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Jia XY, Guo XP, Yao Y, Deng K, Lian W, Xing B. Surgical management of pituitary adenoma during pregnancy. World J Clin Cases 2023; 11:2694-2707. [PMID: 37214566 PMCID: PMC10198099 DOI: 10.12998/wjcc.v11.i12.2694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/01/2023] [Accepted: 03/24/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Although conservative treatment is typically recommended for pregnant patients with pituitary adenoma (PA), surgical treatment is occasionally necessary for those with acute symptoms. Currently, surgical interventions utilized among these patients is poorly studied.
AIM To evaluate the surgical indications, timing, perioperative precautions and postoperative complications of PAs during pregnancy and to provide comprehensive guidance.
METHODS Six patients with PAs who underwent surgical treatment during pregnancy at Peking Union Medical College Hospital between January 1990 and June 2021 were recruited for this study. Another 35 pregnant patients who were profiled in the literature were included in our analysis.
RESULTS The 41 enrolled patients had acute symptoms including visual field defects, severe headaches or vision loss that required emergency pituitary surgeries. PA apoplexies were found in 23 patients. The majority of patients (55.9%) underwent surgery in the second trimester of pregnancy. A multidisciplinary team was involved in patient care from the preoperative period through the postpartum period. With the exception of 1 patient who underwent an induced abortion and 1 fetus that died due to a nuchal cord, 39 patients delivered successfully. Among them, 37 fetuses were healthy until the most recent follow-up.
CONCLUSION PA surgery during pregnancy is effective and safe during the second and third trimesters. Pregnant patients requiring emergency PA surgery require multidisciplinary evaluation and healthcare management.
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Affiliation(s)
- Xin-Yu Jia
- Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100144, China
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing 100730, China
- Department of Plastic Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xiao-Peng Guo
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing 100730, China
- Department of Neurosurgery, Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing 100730, China
| | - Yong Yao
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing 100730, China
- Department of Neurosurgery, Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing 100730, China
| | - Kan Deng
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing 100730, China
- Department of Neurosurgery, Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing 100730, China
| | - Wei Lian
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing 100730, China
- Department of Neurosurgery, Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing 100730, China
| | - Bing Xing
- Department of Neurosurgery, Key Laboratory of Endocrinology of Ministry of Health, China Pituitary Adenoma Specialist Council, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing 100730, China
- Department of Neurosurgery, Medical Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital, Beijing 100730, China
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The importance of the electrophysiological tests in the early diagnosis of ganglion cells and/or optic nerve dysfunction coexisting with pituitary adenoma: an overview. Doc Ophthalmol 2018; 137:193-202. [PMID: 30374652 PMCID: PMC6244962 DOI: 10.1007/s10633-018-9659-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 10/16/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND METHODS Based on the available literature, it is suggested, in the clinical evaluation of the chiasmal tumors, that the following electrophysiological tests: visual evoked potentials to pattern-reversal stimulation, multifocal visual evoked potentials (mfVEPs), and pattern electroretinogram (PERG) play an important role in the diagnosis of the optic nerve and retinal dysfunction in the course of pituitary tumors. RESULTS Macroadenomas and also microadenomas may cause dysfunction of retinal ganglion cells (RGCs) and their axons, even in the absence of changes in the routine ophthalmological examination, retinal sensitivity in standard automated perimetry, and retinal nerve fiber layer thickness in optical coherent tomography. The most frequently observed changes in electrophysiological tests were as follows: in PVEPs-the crossed/uncrossed asymmetry distribution, altered waveform, increase in P100-wave peak time, and/or reduction in amplitude; in mfVEPs-the peak time prolongation and/or amplitude reduction in C1-wave; in PERG-the reduction in N95-wave amplitude and decreased N95:P50 amplitude ratio. Hemifield PVEPs were more often abnormal than full-field PVEPs. Multi-channel recording is recommended for the assessment of the anterior visual pathway. The use of mfVEP offers the possibility to register localized disturbances of the optic nerve and ganglion cells. Additionally, an amplitude of N95-wave reduction in PERG correlated with a lack of postoperative visual acuity recovery. The postoperative improvement in the visual field was found to be associated with a normal N95:P50 amplitude ratio. The RGCs dysfunction manifested by decrease in PhNR/b-wave amplitude ratio was associated with the worse visual fields outcome. A review of the literature summarizing the electrophysiological testing in the pituitary adenoma is discussed. CONCLUSION In patients with pituitary tumor, detection of the early dysfunction of the visual pathway may lead to modification of the medical treatment regimen and reduce the incidence of irreversible optic nerve damage.
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Negro A, Delaruelle Z, Ivanova TA, Khan S, Ornello R, Raffaelli B, Terrin A, Reuter U, Mitsikostas DD. Headache and pregnancy: a systematic review. J Headache Pain 2017; 18:106. [PMID: 29052046 PMCID: PMC5648730 DOI: 10.1186/s10194-017-0816-0] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 10/11/2017] [Indexed: 02/06/2023] Open
Abstract
This systematic review summarizes the existing data on headache and pregnancy with a scope on clinical headache phenotypes, treatment of headaches in pregnancy and effects of headache medications on the child during pregnancy and breastfeeding, headache related complications, and diagnostics of headache in pregnancy. Headache during pregnancy can be both primary and secondary, and in the last case can be a symptom of a life-threatening condition. The most common secondary headaches are stroke, cerebral venous thrombosis, subarachnoid hemorrhage, pituitary tumor, choriocarcinoma, eclampsia, preeclampsia, idiopathic intracranial hypertension, and reversible cerebral vasoconstriction syndrome. Migraine is a risk factor for pregnancy complications, particularly vascular events. Data regarding other primary headache conditions are still scarce. Early diagnostics of the disease manifested by headache is important for mother and fetus life. It is especially important to identify “red flag symptoms” suggesting that headache is a symptom of a serious disease. In order to exclude a secondary headache additional studies can be necessary: electroencephalography, ultrasound of the vessels of the head and neck, brain MRI and MR angiography with contrast ophthalmoscopy and lumbar puncture. During pregnancy and breastfeeding the preferred therapeutic strategy for the treatment of primary headaches should always be a non-pharmacological one. Treatment should not be postponed as an undermanaged headache can lead to stress, sleep deprivation, depression and poor nutritional intake that in turn can have negative consequences for both mother and baby. Therefore, if non-pharmacological interventions seem inadequate, a well-considered choice should be made concerning the use of medication, taking into account all the benefits and possible risks.
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Affiliation(s)
- A Negro
- Department of Clinical and Molecular Medicine, Regional Referral Headache Centre, Sapienza University of Rome, Sant'Andrea Hospital, 00189, Rome, Italy.
| | - Z Delaruelle
- Department of Neurology, Ghent University Hospital, 9000, Ghent, Belgium
| | - T A Ivanova
- Institute of Professional Education, Chair of Neurology. I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - S Khan
- Danish Headache Center and Department of Neurology, Rigshospitalet Glostrup, -2600, Glostrup, DK, Denmark
| | - R Ornello
- Department of Neurology, University of L'Aquila, 67100, L'Aquila, Italy
| | - B Raffaelli
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - A Terrin
- Department of Neurosciences, Headache Centre, University of Padua, 35128, Padua, Italy
| | - U Reuter
- Department of Neurology, Charité Universitätsmedizin Berlin, 10117, Berlin, Germany
| | - D D Mitsikostas
- Neurology Department, Aeginition Hospital, National and Kapodistrian University of Athens, 11528, Athens, Greece
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Abstract
With advances in surgical and medical treatment and the availability of assisted reproductive techniques, pregnancy in women with acromegaly is more frequently encountered. Diagnosis of acromegaly during pregnancy is difficult because of changes in growth hormone and insulin like growth factor-1 (IGF-1) axis secondary to placental production of growth hormone. The difficulty is compounded by the inability of routine hormone assays to detect placental growth hormone. In the majority of patients with acromegaly, pregnancy does not have an adverse effect on mother or fetus and pituitary mass does not increase in size. The level of IGF-1 usually remains stable because of the effect of estrogen causing a growth hormone resistant state. In patients with pituitary macroadenoma, the possibility of an increase in size of the pituitary mass needs to be kept in mind and more frequent monitoring is required. In case of tumor enlargement, pituitary surgery can be considered in the mid trimester. Experience with the use of medical treatment for acromegaly during pregnancy is increasing. Dopamine agonists, somatostatin analogs or growth hormone receptor antagonists have been used without any adverse consequences on mother or fetus. At present, it is advisable to stop any medical treatment after confirmation of pregnancy till more data are available on the safety of these drugs.
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Hayes AR, O'Sullivan AJ, Davies MA. A case of pituitary apoplexy in pregnancy. Endocrinol Diabetes Metab Case Rep 2014; 2014:140043. [PMID: 25031837 PMCID: PMC4075026 DOI: 10.1530/edm-14-0043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 06/11/2014] [Indexed: 11/17/2022] Open
Abstract
Pituitary apoplexy is a rare event in pregnancy. A 41-year-old woman with a known pituitary microadenoma presented with visual disturbance and headache during the second trimester of pregnancy. Magnetic resonance imaging (MRI) demonstrated pituitary apoplexy with chiasmal compression. After treatment with corticosteroid therapy, she underwent transsphenoidal excision of the pituitary adenoma. Visual abnormalities were completely restored and pituitary function preserved. There was no evidence of impact on the foetus. The literature on the subject is reviewed with emphasis on the management of the apoplectic patient with mild and stable neuro-ophthalmological signs.
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Affiliation(s)
- Aimee R Hayes
- Departments of Endocrinology and Neurosurgery St George Hospital and University of New South Wales, Kogarah Sydney, New South Wales, 2217 Australia
| | - Anthony J O'Sullivan
- Departments of Endocrinology and Neurosurgery St George Hospital and University of New South Wales, Kogarah Sydney, New South Wales, 2217 Australia
| | - Mark A Davies
- Departments of Endocrinology and Neurosurgery St George Hospital and University of New South Wales, Kogarah Sydney, New South Wales, 2217 Australia
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Shahzad H, Sheikh A, Sheikh L. Cabergoline therapy for macroprolactinoma during pregnancy: a case report. BMC Res Notes 2012; 5:606. [PMID: 23110890 PMCID: PMC3575245 DOI: 10.1186/1756-0500-5-606] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 10/30/2012] [Indexed: 11/25/2022] Open
Abstract
Background We assessed the safety of Cabergoline therapy during pregnancy in a lady with hyperprolactinemia intolerant to Bromocriptine. Case presentation We report the case of a 31 year old lady who presented to us with uncontrolled hyperprolactinemia. A pituitary Macroadenoma was demonstrated by MRI. Due to intolerance to Bromocriptine, Cabergoline was started. The patient improved and subsequently conceived. MRI in the second trimester demonstrated further reduction in the tumor size. It was decided to continue Cabergoline throughout pregnancy to ensure further reduction in tumor size until delivery and to hold Cabergoline during postpartum period to allow for an adequate interval of breastfeeding. At 37 weeks of gestation, the patient delivered a healthy baby. Conclusion We were able to safely treat macroprolactinemia in our patient during pregnancy with cabergoline. This case report contributes to the relatively meager data available which advocates the safety of cabergoline therapy in pregnant hyperprolactinemic patients.
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Affiliation(s)
- Hira Shahzad
- Medical College, Aga Khan University Hospital, Karachi, Pakistan.
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Babey M, Sahli R, Vajtai I, Andres RH, Seiler RW. Pituitary surgery for small prolactinomas as an alternative to treatment with dopamine agonists. Pituitary 2011; 14:222-30. [PMID: 21170594 PMCID: PMC3146980 DOI: 10.1007/s11102-010-0283-y] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Despite the fact that consensus guidelines recommend long-term dopamine agonist (DA) therapy as a first-line approach to the treatment of small prolactinoma, some patients continue to prefer a primary surgical approach. Concerns over potential adverse effects of long-term medical therapy and/or the desire to become pregnant and avoid long-term medication are often mentioned as reasons to pursue surgical removal. In this retrospective study, 34 consecutive patients (30 female, 4 male) preferably underwent primary pituitary surgery without prior DA treatment for small prolactinomas (microprolactinoma 1-10 mm, macroprolactinoma 11-20 mm) at the Department of Neurosurgery, University of Bern, Switzerland. At the time of diagnosis, 31 of 34 patients (91%) presented with symptoms. Patients with microprolactinomas had significantly lower preoperative prolactin (PRL) levels compared to patients with macroprolactinomas (median 143 μg/l vs. 340 μg/l). Ninety percent of symptomatic patients experienced significant improvement of their signs and symptoms upon surgery. The postoperative PRL levels (median 3.45 μg/l) returned to normal in 94% of patients with small prolactinomas. There was no mortality and no major morbidities. One patient suffered from hypogonadotropic hypogonadism after surgery despite postoperative normal PRL levels. Long-term remission was achieved in 22 of 24 patients (91%) with microprolactinomas, and in 8 of 10 patients (80%) with macroprolactinomas after a median follow-up period of 33.5 months. Patients with small prolactinomas can safely consider pituitary surgery in a specialized centre with good chance of long-term remission as an alternative to long-term DA therapy.
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Affiliation(s)
- Muriel Babey
- Department of Neurosurgery, University of Berne, Inselspital, 3010 Berne, Switzerland
- Division of Endocrinology, Diabetes and Clinical Nutrition, University of Berne, Inselspital, 3010 Berne, Switzerland
- Endocrine Research Unit, Division of Endocrinology, University of California, San Francisco, 4150 Clement Street, San Francisco, CA 94121 USA
| | - Rahel Sahli
- Division of Endocrinology, Diabetes and Clinical Nutrition, University of Berne, Inselspital, 3010 Berne, Switzerland
| | - Istvan Vajtai
- Institute of Pathology, University of Berne, Inselspital, 3010 Berne, Switzerland
| | - Robert H. Andres
- Department of Neurosurgery, University of Berne, Inselspital, 3010 Berne, Switzerland
| | - Rolf W. Seiler
- Department of Neurosurgery, University of Berne, Inselspital, 3010 Berne, Switzerland
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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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