Bromocriptine-induced pregnancies in women with large prolactinomas

Macroprolactinomas with suprasellar extension: effect of bromocriptine withdrawal during one or more pregnancies

OBJECTIVE

To investigate the effects of bromocriptine withdrawal during one or more pregnancies in patients who presented with pituitary macroprolactinomas with suprasellar extension.

DESIGN

Four infertile patients presenting with a macroprolactinoma with suprasellar extension conceived during treatment with bromocriptine on 10 occasions resulting in eight full-term normal deliveries. Treatment was withheld shortly after conception in each pregnancy.

RESULTS

Serum prolactin (PRL) levels fell initially from a mean of 2,776 (range 1,682 to 4,515) to 27 micrograms/L (range 1 to 71) with the development of a partially empty sella in all patients. Recovery of visual field defects occurred in the only affected individual. In case 1, PRL levels remained within the normal range, after bromocriptine withdrawal in the first pregnancy, with the development of an empty sella. Prolactin levels, however, increased substantially in cases 2 to 4. An asymptomatic suprasellar tumor extension returned in cases 2 and 3. After two or more pregnancies (cases 1, 3, and 4), there was a progressive decline in the serum PRL levels. Although still elevated in cases 3 and 4, the PRL levels were considerably below those obtained at presentation or in the first pregnancy. Tumor regression with the development of an empty sella was observed in both these patients as well in their pregnancy or postpartum period.

CONCLUSIONS

Bromocriptine may be safely withdrawn during pregnancy in patients presenting with a macroprolactinoma. With multiple bromocriptine induced pregnancies, PRL levels and tumor size may progressively decrease with the eventual development of an empty sella.

The pregnant woman's eye

The effects of pregnancy on the eye fall into three categories. Nonpathological physiologic changes in pressures, corneal sensitivity and thickness, and visual function can occur. Pathologic conditions reported to develop during pregnancy include central serous chorioretinopathy, hypertensive and vascular disorders, and uveal melanoma. Pregnancy also can affect pre-existing ocular conditions, such as diabetic retinopathy, tumors, and a variety of immunological disorders and can have beneficial effects on such pre-existing conditions as glaucoma. This review covers ocular disorders in these three categories, and summarizes the systemic changes of pregnancy and the effects of ocular medications on the fetus.

Rapid regression through bromocriptine therapy of a suprasellar extending prolactinoma during pregnancy

A 29-year-old woman is described who presented with amenorrhea and galactorrhea with a large prolactinoma which regressed on bromocriptine therapy. Treatment with bromocriptine was stopped when pregnancy was diagnosed but 6 weeks later the prolactinoma had regrown with suprasellar extension and lateral invasion of the cavernous sinus. When treatment with bromocriptine was reinstituted symptoms subsided within 24 h and serum prolactin concentrations fell from 54,000 mM/l to 2800 mU/l within 5 days and 500 mU/l 2 days after that. Pregnancy proceeded without complications and she entered spontaneous labor at term and delivered a healthy baby. One year after delivery, on treatment with bromocriptine, her serum prolactin concentration remains within the normal range and the CT scan shows persistence of a small prolactinoma, confined to the pituitary fossa. Bromocriptine should be the primary treatment for prolactinomas regardless of tumor size and may be safely stopped when pregnancy is desired. If pituitary tumor complications occur during pregnancy, reintroduction of treatment with bromocriptine should again be the treatment of choice.

The safety of bromocriptine in long-term use: a review of the literature

This paper reviews the safety data on bromocriptine administration for 1 to 10 years at daily doses of 1.25 to 80 mg in over 1100 patients with pituitary hormone overproduction (mainly from prolactinomas and growth-hormone producing adenomas), at daily doses of 3.75 to 170 mg in over 700 patients with Parkinson's disease, and at daily doses of 2.5 to 20 mg in 28 patients with various other conditions. In addition, information is provided on the safety for mother and child of bromocriptine administered at daily doses of 2.5 to 35 mg throughout gestation (54 pregnancies) or during its later stages (39 pregnancies). The side-effects of long-term bromocriptine treatment are usually no different from those seen during short-term treatment; most of them are relatively benign, and they have been shown in virtually all patients to be reversible. Bromocriptine appears to have no harmful effect on hepatic, renal, haematologic, or cardiac functions. It is considered that a hitherto unknown, severe though rare side-effect of bromocriptine is unlikely to be reported after such long experience.

Lack of tumor reduction in hyperprolactinemic women with extrasellar macroadenomas treated with bromocriptine

Three patients with hyperprolactinemia and large extrasellar pituitary macroadenomas were treated with bromocriptine, 10 mg daily, for 8 weeks. In spite of correction of their amenorrhea, galactorrhea, and hyperprolactinemia, radiologic evaluation by CT scan failed to show evidence of tumor shrinkage. After surgical resection, histologic examination revealed that PRL-secreting cells comprised only a small portion of the tumor cell population in two patients and in the third patient were completely absent. These cases illustrate that large nonfunctional pituitary tumors may mimic signs and symptoms of a prolactinoma and stress the importance of adequate radiologic evaluation during medical management.

Return of menstruation and normalization of prolactin in hyperprolactinemic women with bromocriptine-induced pregnancy

Fifty-eight hyperprolactinemic women were followed up for 13 to 108 months after at least one bromocriptine-induced pregnancy for investigation of whether the pregnancy had any adverse long-term effects on the hyperprolactinemic state. Fifteen women had two term pregnancies. The prolactin (PRL) level decreased greater than 50% in 20 women after the pregnancy. Only two women showed a PRL level increase. Spontaneous uterine bleedings returned in 16 women, whereas 42 remained amenorrheic. Thus, bromocriptine-induced pregnancy in women with hyperprolactinemia has no negative long-term effect on PRL secretion.

Management of endocrine disorders in pregnancy. Part II. Pituitary, ovarian and adrenal disease

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Bromocriptine-induced regression of a suprasellar extending prolactinoma during pregnancy

A 21-year-old amenorrheic woman with hyperprolactinemia had rapid pituitary tumor enlargment during a bromocriptine-induced pregnancy. Before treatment the sella turcica was normal. In the 31st week of pregnancy she developed bitemporal hemianopsia and markedly decreased visual acuity. Computerized tomography showed a pituitary adenoma with suprasellar extension. Reinstitution of bromocriptine therapy resulted in rapid recovery of normal vision and radiologically verified tumor regression. Pregnancy continued to term and a healthy child was born. If pituitary tumor complications should occur during pregnancy, reinstitution of bromocriptine is the primary treatment of choice.