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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.
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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
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Barraud S, Guédra L, Delemer B, Raverot G, Ancelle D, Fèvre A, Jouanneau E, Litré CF, Wolak-Thierry A, Borson-Chazot F, Decoudier B. Evolution of macroprolactinomas during pregnancy: A cohort study of 85 pregnancies. Clin Endocrinol (Oxf) 2020; 92:421-427. [PMID: 31957911 DOI: 10.1111/cen.14162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 01/09/2020] [Accepted: 01/13/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Pregnancy in patients with macroprolactinomas has been associated with a higher risk of pituitary tumour growth. However, the incidence and risk factors remain unclear. We aimed to evaluate the evolution of macroprolactinomas during pregnancy and to identify potential risk factors. DESIGN, PATIENTS AND MEASUREMENTS This is a two-centre, retrospective, observational study. All patients with macroprolactinomas, treated with a dopamine receptor agonist (DA), and who had at least one pregnancy were included. RESULTS There were a total of 85 viable pregnancies in 46 patients with macroprolactinomas. At diagnosis, mean size of pituitary adenomas was 17.9 ± 8.2 mm (10-43 mm) and mean plasma prolactin level was 1012.2 ± 1606.1 µg/L (60-7804 µg/L). Tumour growth-related symptoms were identified 12 times in 9 patients (19.6%) including 3 cases of apoplexy. Restarting, changing and/or increasing DA treatment was effective in 10 cases. Emergency surgery had to be performed twice (due to pituitary apoplexy). Patients with tumour progression tended to present with larger tumours after initial treatment and before pregnancy (9.9 vs 5.9 mm; P = .0504 and 11.5 vs 7.3 mm; P = .0671, respectively), whereas adenoma size at diagnosis did not seem to be a significant factor. The obstetrical outcomes were comparable to the general population. CONCLUSIONS Symptomatic growth of macroprolactinoma during pregnancy occurred in 19.6% of medically treated patients. This risk seems higher for patients with poor initial tumour response to the DA treatment. Tumour progression is generally well controlled with medical treatment during pregnancy.
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Affiliation(s)
- Sara Barraud
- Université de Reims Champagne-Ardenne UFR de Médecine, Reims, France
- Service d'Endocrinologie - Diabète - Nutrition, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Lucile Guédra
- Service d'Endocrinologie - Diabète - Nutrition, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Brigitte Delemer
- Université de Reims Champagne-Ardenne UFR de Médecine, Reims, France
- Service d'Endocrinologie - Diabète - Nutrition, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Gérald Raverot
- Fédération d'Endocrinologie, Centre de Référence des Maladies Rares Hypophysaires HYPO, Groupement Hospitalier Est, Hospices Civiles de Lyon, Bron, France
| | - Déborah Ancelle
- Service d'Endocrinologie - Diabète - Nutrition, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Anne Fèvre
- Service d'Endocrinologie - Diabète - Nutrition, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Emmanuel Jouanneau
- Service de Neurochirurgie B, Groupement Hospitalier Est, Hospices Civiles de Lyon, Bron, France
| | - Claude-Fabien Litré
- Université de Reims Champagne-Ardenne UFR de Médecine, Reims, France
- Neurochirurgie, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Aurore Wolak-Thierry
- Unité d'aide méthodologique, pôle recherche et santé publique, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Françoise Borson-Chazot
- Fédération d'Endocrinologie, Centre de Référence des Maladies Rares Hypophysaires HYPO, Groupement Hospitalier Est, Hospices Civiles de Lyon, Bron, France
| | - Bénédicte Decoudier
- Service d'Endocrinologie - Diabète - Nutrition, Centre Hospitalier Universitaire de Reims, Reims, France
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Sant' Anna BG, Musolino NRC, Gadelha MR, Marques C, Castro M, Elias PCL, Vilar L, Lyra R, Martins MRA, Quidute ARP, Abucham J, Nazato D, Garmes HM, Fontana MLC, Boguszewski CL, Bueno CB, Czepielewski MA, Portes ES, Nunes-Nogueira VS, Ribeiro-Oliveira A, Francisco RPV, Bronstein MD, Glezer A. A Brazilian multicentre study evaluating pregnancies induced by cabergoline in patients harboring prolactinomas. Pituitary 2020; 23:120-128. [PMID: 31728906 DOI: 10.1007/s11102-019-01008-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the maternal-fetal outcomes of CAB-induced pregnancies in patients with prolactinoma in a large cohort. METHODS The prevalence of tumor growth, miscarriage, preterm, low birth weight, congenital malformations and impairment in neuropsychological development in children among women treated with CAB were assessed in a Brazilian multicentre retrospective observational study, RESULTS: We included 194 women with a mean age of 31 (17-45) years, 43.6% presenting microadenomas and 56.4% macroadenomas, at prolactinoma diagnosis. In 233 pregnancies, CAB was withdrawn in 89%, after pregnancy confirmation. Symptoms related to tumor growth occurred in 25 cases, more frequently in macroadenomas. The overall miscarriage rate was 11%, although higher in the subgroup of patients with CAB maintainance after pregnancy confirmation (38% vs. 7.5%). Amongst the live-birth deliveries, preterm occurred in 12%, low birth weight in 6% and congenital malformations in 4.3%. Neuropsychological development impairment was reported in 7% of cases. CONCLUSIONS Our findings confirm previous results of safety in maternal and fetal outcomes in CAB-induced pregnancies; nevertheless, CAB maintenance after pregnancy confirmation was associated with higher miscarriage rate; result that must be further confirmed.
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Affiliation(s)
- B G Sant' Anna
- Division of Endocrinology and Metabolism, Hospital das Clinicas, Neuroendocrine Unit, University of Sao Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, no 155, 8° andar, bloco 3 (Endocrinologia), Sao Paulo, SP, 05403-000, Brazil.
| | - N R C Musolino
- Division of Neurosurgery, Institute of Psychiatry, University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - M R Gadelha
- Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - C Marques
- Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
| | - M Castro
- University of Sao Paulo Medical School of Ribeirao Preto, Ribeirao Preto, SP, Brazil
| | - P C L Elias
- University of Sao Paulo Medical School of Ribeirao Preto, Ribeirao Preto, SP, Brazil
| | - L Vilar
- Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | - R Lyra
- Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | - M R A Martins
- Federal University of Ceara, Fortaleza, Ceara, Brazil
| | - A R P Quidute
- Federal University of Ceara, Fortaleza, Ceara, Brazil
| | - J Abucham
- Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
| | - D Nazato
- Escola Paulista de Medicina, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
| | - H M Garmes
- State University of Campinas, Campinas, SP, Brazil
| | | | - C L Boguszewski
- Endocrine Division (SEMPR), Department of Internal Medicine, Federal University of Parana, Curitiba, Parana, Brazil
| | - C B Bueno
- Irmandade da Santa Casa de Misericórdia de São Paulo, Sao Paulo, SP, Brazil
| | - M A Czepielewski
- Division of Endocrinology, Hospital de Clinicas de Porto Alegre (UFRGS), Porto Alegre, Rio Grande do Sul, Brazil
| | - E S Portes
- Institute of Medical Assistance to the State Public Hospital, Sao Paulo, SP, Brazil
| | - V S Nunes-Nogueira
- São Paulo State University (UNESP), Medical School, Botucatu, SP, Brazil
| | - A Ribeiro-Oliveira
- Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - R P V Francisco
- Disciplina de Obstetrícia, Departamento de Obstetrícia e Ginecologia, Faculdade de Medicina (FMUSP), Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - M D Bronstein
- Division of Endocrinology and Metabolism, Hospital das Clinicas, Neuroendocrine Unit, University of Sao Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, no 155, 8° andar, bloco 3 (Endocrinologia), Sao Paulo, SP, 05403-000, Brazil
| | - A Glezer
- Division of Endocrinology and Metabolism, Hospital das Clinicas, Neuroendocrine Unit, University of Sao Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, no 155, 8° andar, bloco 3 (Endocrinologia), Sao Paulo, SP, 05403-000, Brazil
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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.
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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.
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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.
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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.
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Jallad RS, Shimon I, Fraenkel M, Medvedovsky V, Akirov A, Duarte FH, Bronstein MD. Outcome of pregnancies in a large cohort of women with acromegaly. Clin Endocrinol (Oxf) 2018; 88:896-907. [PMID: 29574986 DOI: 10.1111/cen.13599] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/15/2018] [Accepted: 03/16/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the outcome of pregnancies in a large cohort of women with acromegaly. DESIGN AND METHODS This is a retrospective analysis of 31 pregnancies in 20 patients with acromegaly. RESULTS Twenty-seven pregnancies resulted in healthy offspring, and 4 resulted in abortion. Three patients underwent transsphenoidal surgery during pregnancy. IGF-1 levels remained elevated during pregnancy in 4 pregnancies and normalized in 23 cases. Fifteen cases were followed during pregnancy without any medical or surgical treatment, and 13 of these exhibited normal IGF-1 levels. Before or during pregnancy, somatostatin receptor ligands usage was not associated with higher risk for adverse outcomes. Arterial hypertension worsening (45%) and impairment of glucose levels (32%) were the most common complications during pregnancies. There were no maternal or neonatal deaths. One woman delivered twins. Two cases of congenital malformations and one with foetal macrosomia were observed. Caesarean delivery was performed in sixteen cases. CONCLUSION Our study confirms the impact of gestation on IGF-1 levels. However, it also indicates that acromegaly still holds an increased risk for worsening of comorbidities, especially in uncontrolled patients.
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Affiliation(s)
- R S Jallad
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - I Shimon
- Institute of Endocrinology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - M Fraenkel
- Endocrinology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - V Medvedovsky
- Endocrinology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - A Akirov
- Institute of Endocrinology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - F H Duarte
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
- Endocrine Service, AC Camargo Cancer Center, São Paulo, Brazil
| | - M D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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Perdomo CM, Árabe JA, Idoate MÁ, Galofré JC. Management of a pregnant woman with thyrotropinoma: a case report and review of the literature. Gynecol Endocrinol 2017; 33:188-192. [PMID: 27910710 DOI: 10.1080/09513590.2016.1260110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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
INTRODUCTION Pituitary disorders during pregnancy are uncommon. The approach should include a close follow-up in order to reduce maternal and fetal risks associated with physiological changes during pregnancy or treatment side effects. MATERIALS AND METHODS We report a 21-year-old woman with a thyroid-stimulating hormone-secreting pituitary macroadenoma and positive antithyroid antibodies. She was initially treated using transsphenoidal pituitary surgery. The patient relapsed 17-month post-surgery. Somatostatin analog therapy was started which rapidly controlled the hyperthyroidism. Eleven months later, while receiving octreotide, the patient reported to be pregnant and the medication was stopped. Gestation and delivery went well with a healthy full-term newborn. The patient developed a postpartum thyroiditis 15 weeks after giving birth. Twenty-eight months postpartum the patient remains euthyroid without medication. CONCLUSIONS The overall positive outcomes of the four cases reported in literature, including this new case, suggest that pregnancy should not be absolutely contraindicated in women with thyrotropinomas. We emphasize the effectiveness of octreotide to control hyperthyroidism, as well as stopping medication when a patient is found to be pregnant. In our case, close observation following octreotide cessation had a positive outcome.
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Affiliation(s)
- Carolina M Perdomo
- a Department of Endocrinology and Nutrition , Clínica Universidad de Navarra, University of Navarra , Pamplona , Spain
| | - Jorge A Árabe
- b Department of Pathological Anatomy , Clínica Universidad de Navarra, University of Navarra , Pamplona , Spain , and
| | - Miguel Á Idoate
- b Department of Pathological Anatomy , Clínica Universidad de Navarra, University of Navarra , Pamplona , Spain , and
| | - Juan C Galofré
- a Department of Endocrinology and Nutrition , Clínica Universidad de Navarra, University of Navarra , Pamplona , Spain
- c IdiSNA (Instituto de investigación en la Salud de Navarra) , Pamplona , Spain
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Yamaguchi R, Kohga H, Tosaka M, Sekine A, Mizushima K, Harigaya Y, Yoshimoto Y. A Case of Optic Neuritis Concomitant with Pituitary Tumor During Pregnancy. World Neurosurg 2016; 93:488.e1-4. [PMID: 27373939 DOI: 10.1016/j.wneu.2016.06.103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 06/21/2016] [Accepted: 06/22/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Optic neuritis (ON) is unilateral painful optic nerve inflammation in a young healthy female diagnosed by excluding glaucoma. ON onset during pregnancy is rare, with only 2 cases reported to date. CASE DESCRIPTION A 35-year-old previously healthy parous woman who was pregnant with her second child suffered rapidly progressive visual acuity loss. Magnetic resonance imaging (MRI) revealed a pituitary tumor. Emergency surgery was performed for optic nerve compression; however, her visual impairment worsened. Postoperative diffusion-weighted MRI showed high intensity in the bilateral optic nerves, and ON was diagnosed. Administration of methylprednisolone was effective, and her visual acuity recovered over 6 months. CONCLUSIONS Associated pituitary macroadenoma complicated the true diagnosis of ON, because contrast medium cannot be used in pregnant women. The diffusion-weighted MRI findings were useful for diagnosing this complex clinical condition.
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Affiliation(s)
- Rei Yamaguchi
- Department of Neurosurgery, General Fujioka Hospital, Fujioka, Gunma, Japan; Department of Neurosurgery, Japanese Red Cross Maebashi Hospital, Maebashi, Gunma, Japan.
| | - Hideaki Kohga
- Department of Neurosurgery, General Fujioka Hospital, Fujioka, Gunma, Japan
| | - Masahiko Tosaka
- Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Akiko Sekine
- Department of Neurology, Japanese Red Cross Maebashi Hospital, Maebashi, Gunma, Japan
| | - Kazuyuki Mizushima
- Department of Neurology, Japanese Red Cross Maebashi Hospital, Maebashi, Gunma, Japan
| | - Yasuo Harigaya
- Department of Neurology, Japanese Red Cross Maebashi Hospital, Maebashi, Gunma, Japan
| | - Yuhei Yoshimoto
- Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Carvalho JC, Lisboa PC, de Oliveira E, Peixoto-Silva N, Pinheiro CR, Fraga MC, Claudio-Neto S, Franci CR, Manhães AC, Moura EG. Effects of early and late neonatal bromocriptine treatment on hypothalamic neuropeptides, dopaminergic reward system and behavior of adult rats. Neuroscience 2016; 325:175-87. [DOI: 10.1016/j.neuroscience.2016.03.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 03/16/2016] [Accepted: 03/18/2016] [Indexed: 10/22/2022]
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Abbassy M, Kshettry VR, Hamrahian AH, Johnston PC, Dobri GA, Avitsian R, Woodard TD, Recinos PF. Surgical management of recurrent Cushing's disease in pregnancy: A case report. Surg Neurol Int 2015; 6:S640-5. [PMID: 26682090 PMCID: PMC4672578 DOI: 10.4103/2152-7806.170472] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 08/21/2015] [Indexed: 12/20/2022] Open
Abstract
Background: Cushing's disease is a condition rarely encountered during pregnancy. It is known that hypercortisolism is associated with increased maternal and fetal morbidity and mortality. When hypercortisolism from Cushing's disease does occur in pregnancy, the impact of achieving biochemical remission on fetal outcomes is unknown. We sought to clarify the impact of successful surgical treatment by presenting such a case report. Case Description: A 38-year-old pregnant woman with recurrent Cushing's disease after 8 years of remission. The patient had endoscopic transsphenoidal of her pituitary adenoma in her 18th week of pregnancy. The patient had postoperative biochemical remission and normal fetal outcome with no maternal complications. Conclusion: Transsphenoidal surgery for Cushing's disease can be performed safely during the second trimester of pregnancy.
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Affiliation(s)
- Mahmoud Abbassy
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA ; Minimally Invasive Cranial Base and Pituitary Surgery Program, Cleveland Clinic, Cleveland, Ohio, USA
| | - Varun R Kshettry
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA ; Minimally Invasive Cranial Base and Pituitary Surgery Program, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amir H Hamrahian
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, Ohio, USA
| | - Philip C Johnston
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, Ohio, USA
| | - Georgianna A Dobri
- Department of Endocrinology, Diabetes, and Metabolism, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rafi Avitsian
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Troy D Woodard
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA ; Minimally Invasive Cranial Base and Pituitary Surgery Program, Cleveland Clinic, Cleveland, Ohio, USA ; Section of Skull Base Rhinology and Sinus Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Pablo F Recinos
- Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio, USA ; Minimally Invasive Cranial Base and Pituitary Surgery Program, Cleveland Clinic, Cleveland, Ohio, USA ; Section of Skull Base Rhinology and Sinus Surgery, Head and Neck Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Adenomi ipofisari. Neurologia 2015. [DOI: 10.1016/s1634-7072(15)72180-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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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.
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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
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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.
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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
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Abstract
The pituitary gland is significantly affected during gestation in terms of both size and function. Due to this physiologic adaptation, endocrine evaluation and interpretation of imaging is far more complex than in the non-pregnant state. Pituitary disorders are rare in pregnancy, as they are usually associated with gonadal dysfunction, thereby posing difficulties with fertility. This review will focus on pituitary adenomas (prolactinomas, GH-secreting and ACTH-secreting), their diagnostic handicaps and the recommendations for treatment. We will also discuss the two pituitary disorders encountered in pregnancy, Sheehan's syndrome and lymphocytic hypophysitis.
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Affiliation(s)
| | - Maria Boudina
- Unit of Endocrinology, Theagenio Hospital, Aristotle University of Thessaloniki, Greece
| | - Niki Karavitaki
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Eleni Bili
- 1st Department of Obstetrics & Gynaecology, Aristotle University of Thessaloniki, Greece
| | - John Wass
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
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Colao A, Boscaro M, Ferone D, Casanueva FF. Managing Cushing's disease: the state of the art. Endocrine 2014; 47:9-20. [PMID: 24415169 DOI: 10.1007/s12020-013-0129-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 11/21/2013] [Indexed: 12/28/2022]
Abstract
Cushing's disease is a rare chronic disease caused by a pituitary adenoma, which leads to excess secretion of adrenocorticotropic hormone (ACTH). The over-production of ACTH leads to hyperstimulation of the adrenal glands and a chronic excess of cortisol, resulting in the signs and symptoms of a severe clinical state (Cushing's syndrome) that leads to significant morbidity, negative impacts on the patient's quality of life, and, if untreated, increased mortality. The management of patients with Cushing's disease is complicated by the heterogeneity of the condition, with signs and symptoms that overlap with those of other diseases, and high subclinical incidence rates. Controversies surrounding the tests used for screening and identifying patients with Cushing's disease add to the challenge of patient management. Surgical intervention to remove the adenoma is the first-line treatment for patients with Cushing's disease, but medical therapies are useful in patients who relapse or are unsuitable for surgery. The recent introduction of pasireotide, the first pituitary-directed medical therapy, expands the number of treatment options available for patients with Cushing's disease. This state-of-the-art review aims to provide an overview of the most recent scientific research and clinical information regarding Cushing's disease. Continuing research into improving the diagnosis and treatment of Cushing's disease will help to optimize patient management.
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Affiliation(s)
- Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Università Federico II di Napoli, Via S. Pansini 5, 80131, Naples, Italy,
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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.
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Affiliation(s)
- Marie-Eve Domingue
- Department of Endocrinology and Nutrition, Cliniques Saint-Luc, Université catholique de Louvain, Brussels, Belgium
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Hirshfeld-Cytron J, Kim HH. Treatment of infertility in women with pituitary tumors. Expert Rev Anticancer Ther 2014; 6 Suppl 9:S55-62. [PMID: 17004858 DOI: 10.1586/14737140.6.9s.s55] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Due to the pituitary's critical position, a pituitary tumor may disrupt gonadal function, either by its expanding size or the inappropriate secretion of hormones. Menstrual cycles may be disrupted even without frank hypogonadism, particularly in the case of hormone-secreting adenomas. Despite optimal medical and surgical management of pituitary tumors, ovulation-induction therapy with gonadotropins is often required to restore fertility in these women. This article will provide an overview of the therapeutic options available for women with infertility resulting from pituitary tumors. Treatment strategies including dopamine agonists, gonadotropins and the role of assisted reproductive technologies will be discussed. Unique pregnancy considerations in the female patient with hypopituitarism will also be addressed.
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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.
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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
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Cheng S, Grasso L, Martinez-Orozco JA, Al-Agha R, Pivonello R, Colao A, Ezzat S. Pregnancy in acromegaly: experience from two referral centers and systematic review of the literature. Clin Endocrinol (Oxf) 2012; 76:264-71. [PMID: 21777265 DOI: 10.1111/j.1365-2265.2011.04180.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acromegaly results from increased growth hormone and its target insulin-like growth factor-1, most commonly due to a pituitary tumour. As it is frequently accompanied by infertility, little is known about the course of this disease in pregnancy. OBJECTIVE We describe 13 new pregnancies in acromegalic women and compare their outcomes in a systematic review of the literature. METHODS We collected clinical, biochemical, imaging, and outcomes data during and following pregnancy and performed a systematic review for a total of 47 pregnancies. An extended analysis of 106 pregnancies was also performed. RESULTS In 13 newly described cases, pregnancy was un-complicated without need for additional surgical intervention. In these pregnancies, adjunctive medical therapy was required in three patients. This was in the form of somatostatin analogs (SA) (3/13) as well as pegvisomant in 1/13 to control symptomatic and biochemical progression. One 37-year-old female succeeded in having two separate pregnancies 2 years apart both without need for any form of medical therapy. Review of an additional 34 published reports allowed for an analysis of outcomes in 47 pregnancies. Adjunctive medical therapy during pregnancy was required in 15 of these cases where 12 received SA and an additional three received dopamine agonists. None of these patients developed endocrine or neurologic complications during pregnancy. In an extended analysis of 106 pregnancies, treatment during pregnancy appears to be associated with good disease control but increased risk of microsomic or macrosomic newborns depending on the medical agent used. CONCLUSIONS In 13 newly described pregnancies along with systematic review of an additional 34 cases indicate that pregnancy in treated acromegalic women can proceed without significant complications or teratogenicity. Medical treatment during pregnancy with DA or SA appears to be associated with altered neonatal weight. Nevertheless, gestation may have a beneficial impact on acromegaly control both during and following pregnancy.
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Affiliation(s)
- Sonia Cheng
- Department of Medicine, University Health Network, Toronto, ON, Canada
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Karaca Z, Kelestimur F. Pregnancy and other pituitary disorders (including GH deficiency). Best Pract Res Clin Endocrinol Metab 2011; 25:897-910. [PMID: 22115165 DOI: 10.1016/j.beem.2011.07.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
The pituitary gland is one of the most affected organs with altered anatomy and physiology during pregnancy. Acromegaly is the second most common pituitary adenoma seen in relation to gestation after prolactinomas. Acromegaly should be treated before conception to prevent potential tumor growth in patients who desire fertility. Medical therapy can be ceased safely after confirmation of pregnancy in acromegalic patients, but octreotide may be used in selected cases with compressive signs. Other hormonal and non-functional tumors are rarer and have been presented as case reports. Sheehan's syndrome, which is one of the most common causes of hypopituitarism in developing countries, and lymphocytic hypophysitis are known to be associated with pregnancy. They usually result in hypopituitarism, sometimes with delays in diagnosis and difficulties in differential diagnosis. Pregnancy is not common among patients with hypopituitarism or pituitary adenomas due to altered gonadotroph functions. Ovulation induction is essential for fertility achievement, but the replacement of other deficient pituitary hormones, including GH, seems to play an important role in the preparation of the uterus for implantation of the embryo.
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Affiliation(s)
- Zuleyha Karaca
- Erciyes University Medical School, Department of Endocrinology, Kayseri, Turkey.
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Motivala S, Gologorsky Y, Kostandinov J, Post KD. Pituitary disorders during pregnancy. Endocrinol Metab Clin North Am 2011; 40:827-36. [PMID: 22108282 DOI: 10.1016/j.ecl.2011.08.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The pituitary gland undergoes much anatomic and physiologic variation during pregnancy. Pituitary disease may have a significant impact on a patient prior to conception as well as throughout her pregnancy. It is imperative to provide care to patients affected by pituitary disease with a multidisciplinary approach involving endocrinologists, obstetricians and, when appropriate, neurosurgical care, as this group of disorders can represent a substantial level of morbidity and mortality for both mother and fetus.
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Abstract
Prolactinomas commonly cause infertility and treatment usually restores ovulation and fertility. The dopamine agonists are the preferred mode of treatment, with cabergoline generally being preferred to bromocriptine because of its higher therapeutic ratio. Experience with both drugs shows no increase in spontaneous abortions, preterm deliveries, multiple births, or congenital malformations, compared to what is expected in the normal population but the experience with bromocriptine is approximately 10-fold greater than with cabergoline. Clinically significant tumor growth may occur in 2.7% of those with microadenomas, 22.9% in those with macroadenomas without prior ablative treatment and 4.8% of those with macroadenomas with prior ablative treatment. Patients with macroadenomas should have visual fields assessed periodically during gestation. Should symptomatic tumor growth occur, reinstitution of the dopamine agonist is usually successful in shrinking the tumor but delivery if the pregnancy is sufficiently advanced is also an option and transsphenoidal debulking is rarely necessary.
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Affiliation(s)
- Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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24
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Acromegaly and pregnancy. ANNALES D'ENDOCRINOLOGIE 2011; 72:282-286. [DOI: 10.1016/j.ando.2011.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 07/11/2011] [Indexed: 11/22/2022]
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Famini P, Maya MM, Melmed S. Pituitary magnetic resonance imaging for sellar and parasellar masses: ten-year experience in 2598 patients. J Clin Endocrinol Metab 2011; 96:1633-41. [PMID: 21470998 PMCID: PMC3100749 DOI: 10.1210/jc.2011-0168] [Citation(s) in RCA: 144] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
CONTEXT Sellar and parasellar masses present with overlapping clinical and radiological features ranging from asymptomatic incidental presentations and hormonal effects to compressive local mass effects. Pituitary masses are diagnosed with increased frequency with magnetic resonance imaging (MRI) advancements and availability, but indications and diagnostic outcomes of MRI screening for sellar lesions are not defined. Although pituitary adenomas are the most frequently encountered sellar mass lesions, other etiologies should be considered in the differential diagnosis of a sellar mass. SETTING The study was conducted at a tertiary pituitary center. PATIENTS This study was a retrospective review of 2598 subjects undergoing at least one pituitary MRI scan from 1999 to 2009. MAIN OUTCOME MEASURE Prevalence and diagnosis of specific sellar and parasellar masses as screened by pituitary MRI. RESULTS The most common indications for pituitary imaging, excluding known mass follow-up, were for evaluation of hyperprolactinemia or hypogonadism. A normal pituitary gland was reported in 47% of subjects undergoing pituitary MRI. The most common pituitary adenomas initially identified by MRI included prolactinoma (40%), nonfunctioning adenoma (37%), and GH adenoma (13%). Nonadenomatous sellar masses accounted for 18% of visible lesions, of which the most common were Rathke's cleft cyst (19%), craniopharyngioma (15%), and meningioma (15%). Metastases accounted for 5% of nonpituitary lesions and breast cancer was the most common primary source. CONCLUSIONS Half of all pituitary MRI scans performed in a large patient population yielded no visible lesion. Nonadenomatous pituitary lesions should be considered in the diagnosis of sellar masses observed on MRI, and a high clinical suspicion is required to exclude the presence of a nonfunctioning pituitary adenoma.
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Affiliation(s)
- Pouyan Famini
- Departments of Medicine, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Room 2015, Los Angeles, California 90048, USA
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Abstract
Pituitary tumors, usually adenomas, account for about 10-15% of all intracranial tumors. Their treatment, which includes surgery, medicine or radiotherapy, either isolated or in combination, aims to halt tumor growth or achieve tumor shrinkage, as well as control hormone hypersecretion or ensure hormone replacement. Such approaches have made pregnancy possible for women with pituitary adenomas. Medical therapy with dopamine agonists is the treatment of choice for most patients with prolactinomas, with surgery reserved for individuals resistant to drugs. On the other hand, surgery before conception is indicated as a first-line approach in patients with acromegaly, Cushing disease or clinically nonfunctioning pituitary macroadenomas. In these patient populations, medical therapy with somatostatin analogues (acromegaly) or drugs that target the adrenal glands, such as metyrapone and ketoconazole (Cushing disease), should be reserved for those in whom surgery is unsuccessful or contraindicated.
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Affiliation(s)
- Marcello D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of São Paulo Medical School, Avenida 9 de Julho 3858, 01406-100 São Paulo, SP, Brazil.
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Stalldecker G, Mallea-Gil MS, Guitelman M, Alfieri A, Ballarino MC, Boero L, Chervin A, Danilowicz K, Diez S, Fainstein-Day P, García-Basavilbaso N, Glerean M, Gollan V, Katz D, Loto MG, Manavela M, Rogozinski AS, Servidio M, Vitale NM. Effects of cabergoline on pregnancy and embryo-fetal development: retrospective study on 103 pregnancies and a review of the literature. Pituitary 2010; 13:345-50. [PMID: 20676778 DOI: 10.1007/s11102-010-0243-6] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The aim of the study is to assess the rate of any potential adverse effects on women who became pregnant under cabergoline (CAB) treatment and to evaluate any effects on the embryo-fetal development and on children who were born from mothers exposed to CAB in early weeks of gestation. Observational, retrospective and multicenter study on 103 pregnancies in 90 women with hyperprolactinemia. All patients were under CAB at conception. Serum prolactin at baseline was between 30 and 1921 ng/ml. Duration of therapy before pregnancy ranged from 1 to 120 months and doses ranged from 0.125 to 5 mg/week. Fetal exposure ranged from 3 to 25 weeks, 96.9% of patients received CAB during the first trimester of pregnancy and the rest until the second one. No significant complications during pregnancy were found. Seven women (7.2%) had spontaneous abortions. Preterm deliveries were recorded in eight (8.8%), only one with low weight for gestational age. Neonatal abnormalities were observed in 3 (3.6%): 1 major (Down syndrome) and 2 minor malformations (umbilical and inguinal hernia). We were able to asses the children's development in 61. Two had epilepsy and two had Pervasive Developmental Disorder (PDD). No significantly higher frequency of complications was found in pregnancies and/or offspring exposed to CAB than in the normal population. We registered 2 abnormalities in the development of the children: epilepsy and PDD. Larger series of patients are needed to assess the safety of this drug during pregnancy.
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Affiliation(s)
- Graciela Stalldecker
- Departamento de Neuroendocrinología, Sociedad Argentina de Endocrinología y Metabolismo, Diaz Velez 3889, 1200 Buenos Aires, Argentina,
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Kann PH, Juratli N, Kabalan Y. Prolactinoma and hyperprolactinaemia: a transcultural comparative study between Germany as a western, liberal, industrialised country and Syria as an oriental society with a strong Islamic tradition. Gynecol Endocrinol 2010; 26:749-54. [PMID: 20500104 DOI: 10.3109/09513590.2010.487600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Prolactinomas and hyperprolactinaemia cause hypogonadism and impairment of sexual and reproductive function. In this transcultural study, clinical characteristics of prolactinoma/hyperprolactinaemia were compared between a liberal, western, industrialised country and a more traditional, Islamic, oriental society. METHODS Sixty-two Syrian patients with hyperprolactinaemia were compared to 62 German patients with hyperprolactinaemia. RESULTS In Syria and Germany, prolactinoma and hyperprolactinaemia were more frequent in females than in males (Syria 87% females; Germany 63% females). Prolactinomas were larger in males, males were older at diagnosis in both countries. Recorded clinical symptoms were comparable, even if culturally determined differences in spontaneous reporting of and asking for symptoms might be considered. The average age of the Syrian patients at diagnosis of hyperprolactinaemia was more than 6 years lower than in the German cohort (33.4 ± 10.4 vs. 39.7 ± 17.6 years). In Germany, a variety of therapeutic regimens were applied. In Syria, bromocriptine was prescribed exclusively. DISCUSSION AND CONCLUSION The differences may be attributed to culturally determined differences in sexual and reproductive behaviour, i.e. sexual intercourses of young, unmarried girls and women in association to the use of oral contraceptives regulating the menstrual cycle, maternal age at first delivery and birth frequency. Exclusive prescription of bromocriptine in Syria may be associated to limited resources and the safety of bromocriptine during pregnancy.
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Vilar L, Naves LA, Casulari LA, Azevedo MF, Albuquerque JL, Serfaty FM, Pinho Barbosa FR, de Oliveira AR, Montenegro RM, Montenegro RM, Ramos AJS, Dos Santos Faria M, Musolino NRC, Gadelha MR, Boguszewski CL, Bronstein MD. Management of prolactinomas in Brazil: an electronic survey. Pituitary 2010; 13:199-206. [PMID: 20107911 DOI: 10.1007/s11102-010-0217-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Dopamine agonists are the treatment of choice for prolactinomas. However, there are still controversies concerning dose, treatment duration and criteria for drug withdrawal in different clinical situations. The aim of this study was to assess diagnostic and therapeutic approaches to prolactinomas among members of the Brazilian Society of Endocrinology and Metabolism (SBEM). SBEM members answered a questionnaire sent by e-mail that included 18 questions related to controversial issues about the management of prolactinomas. Among SBEM members, 721 (approximately 24% of total) answered the questionnaire. Concerning the diagnosis, 38% of the respondents stated that prolactin levels < 100 ng/ml would exclude the presence of a prolactinoma. Most of them favored the screening for macroprolactin in asymptomatic individuals instead of a routine screening (74% vs. 26%). Regarding the treatment, 70% of the respondents chose cabergoline as the drug of choice to treat macroprolactinomas whereas similar proportions advised cabergoline or bromocriptine as the best treatment for microprolactinomas (52% vs. 48%). Only 20% and 34% of respondents favored treatment withdrawal 2-3 years after prolactin normalization in patients with macroprolactinomas and microprolactinomas, respectively. In case of pregnancy, only 58 and 70% of respondents advocated discontinuation of treatment with dopamine agonists in patients with macroprolactinomas and microprolactinomas, respectively. Finally, only 36% would allow breast-feeding without restriction, 44% would restrict it to patients with microprolactinomas and 20% would not recommend it for women with prolactinomas There are several points of disagreement among SBEM members regarding the management of prolactinomas.
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Affiliation(s)
- Lucio Vilar
- Division of Endocrinology, Hospital das Clinicas, Pernambuco Federal University, Rua Clovis Silveira Barros, 84/1202, Boa Vista, Recife, PE, CEP 50.050-270, Brazil.
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Prise en charge de l’acromégalie évolutive au cours de la grossesse. ANNALES D'ENDOCRINOLOGIE 2010; 71:60-3. [DOI: 10.1016/j.ando.2009.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Revised: 09/23/2009] [Accepted: 10/12/2009] [Indexed: 12/29/2022]
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Halperin Rabinovich I, Obiols Alfonso G, Soto Moreno A, Torres Vela E, Tortosa Henzi F, Català Bauset M, Gilsanz Peral A, Girbés Borràs J, Moreno Esteban B, Picó Alfonso A, Del Pozo Picó C, Zugasti Murillo A, Lucas Morante T, Páramo Fernández C, Varela da Sousa C, Villabona Artero C. Clinical practice guideline for hypotalamic-pituitary disturbances in pregnancy and the postpartum period. ACTA ACUST UNITED AC 2008; 55:29-43. [PMID: 22967849 DOI: 10.1016/s1575-0922(08)70633-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2007] [Accepted: 10/22/2007] [Indexed: 12/12/2022]
Abstract
During pregnancy, the body undergoes a major adaptation process as a result of the interaction between mother, placenta and fetus. Major anatomical and histological changes are produced in the pituitary, with an increase of up to 40% in the size of the gland. There are wide variations in the function of the hypothalamus-pituitary-thyroid axis that effect iodine balance, the overall activity of the gland, as well as transport of thyroid hormones in plasma and peripheral metabolism of thyroid hormones. The incidence of goiter and thyroid nodules increases throughout pregnancy. The management of differentiated thyroid carcinoma should be individually tailored according to tumoral type and pregnancy stage. Given the effects of hypothyroidism on fetal development, both the diagnosis and appropriate therapeutic management of thyroid hypofunction are essential. The most important modification to the hypothalamus-pituitary-adrenal axis during pregnancy is the rise in serum cortisol levels due to an increase in cortisol-binding proteins. Although Cushing's syndrome during pregnancy is infrequent, both diagnosis and treatment of this disorder are especially difficult. Adrenal insufficiency during pregnancy does not substantially differ from that occurring outside pregnancy. However, postpartum pituitary necrosis (Sheehan's syndrome) is a well-known complication that occurs after delivery and, together with lymphocytic hypophysitis, constitutes the most frequent cause of adrenal insufficiency. The management of prolactinoma during pregnancy requires suppression of dopaminergic agonists and their reintroduction if there is tumoral growth. Notable among the neuropituitary disorders that can occur throughout pregnancy is diabetes insipidus, which occurs as a consequence of increased vasopressinase activity.
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Biller BMK, Grossman AB, Stewart PM, Melmed S, Bertagna X, Bertherat J, Buchfelder M, Colao A, Hermus AR, Hofland LJ, Klibanski A, Lacroix A, Lindsay JR, Newell-Price J, Nieman LK, Petersenn S, Sonino N, Stalla GK, Swearingen B, Vance ML, Wass JAH, Boscaro M. Treatment of adrenocorticotropin-dependent Cushing's syndrome: a consensus statement. J Clin Endocrinol Metab 2008; 93:2454-62. [PMID: 18413427 PMCID: PMC3214276 DOI: 10.1210/jc.2007-2734] [Citation(s) in RCA: 557] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Our objective was to evaluate the published literature and reach a consensus on the treatment of patients with ACTH-dependent Cushing's syndrome, because there is no recent consensus on the management of this rare disorder. PARTICIPANTS Thirty-two leading endocrinologists, clinicians, and neurosurgeons with specific expertise in the management of ACTH-dependent Cushing's syndrome representing nine countries were chosen to address 1) criteria for cure and remission of this disorder, 2) surgical treatment of Cushing's disease, 3) therapeutic options in the event of persistent disease after transsphenoidal surgery, 4) medical therapy of Cushing's disease, and 5) management of ectopic ACTH syndrome, Nelson's syndrome, and special patient populations. EVIDENCE Participants presented published scientific data, which formed the basis of the recommendations. Opinion shared by a majority of experts was used where strong evidence was lacking. CONSENSUS PROCESS Participants met for 2 d, during which there were four chaired sessions of presentations, followed by general discussion where a consensus was reached. The consensus statement was prepared by a steering committee and was then reviewed by all authors, with suggestions incorporated if agreed upon by the majority. CONCLUSIONS ACTH-dependent Cushing's syndrome is a heterogeneous disorder requiring a multidisciplinary and individualized approach to patient management. Generally, the treatment of choice for ACTH-dependent Cushing's syndrome is curative surgery with selective pituitary or ectopic corticotroph tumor resection. Second-line treatments include more radical surgery, radiation therapy (for Cushing's disease), medical therapy, and bilateral adrenalectomy. Because of the significant morbidity of Cushing's syndrome, early diagnosis and prompt therapy are warranted.
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Affiliation(s)
- B M K Biller
- Institute of Internal Medicine, Division of Endocrinology, School of Medicine, Polytechnic University of Marche, Torrette, Ancona, Italy
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Lau SL, McGrath S, Evain-Brion D, Smith R. Clinical and biochemical improvement in acromegaly during pregnancy. J Endocrinol Invest 2008; 31:255-61. [PMID: 18401209 DOI: 10.1007/bf03345599] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Numerous case reports of pregnancy in acromegaly exist, however detailed descriptions of changes in placental and pituitary GH and IGF-I throughout gestation are rare. A 19-yr-old female presented to this institution with signs and symptoms of a GH-secreting pituitary adenoma. Following transphenoidal hypophysectomy, she had 3 unplanned pregnancies, despite ongoing active disease. No pregnancy was complicated by glucose intolerance or hypertension and 3 healthy newborns were delivered near or at term. Clinical improvement was observed during each pregnancy, accompanied by IGF-I levels lower than in the non-pregnant state, the majority lying within the normal range. This was despite increasing placental GH levels, and was not consistent with previous reports in the literature. Further surgical and medical therapies for acromegaly failed to normalize nonpregnant GH or IGF-I levels in this woman. Estrogen is known to alter GH signaling via its interaction with Janus kinase/signal transducers and activators of transcription (JAK-STAT) pathways. We hypothesize that increasing concentrations of estrogen or other pregnancy-related hormones resulted in her clinical and biochemical improvement during pregnancy. This may be used for future therapeutic benefit.
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Affiliation(s)
- S L Lau
- Department of Endocrinology, John Hunter Hospital, Newcastle, Australia
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Lynch JC, Emmerich JC, Kislanov S, Gouvêa F, Câmara L, Silva SMS, D’Ippolito MM. Tumor cerebral e gravidez. ARQUIVOS DE NEURO-PSIQUIATRIA 2007; 65:1211-5. [DOI: 10.1590/s0004-282x2007000700023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Accepted: 09/13/2007] [Indexed: 11/21/2022]
Abstract
O diagnóstico de um tumor cerebral durante a gravidez é um fato raro que coloca a mãe e o concepto em risco de vida. OBJETIVO: Avaliar a melhor forma de conduzir uma paciente grávida portadora de um tumor cerebral. MÉTODO: Realizamos análise retrospectiva dos prontuários e imagens de seis pacientes grávidas portadoras de tumor cerebral. RESULTADOS: Vários tipos histológicos de tumor cerebral podem estar associados à gravidez. O meningioma é o mais freqüente. Nessa série não observamos óbito cirúrgico materno. Em duas pacientes, o parto ocorreu antes da craniotomia e em outras quatro o parto foi realizado após a neurocirurgia. CONCLUSÃO: O momento mais adequado para a realização da craniotomia para remoção tumoral irá depender da gravidade do quadro neurológico, do tipo histológico presumível da lesão, e da idade gestacional do embrião.
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Affiliation(s)
| | | | - Sara Kislanov
- Hospital dos Servidores do Estado do Rio de Janeiro, Brasil
| | - Fabiano Gouvêa
- Hospital dos Servidores do Estado do Rio de Janeiro, Brasil
| | - Lygia Câmara
- Hospital dos Servidores do Estado do Rio de Janeiro, Brasil
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Affiliation(s)
- Mark E Molitch
- Division of Endocrinology, Metabolism, and Molecular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Tarry 15-731, Chicago, IL 60611, USA.
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Hisano M, Sakata M, Watanabe N, Kitagawa M, Murashima A, Yamaguchi K. An acromegalic woman first diagnosed in pregnancy. Arch Gynecol Obstet 2005; 274:171-3. [PMID: 16374603 DOI: 10.1007/s00404-005-0114-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Accepted: 11/16/2005] [Indexed: 11/27/2022]
Abstract
BACKGROUND Reports of pregnancy in acromegalic women are uncommon, numbering less than 100, in which a case of acromegaly first diagnosed in pregnancy is rare. CASE A 40-year-old woman in 19-week gestation was presented with a 10-week history of photophobia and visual disturbance. Elevated growth hormone (GH) levels in the serum, an inadequate suppression of GH secretion with glucose administration and a mass image in the pituitary fossa confirmed the diagnosis of acromegaly. We initiated dopamine agonist treatment, bromocriptine at a weekly dose of 1 mg at 27-week gestation. Ten weeks after the start of the bromocriptine treatment, the GH levels gradually decreased to a normal range, and visual symptoms were improved. Enlargement of the tumor was not observed throughout the pregnancy and the patient delivered a healthy infant following an eventful pregnancy. At 3 weeks after delivery, she underwent a transsphenoidal resection of a pituitary adenoma. CONCLUSION Pregnancy may lead to pituitary tumor growth and increase the risk of developing loss of vision. It is important to take pituitary tumors into consideration when encountering gravida with visual disturbance.
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Affiliation(s)
- Michi Hisano
- Department of Perinatology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-ku, 157-8535 Tokyo, Japan.
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Abstract
Hyperprolactinemia affects the gonadotropic axis. Its results in women include amenorrhea, menstrual disorders and galactorrhea; in men, the frequency of macroadenomas tends to lead to problems related to sexual performance or tumor volume. Radioimmunoassays make diagnosis easy. Secondary causes of hyperprolactinemia, drug reactions in particular, must be ruled out before MRI exploration to look for a pituitary tumor. First-line treatment of prolactin adenomas is based on the use of dopaminergic agonists, especially cabergoline, because of their excellent efficacy and the risk of relapse following surgery. For patients who wish to become pregnant, the dopaminergic agonist must be continued during pregnancy for those with macroadenoma and withdrawn for women with microadenoma. When hyperprolactinemia is induced by anti-psychotic agents, treatment requires an in-depth assessment.
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Affiliation(s)
- Anne Bachelot
- Service d'endocrinologie et médecine de la reproduction, Hôpital Necker, Paris (75)
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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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