregnancy when she was 29 years old, she had the diagnosis of postpartum thyroiditis with hypothyroidism.We followed up the patient when she had her second pregnancy. RESULTS When she was being followed up with levothyroxine replacement, 5 years later she had her second delivery after which she had complaints of polydipsia, polyuria, weight loss and had the diagnosis of central diabetes insipitus and she has started desmopressin treatment and 17 months later the delivery she again applied with amenorrhea, continuation of lactation later she noticed oligomenorrhea, and her gonadotropin levels were found to be low as well as her TSH levels, although the L-thyroxine treatment dose was not changed. Dynamic tests of hypophysis revealed hypophyseal insufficiency and repeated hypophyseal MRI was in concordance with lymphocytic hypophysitis which explains the pattern of endocrinological abnormalities after the second delivery. CONCLUSION This case signals role of autoimmune mechanisms underlying the endocrinopathies seen after successive pregnancies of the same patient.
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Affiliation(s)
- Sibel Ertek
- Department of Endocrinology and Metabolic Diseases, Ufuk University Medical Faculty, Dr. Ridvan Ege Hospital, Ankara, Turkey.
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15
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Soares DV, Conceição FL, Vaisman M. [Clinical, laboratory and therapeutics aspects of Sheehan's syndrome]. ACTA ACUST UNITED AC 2009; 52:872-8. [PMID: 18797595 DOI: 10.1590/s0004-27302008000500020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Accepted: 05/22/2008] [Indexed: 11/22/2022]
Abstract
Sheehan's syndrome is characterized by hypopituitarism that occurs as a result of ischemic pituitary necrosis due to severe postpartum hemorrhage. Nowadays it is not usually seen in developed countries because of the improvements in obstetric care. However, in developing countries it is still frequent and probably one of the most common causes of hypopituitarism. Most patients usually present it months to years later, with a history of failure of postpartum lactation, failure to resume menses and other signs of panhypopituitarism. In mild forms of the disease, patients may remain undetected and do not receive treatment for many years. Early diagnosis and appropriate treatment are important to reduce the morbimortality of the patients with Sheehan's syndrome. The aim of this review is to describe clinical, laboratory and therapeutic aspects of Sheehan's syndrome, including our experience in the replacement of recombinant GH in these patients.
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Affiliation(s)
- Débora Vieira Soares
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, RJ, Brazil.
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16
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Errarhay S, Kamaoui I, Bouchikhi C, Châara H, Bouguern H, Tizniti S, Melhouf A, Banani A. Sheehan's Syndrome A Case Report and Literature Review. Libyan J Med 2009; 4:81-2. [PMID: 21483515 PMCID: PMC3066722 DOI: 10.4176/081201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Post-partum pituitary necrosis (Sheehan's syndrome) is a rare complication of post-partum hemorrhage. The diagnosis can be erratic and often delayed. In this case report of Sheehan's syndrome in the post-partum period, the signs were characterized by agalactia, severe hypoglycemia, and low serum levels of thyroid hormones, cortico-adrenal hormones, and gonadotrophin (FSH, LH). The hypophyseal magnetic resonance imaging confirmed the diagnosis of hypopituitarism secondary to pituitary necrosis.
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Affiliation(s)
- S Errarhay
- Department of gynecology and obstetrics, University Hospital of Fez, Morocco
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17
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Ducarme G, Châtel P, Luton D. [Postpartum endocrine syndrome]. JOURNAL DE GYNECOLOGIE, OBSTETRIQUE ET BIOLOGIE DE LA REPRODUCTION 2008; 37:223-228. [PMID: 18314279 DOI: 10.1016/j.jgyn.2008.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Revised: 01/09/2008] [Accepted: 01/16/2008] [Indexed: 05/26/2023]
Abstract
Postpartum endocrine syndromes occur in the year after delivery. They are due to immunologic and vascular modifications during pregnancy. The Sheehan syndrome is the first described postpartum endocrine syndrome and consists on a hypophyse necrosis in relation with a hypovolemic shock during delivery. The immunologic consequences of the pregnancy are the most frequent, sometimes discrete and transitory. The physiological evolution of the endocrine glands during pregnancy and the most frequent post-partum endocrine syndromes are discussed: postpartum lymphocytic hypophysitis, thyroiditis and Sheehan' syndrome.
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Affiliation(s)
- G Ducarme
- Service de gynécologie obstétrique, hôpital Beaujon, Assistance publique-hôpitaux de Paris (AP-HP), université Paris-7, 100, boulevard du Général-Leclerc, 92110 Clichy, France.
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18
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Tuberculum sellae meningioma symptomatic during pregnancy: pathophysiological considerations. Acta Neurochir (Wien) 2008; 150:189-93; discussion 193. [PMID: 18213441 DOI: 10.1007/s00701-007-1417-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Accepted: 10/08/2007] [Indexed: 10/22/2022]
Abstract
A 31 year old woman in her second pregnancy presented in the 31st (+4) week of gestation with progressive visual impairment of the right eye. Magnetic resonance imaging (MRI) demonstrated a tuberculum sellae meningioma that was displaced upward by a markedly enlarged pituitary gland. Neuro-ophthalmological follow-up examinations showed a progressive decrease of visual acuity and right temporal field loss. Therefore, a caesarean section was performed in the 34th (+8) week. The meningioma was removed three days after childbirth via a right-sided pterional approach. Post-operatively, visual function was completely restored. Immunohistochemical examination showed positive staining for progesterone receptors (PR) in approximately 50% of tumour cells. Enlargement of the pituitary gland during late pregnancy in conjunction with a preexisting tuberculum sellae meningioma is the most likely pathophysiological factor responsible for visual loss. Enlargement of the PR-positive meningioma in the hormonal milieu of pregnancy might have contributed additionally to visual loss.
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19
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Errarhay S, Kamaoui I, Bouchikhi C, Châara H, Bouguern H, Tizniti S, Melhouf A, Banani A. Sheehan’s Syndrome A Case Report and Literature Review. Libyan J Med 2008. [DOI: 10.3402/ljm.v4i2.4817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- S. Errarhay
- Department of gynecology and obstetrics, University Hospital of Fez, Morocco
| | - I. Kamaoui
- Department of gynecology and obstetrics, University Hospital of Fez, Morocco
| | - C. Bouchikhi
- Department of gynecology and obstetrics, University Hospital of Fez, Morocco
| | - H. Châara
- Department of gynecology and obstetrics, University Hospital of Fez, Morocco
| | - H. Bouguern
- Department of gynecology and obstetrics, University Hospital of Fez, Morocco
| | - S. Tizniti
- Department of gynecology and obstetrics, University Hospital of Fez, Morocco
| | - A. Melhouf
- Department of gynecology and obstetrics, University Hospital of Fez, Morocco
| | - A. Banani
- Department of gynecology and obstetrics, University Hospital of Fez, Morocco
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Takano T, Saito J, Soyama A, Ito H, Iizuka T, Yoshida T, Nishikawa T. Normal delivery following an uneventful pregnancy in a Japanese acromegalic patient after discontinuation of octreotide long acting release formulation at an early phase of pregnancy. Endocr J 2006; 53:209-12. [PMID: 16618979 DOI: 10.1507/endocrj.53.209] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We report a 35-year-old woman with active acromegaly despite pituitary surgery and irradiation who received continuous octreotide LAR treatment for the control of GH excess until discovery of her pregnancy. The patient delivered a healthy boy following an uneventful pregnancy after discontinuing octreotide LAR as soon as possible at the early phase of pregnancy. Despite a substantial maternal-fetal transfer of octreotide, postnatal development was normal at 3 years of age. In almost all previously described cases, octreotide was discontinued after pregnancy was confirmed. No side-effects of mother or fetus have been reported. Octreotide treatment in pregnancy seems to be feasible and safe. Due to the still-limited number of reported cases treated with octreotide LAR, the potential benefits of octreotide LAR treatment should be weighed carefully against its possible risks.
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Abstract
The case of a parturient, who first presented with a partial oculomotor nerve palsy shortly after caesarean delivery while participating in a clinical trial, is presented. The anaesthesia for the caesarean delivery involved a combined spinal-epidural with intrathecal bupivacaine and postoperative epidural pethidine patient-controlled analgesia. The trial was examining the possible effects of magnesium infusions on acute and chronic pain. The partial oculomotor nerve palsy was an unusual presentation and the signs and symptoms were transient. Magnetic resonance imaging confirmed the presence of a presumed pituitary macroadenoma. Possible reasons for the timing of onset and the rapid resolution of symptoms, and the implications and management of pituitary pathology in the peripartum period, are considered. The uncomplicated course of a later caesarean delivery in the same patient, using the same anaesthesia technique, is also noted.
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Affiliation(s)
- M J Paech
- School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia
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Abstract
Common medical conditions, such as head trauma, malignancy,and pregnancy may be associated with rarely seen metabolic emergencies that require prompt recognition and therapy. Although care of the primary disorder is the focus of initial management,identification of the associated endocrinopathy is important. These clinical syndromes, although uncommon, must be considered when evaluating patients, as prompt treatment may minimize the mortality and morbidity of these conditions.
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Affiliation(s)
- Mary Lynn Arvanitis
- Emergency Medicine, Covenant HealthCare, 800 Cooper Avenue, Saginaw, MI 48602, USA
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24
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Wilkinson DA, Popham PA. Seizures and the pituitary gland during pregnancy. Anaesth Intensive Care 2005; 32:835-7. [PMID: 15648999 DOI: 10.1177/0310057x0403200620] [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: 11/16/2022]
Abstract
We present the anaesthetic management of a woman who, at 10 days post partum, suffered a series of convulsions in the context of two episodes of post partum haemorrhage. The probable aetiology of the convulsions is discussed.
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Affiliation(s)
- D A Wilkinson
- Department of Anaesthesia, Royal Women's Hospital, Melbourne, Victoria
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25
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Abstract
Prolactinomas are the most frequent pituitary tumors. Treatment of infertility in such tumors usually is very successful. On the other hand, reports of pituitary tumor growth during pregnancy have been described since bromocriptine started to be used. Since then, dopamine agonists (DA) have been increasingly used as the first-choice treatment of prolactinomas, with surgery being reserved for resistance or persistent intolerance to DA or for special situations. More recently other DA, such as quinagolide and cabergoline have shown better tolerance than bromocriptine with similar or greater efficacy. Cabergoline is now the first choice drug but its use in pregnancy is still under evaluation. We followed 71 term pregnancies in women bearing microprolactinomas. Of the 22 patients with previous surgery, none presented symptoms of tumor growth. Of the 41 pregnant patients treated with bromocriptine alone, only one (2.4%) presented with headaches, which regressed with drug reintroduction. Fifty one term pregnancies in patients with macroprolactinomas were followed by us. Of those, 21 were in patients with previous surgery and none of them presented clinical evidence of tumor growth. On the other hand, of the 30 patients treated only with pre-gestational bromocriptine, 11 (37%) manifested complaints related to tumor growth. A non-hormonal contraceptive should be the use along with a DA drug until tumor shrinkage within sellar boundaries has been evidenced. After pregnancy has been confirmed, the DA can be withdrawn and the patient must be closely followed. If tumor expansion is suspected, confirmation can be made through MRI and by visual field testing. Reintroduction of bromocriptine in such cases can lead to tumor reduction and clinical improvement. Surgery can also be employed as treatment for symptomatic tumor growth in pregnancy.
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Affiliation(s)
- Marcello Delano Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of S. Paulo Medical School, Av 9 de Julho 3858, 01406-100, S. Paulo, SP, Brazil.
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Abstract
Pregnancy is a normal biologic process, but because of a variety of physiologic factors, it increases a woman's risk for death. Maternal deaths in pregnancy may be due to conditions unique to pregnancy, conditions associated with pregnancy, or conditions unrelated to but exacerbated by pregnancy. Death may occur during any trimester, during labor/birth, or postpartum. In this report, we present 45 cases of pregnancy-related maternal deaths that were investigated and autopsied at the Dallas County Medical Examiners office between 1977 and 1999, and we review the topic of pregnancy-related maternal death.
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Affiliation(s)
- Joseph A Prahlow
- South Bend Medical Foundation, Indiana University School of Medicine--South Bend Center for Medical Education at the University of Notre Dame, South Bend, Indiana, USA.
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27
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Abstract
PURPOSE OF REVIEW This review aims to summarize current knowledge about prolactin, and outlines recent information that affects the management of patients with hyperprolactinaemia. RECENT FINDINGS The actions of prolactin have been clarified by studies of prolactin-receptor-deficient mice, which have a clear phenotype of reproductive failure at multiple sites. The treatment of patients with hyperprolactinaemia or prolactinoma is largely achieved using dopamine agonist drugs, which induce the shrinkage of pituitary prolactinomas as well as control of the endocrine syndrome. Recent findings indicate that successful cabergoline treatment may be able to induce long-term remission, allowing drug withdrawal in a substantial proportion of patients. SUMMARY At present, dopamine agonist drugs remain the best treatment for hyperprolactinaemic patients, and can help most affected women achieve pregnancy. Future work is likely to help understand the basis of long-term remission in patients with pituitary prolactinomas.
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Affiliation(s)
- Julian R E Davis
- Department of Endocrinology, Manchester Royal Infirmary, Manchester, UK.
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Catinois ML, Chabre O, Chirossel C, Pellat JM, Payen JF. [Sheehan's syndrome: an erratic diagnosis in the early postpartum]. ACTA ACUST UNITED AC 2004; 23:508-12. [PMID: 15158244 DOI: 10.1016/j.annfar.2004.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2003] [Accepted: 01/20/2004] [Indexed: 11/27/2022]
Abstract
Post-partum pituitary necrosis (Sheehan's syndrome) is a rare complication of the post-partum haemorrhage. The diagnosis can be erratic and often delayed. We report the case of a patient who had headaches and meningitis signs few hours after a post-partum haemorrhage. Magnetic Resonance Imaging (MRI) performed at day 2 showed a specific hypophysitis. The onset of asthenia, loss of weight, polyuro-polydipsy, persistent amenorrhoea and absence of lactation led to hormonal investigation. This permitted to diagnose global antehypopituitarism associated with diabetes insipidus. Progressive pituitary atrophy due to necrosis was found using MRI follow-up over 1 year. Our report summarises pathophysiological features of Sheehan's syndrome and early clinical and biological signs are discussed. MRI of the sellar region may be useful to early suspect the diagnosis.
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Affiliation(s)
- M-L Catinois
- Département d'anesthésie-réanimation, hôpital Michallon, 38043 Grenoble, France.
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31
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Severe Hypernatremia After Cesarean Delivery Secondary to Transient Diabetes Insipidus of Pregnancy. Obstet Gynecol 2003. [DOI: 10.1097/00006250-200311001-00016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sam S, Molitch ME. Timing and special concerns regarding endocrine surgery during pregnancy. Endocrinol Metab Clin North Am 2003; 32:337-54. [PMID: 12800535 DOI: 10.1016/s0889-8529(03)00012-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pregnancy may occur in the setting of endocrine diseases or be the first time these diseases manifest clinically. Management of pregnancy in these circumstances is challenging and requires a high degree of vigilance on the part of the treating physicians. The best outcome is achieved by a multidisciplinary approach consisting of endocrinology, obstetrics, anesthesiology, and endocrine surgery.
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Affiliation(s)
- Susan Sam
- Division of Endocrinology, Metabolism, and Molecular Medicine, Feinberg School of Medicine, Northwestern University, 303 East Chicago Avenue, Chicago, IL 60611, USA.
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Successful Pregnancy in a Woman With Acromegaly Treated With Octreotide Long-acting Release. ACTA ACUST UNITED AC 2003. [DOI: 10.1097/00019616-200301000-00005] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- M Biswas
- Swansea NHS Trust, Singleton Hospital, Sketty, UK
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Affiliation(s)
- Ron Swensen
- Department of Gynecology and Obstetrics, Loma Linda University School of Medicine, California 92354, USA.
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Colao A, di Sarno A, Pivonello R, di Somma C, Lombardi G. Dopamine receptor agonists for treating prolactinomas. Expert Opin Investig Drugs 2002; 11:787-800. [PMID: 12036422 DOI: 10.1517/13543784.11.6.787] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Prolactinomas are the most common hormone-secreting pituitary tumours and cause infertility and gonadal and sexual dysfunction in both sexes. The approach to prolactinomas has changed in the last 25 years thanks to the availability of dopaminergic drugs characterised by a potent prolactin-inhibitory effect, a tumour shrinking effect associated with a satisfactory tolerability. In more recent years, cabergoline 1-[(6-allelylergolin-8beta-yl)carbonyl]-1-[3-(dimethylamino) propyl]-3-ethyl-urea an ergoline derivative with potent, selective and long-lasting inhibitory activity on prolactin release, has been used to suppress prolactin secretion in women with hyperprolactinaemia. Cabergoline was shown to be significantly more effective than bromocriptine in inducing a complete biochemical response and clinical efficacy and was better tolerated than bromocriptine in the majority of patients. Notable tumour shrinkage until tumour disappearance was observed during cabergoline treatment in most patients with macroprolactinoma and it was also proven effective in patients resistant to or with a poor response to bromocriptine. In view of the limited data on cabergoline-associated pregnancies and the long half-life of the drug, it is currently recommended that women hoping to become pregnant, once ovulatory cycles have been established, should discontinue cabergoline therapy 1 month before they intend to conceive. However, no data concerning negative effects on pregnancy or offspring have been reported. The great efficacy of this compound together with its excellent tolerability makes this drug the current treatment of choice for the majority of patients with hyperprolactinaemic disorders.
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Affiliation(s)
- Annamaria Colao
- Department of Molecular and Clinical Endocrinology and Oncology, Federico II University of Naples, via S. Pansini 5, 80131 Naples, Italy.
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Affiliation(s)
- Elaine S Mallmann
- Gynecologic Endocrinology Unit, Division of Endocrinology, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
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Fassnacht M, Capeller B, Arlt W, Steck T, Allolio B. Octreotide LAR treatment throughout pregnancy in an acromegalic woman. Clin Endocrinol (Oxf) 2001; 55:411-5. [PMID: 11589686 DOI: 10.1046/j.1365-2265.2001.01304.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We report a 24-year-old woman with active acromegaly despite pituitary surgery and irradiation who received continuous octreotide LAR treatment for the control of GH excess throughout her pregnancy. The patient delivered a healthy girl following an uneventful pregnancy. Despite a substantial materno-fetal transfer of octreotide, postnatal development was normal with length parameters around the 50th percentile at 3 months of age. In almost all previously described cases (n = 13) octreotide was stopped after the diagnosis of pregnancy was established. No side-effects of mother or fetus have been reported. Octreotide treatment in pregnancy seems to be feasible and safe. Due to the still-limited number of reported cases, the potential benefits of octreotide treatment should be weighed carefully against its possible risks.
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Affiliation(s)
- M Fassnacht
- Department of Endocrinology, University of Wuerzburg, Germany.
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39
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Lust K, McIntyre HD, Morton A. Sheehan's syndrome--acute presentation with hyponatraemia and headache. Aust N Z J Obstet Gynaecol 2001; 41:348-51. [PMID: 11592560 DOI: 10.1111/j.1479-828x.2001.tb01247.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- K Lust
- Department of Endocrinology and Obstetric Medicine, Mater Misericordiae Mothers' Hospital, South Brisbane, Queensland, Australia
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41
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Affiliation(s)
- M Smith
- Department of Neuroanaesthesia, University College London Hospitals, UK
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Musolino NR, Cunha Neto MB, Bronstein MD. Cabergolina como alternativa no tratamento clínico de prolactinomas. experiência na intolerância/resistência à bromocriptina. ACTA ACUST UNITED AC 2000. [DOI: 10.1590/s0004-27302000000200006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Cabergolina (CAB, Pharmacia) é um agonista dopaminérgico derivado do ergot com longa ação após administração oral, que já tem demonstrado ser de utilidade para o tratamento da hiperprolactinemia. Quarenta e cinco pacientes (36 mulheres, 9 homens) com prolactinomas (27 micro, 18 macro), intolerantes e/ou resistentes à bromocriptina (BRC) foram tratados com dose semanal de CAB de 0,25 a 7mg (mediana: 1 mg) dividida de 1 a 7 administrações. O tratamento, em compassionate basis, variou de 1 a 38 meses (mediana: 12 meses). Entre os 38 pacientes com intolerância persistente à BRC (sintomas digestivos, n=27; hipotensão postural, n=13; congestão nasal, n=5; manifestações psiquiátricas, n=4; retenção urinaria, n=1), somente 5 permaneceram intolerantes à CAB (sintomas digestivos, n=2; hipotensão postural, n=2; congestão nasal, n=1). Todos aqueles que toleraram bem a BRC também o fizeram com CAB. Onze casos alcançaram normalização da prolactina durante o uso de BRC. Estes pacientes e outros 19 também resolveram a hiperprolactinemia com CAB. Entretanto, somente 3 dos 7 pacientes resistentes (dose diária de BRC de 10 a 25mg) tiveram a prolactina sérica normalizada durante o uso de CAB. Redução tumoral foi documentada por ressonância magnética ou tomografia computadorizada em 7 macroprolactinomas durante o tratamento com CAB. Assim, devido à sua excelente eficácia, tolerabilidade e comodidade posológica, a CAB apresenta-se como importante alternativa no tratamento clínico dos prolactinomas.
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