Follow-up of children born of bromocriptine-treated mothers

Treatment of Prolactinoma

Prolactinomas are the commonest form of pituitary neuroendocrine tumor (PitNET), representing approximately half of such tumors. Dopamine agonists (DAs) have traditionally been the primary treatment for the majority of prolactinomas, with surgery considered the second line. The aim of this review is to examine the historical and modern management of prolactinomas, including medical therapy with DAs, transsphenoidal surgery, and multimodality therapy for the treatment of aggressive prolactinomas and metastatic PitNETs, with an emphasis on the efficacy, safety, and future directions of current therapeutic modalities. DAs have been the mainstay of prolactinoma management since the 1970s, initially with bromocriptine and more recently with cabergoline. Cabergoline normalizes prolactin in up to 85% of patients and causes tumor shrinkage in up to 80%. Primary surgical resection of microprolactinomas and enclosed macroprolactinomas performed by experienced pituitary neurosurgeons have similar remission rates to cabergoline. Aggressive prolactinomas and metastatic PitNETS should receive multimodality therapy including high dose cabergoline, surgery, radiation therapy (preferably using stereotactic radiosurgery where suitable), and temozolomide. DAs remain a reliable mode of therapy for most prolactinomas but results from transsphenoidal surgery in expert hands have improved considerably over the last one to two decades. Surgery should be strongly considered as primary therapy, particularly in the setting of microprolactinomas, non-invasive macroprolactinomas, or prior to attempting pregnancy, and has an important role in the management of DA resistant and aggressive prolactinomas.

Italian Association of Clinical Endocrinologists (AME) and International Chapter of Clinical Endocrinology (ICCE). Position statement for clinical practice: prolactin-secreting tumors

Prolactinomas are the most frequent pituitary adenomas. Prolactinoma may occur in different clinical settings and always require an individually tailored approach. This is the reason why a panel of Italian neuroendocrine experts was charged with the task to provide indications for the diagnostic and therapeutic approaches that can be easily applied in different contexts. The document provides 15 recommendations for diagnosis and 54 recommendations for treatment, issued according to the GRADE system. The level of agreement among panel members was formally evaluated by RAND-UCLA methodology. In the last century, prolactinomas represented the paradigm of pituitary tumors for which the development of highly effective drugs obtained the best results, allowing to avoid neurosurgery in most cases. The impressive improvement of neurosurgical endoscopic techniques allows a far better definition of the tumoral tissue during surgery and the remission of endocrine symptoms in many patients with pituitary tumors. Consequently, this refinement of neurosurgery is changing the therapeutic strategy in prolactinomas, allowing the definitive cure of some patients with permanent discontinuation of medical therapy.

Outcomes of Patients with Macroprolactinoma Desiring Pregnancy: Follow-Up to 23 Years from a Single Center

Macroprolactinomas are rarely seen in women, and pregnancy is a risk factor for tumor growth. More studies are needed to determine appropriate management for macroprolactinoma and pregnancy. The aim of our study is to evaluate effects of treatment with dopamine agonists on macroadenoma before and during pregnancy, safety of dopamine agonists on fetus, post-pregnancy prognosis and long-term results. This is a single center retrospective study. Thirty-four pregnancies occurred in 21 patients under medical therapy. Prolactin levels, treatment results, tumor diameter changes, maternal-fetal outcomes, and disease activity were evaluated. The median tumor size at the time of diagnosis was 15 mm (10-28). Residual adenoma diameter was smaller in those receiving medical therapy longer than one year till the conception (p=0.047). Treatment was discontinued in 28 pregnancies after pregnancy confirmation, and 6 patients were exposed to bromocriptine throughout pregnancy. There was no symptomatic tumor growth during gestation. Among 27 live births, none of the fetuses developed neonatal malformation except for a case of Down syndrome. While early remission rate after pregnancy was 9.5%, this rate reached 33.3% at last follow-up visit. Lowered PRL levels at postpartum period (p=0.040), smaller tumor size at last follow-up visit (p=0.030), and total disappearance of tumor (p=0.026) were the contributor factors for remission. Use of dopamine agonist over one year may reduce the risk of symptomatic tumor growth during pregnancy in patients without invasive or large macroprolactinoma before pregnancy. Exposure to dopamine agonists seems generally safe for the fetus.

A Brazilian multicentre study evaluating pregnancies induced by cabergoline in patients harboring prolactinomas

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.

Endoscopic Transsphenoidal Surgery of Microprolactinomas: A Reappraisal of Cure Rate Based on Radiological Criteria

BACKGROUND

Current standard treatment of microprolactinomas is dopamine agonist therapy. As this drug treatment is lifelong in up to 80% of cases, many patients consult pituitary surgeons regarding a surgical alternative.

OBJECTIVE

To identify prognostic criteria for surgical remission, we reviewed outcomes of our series of microprolactinomas treated with endoscopic transsphenoidal surgery, with a special emphasis on magnetic resonance adenoma delineation and position.

METHODS

Our study cohort comprises a single center series of 60 patients operated for histopathologically verified magnetic resonance imaging unequivocally identifiable endosellar microprolactinoma between 2003 and 2017. In 31 patients the adenoma was enclosed by pituitary gland (group ENC), in 29 patients the adenoma was located lateral to the gland adherent to the medial cavernous sinus wall (group LAT).

RESULTS

After a mean follow-up of 37 mo (range 4-143 mo), remission rate was significantly higher in adenomas enclosed by pituitary gland (group ENC) than adenomas located lateral to the gland (group LAT), with 87% vs 45%, P = .01. Intraoperatively, 4 patients showed signs of invasiveness. Preoperative prolactin levels did not differ between the groups (mean 155 and 187 ng/ml in group ENC and LAT, respectively).A binary logistic regression model revealed that only the radiological criteria applied showed a significant correlation (P = .003) with endocrine remission.

CONCLUSION

According to our results, remission rate is significantly higher in microprolactinomas enclosed by the pituitary gland. However, the decision for surgery should take into account surgeons experience and possibility of complications.

Prolactinomas in pregnancy: considerations before conception and during pregnancy

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

An observational study of pregnancy and post-partum outcomes in women with prolactinoma treated with dopamine agonists

BACKGROUND

In women with prolactinoma medical treatment with dopamine agonists (DA) can restore fertility. A number of studies have established the safety of DA during pregnancy and the impact of pregnancy and lactation on remission of prolactinoma. However, the total number of reported cases remains modest and further evidence is needed.

AIMS

To evaluate the safety of DA during pregnancy and remission of prolactinoma after pregnancy and lactation.

MATERIALS AND METHODS

Retrospective cohort study (2002-2014) of 57 pregnancies in 47 women with prolactinoma who received DA. Neonatal and pregnancy complications were recorded. Prolactin levels and treatment data were collected at the time of diagnosis, pre-conception, during pregnancy and lactation, and post-partum (up to 114 months).

RESULTS

DA treatment was stopped a median of 4.5 weeks after conception in 49 pregnancies (86%). There were 49 live births (86% of pregnancies) and six miscarriages. Six pregnancies had an adverse neonatal outcome including two with congenital malformations. Following 26% of pregnancies women achieved remission after birth or lactation, and 25% of women were in remission at last follow-up. Remission was associated with older maternal age (P = 0.036), a lower prolactin level at diagnosis (P = 0.037), and a smaller adenoma at diagnosis (P = 0.045).

CONCLUSIONS

Successful pregnancy and lactation is common after DA treatment for prolactinoma. Fetal exposure in the first four weeks of pregnancy appears to be generally safe. Encouragingly, post-partum and after lactation a quarter of women had a normal prolactin level without medical treatment.

Controversial issues in the management of hyperprolactinemia and prolactinomas - An overview by the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism

Prolactinomas are the most common pituitary adenomas (approximately 40% of cases), and they represent an important cause of hypogonadism and infertility in both sexes. The magnitude of prolactin (PRL) elevation can be useful in determining the etiology of hyperprolactinemia. Indeed, PRL levels > 250 ng/mL are highly suggestive of the presence of a prolactinoma. In contrast, most patients with stalk dysfunction, drug-induced hyperprolactinemia or systemic diseases present with PRL levels < 100 ng/mL. However, exceptions to these rules are not rare. On the other hand, among patients with macroprolactinomas (MACs), artificially low PRL levels may result from the so-called "hook effect". Patients harboring cystic MACs may also present with a mild PRL elevation. The screening for macroprolactin is mostly indicated for asymptomatic patients and those with apparent idiopathic hyperprolactinemia. Dopamine agonists (DAs) are the treatment of choice for prolactinomas, particularly cabergoline, which is more effective and better tolerated than bromocriptine. After 2 years of successful treatment, DA withdrawal should be considered in all cases of microprolactinomas and in selected cases of MACs. In this publication, the goal of the Neuroendocrinology Department of the Brazilian Society of Endocrinology and Metabolism (SBEM) is to provide a review of the diagnosis and treatment of hyperprolactinemia and prolactinomas, emphasizing controversial issues regarding these topics. This review is based on data published in the literature and the authors' experience.

Prolactinoma through the female life cycle

Prolactinomas are the most common secretory pituitary adenoma. They typically occur in women in the 3rd-6th decade of life and rarely in the pediatric population or after menopause. Most women present with irregular menses and/or infertility. Dopamine (DA) agonists, used in their treatment, are safe during pregnancy, but in most cases are discontinued at conception with close monitoring for signs or symptoms of tumor growth. Breastfeeding is safe postpartum, provided there was no significant growth during pregnancy. Some women will experience normalization of prolactin levels postpartum. Menopause may also decrease prolactin levels and even those with macroprolactinomas may consider discontinuing their DA agonist with close follow-up. Prolactinomas may be associated with decreased quality of life scores in women, and play a role in bone health and cardiovascular risk factors. This review discusses the current literature and clinical understanding of prolactinomas throughout the entirety of the female life cycle.

Medical versus surgical treatment of prolactinomas: an analysis of treatment outcomes

INTRODUCTION

Prolactinomas are unique tumors that may go into both hormonal and radiographic remission with dopamine agonist therapy or transsphenoidal surgery. Regardless of modality, the goals of therapy remain the same: (1) biochemical remission, including reduction of prolactin and normalization of sex hormones; (2) radiographic tumor control, with a range including prevention of tumor growth, tumor regression, or complete tumor resolution; (3) resolution of preoperative symptoms, including those that are hormonal or neurologic; and (4) prevention of new hypopituitarism or new neurologic symptoms.

AREAS COVERED

In the following review, we performed a search of the literature using keywords 'prolactinoma,' 'dopamine agonist,' 'surgery,' 'cost-effectiveness,' 'recurrence,' and 'complication' to compare the relative merits of medical versus surgical therapy for prolactinoma, including special circumstances such as cystic tumors, pregnant patients, and the cost-effectiveness of different strategies.

EXPERT COMMENTARY

Medical therapy can offer a cure, but surgery provides an important adjunct to patients with resistance or intolerance to dopamine agonists, and offers excellent outcomes including when combined with continued postoperative medical therapy. Further head to head comparisons will benefit patients and practitioners weighing the relative risks and benefits of medical and surgical intervention, including the issue of their relative cost-effectiveness.

Endocrinology in pregnancy: management of the pregnant patient with a prolactinoma

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.

Prolactin-secreting tumors: what’s new?

Prolactinomas are a common cause of reproductive/sexual dysfunction. Once other causes of hyperprolactinemia have been excluded with a careful history and physical examination, routine chemistries, a pregnancy test and a thyroid-stimulating hormone, imaging with magnetic resonance imaging or computed tomography will delineate the size and extent of the tumor. Medical therapy with cabergoline or bromocriptine is the initial treatment of choice. When infertility is the primary indication for treatment, bromocriptine use has an extensive safety experience and is preferred by some clinicians. However, for other indications, cabergoline appears to be more efficacious and better tolerated. Transsphenoidal surgery remains an option, especially for patients with microadenomas, when medical therapy is ineffective or not tolerated.

Review of Presentation, Diagnosis and Management of Pituitary Tumours in Pregnancy

Although pituitary tumours are relatively uncommon, their association with menstrual irregularity and infertility brings them into the domain of obstetrics and gynaecology. This review addresses the range of pituitary tumours with particular regard to diagnosis, growth and behaviour and management during pregnancy.

Vanishing tumor in pregnancy

A patient with microprolactinoma, who had two successful pregnancies, is described for management issues. First pregnancy was uneventful. During the second pregnancy, the tumor enlarged to macroprolactinoma with headache and blurring of vision which was managed successfully with bromocriptine. Post delivery, complete disappearance of the tumor was documented.

Transsphenoidal surgery for microprolactinomas in women: results and prognosis

BACKGROUND

Long-term dopamine agonist (DA) therapy is recommended as a first-line approach for the management of microprolactinomas. However, DA therapy may be poorly tolerated by some patients, and therefore some patients continue to prefer surgery over DA therapy.

AIM

The aim of our study was to evaluate factors associated with favorable outcomes after surgical treatment of microprolactinomas in women.

METHODS

Thirty-two women (mean age 31.0 ± 8.2 years) with confirmed microprolactinomas who were operated using transsphenoidal approach were included to the study. Twenty-two (61 %) women had previous DA therapy and ten (39 %) women preferred surgery as a first treatment. Mean follow-up was 4.2 ± 2.7 years. Surgery was considered to be effective and remission achieved if serum prolactin was normal without DA therapy and there were no signs of tumor re-growth on neuroimaging.

RESULTS

Nine (47.4 %) patients in whom remission was achieved did not receive preoperative DA therapy when compared to one (7.7 %) patient in whom remission was not achieved (p = 0.02). Remission after operation was achieved in nine out of ten (90 %) patients who did not receive DA therapy compared to ten out of 22 patients (45.5 %) who were treated with DAs (p = 0.01). The independent factor associated with good outcome following surgical treatment was no preoperative DA therapy (RR = 14.57 (1.43-148.1), p = 0.02). Surgical complications were permanent diabetes insipidus in two patients (6.3 %) and transient DI in five (15.6 %) patients.

CONCLUSIONS

The main factor associated with favorable microprolactinoma surgery outcome in women was the absence of preoperative DA therapy.

Prolactinoma in pregnancy

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.

Hyperprolactinaemia

Hyperprolactinaemia is a frequent cause of reproductive problems encountered in clinical practice. A variety of pathophysiological conditions can lead to hyperprolactinaemia; therefore, pregnancy, drug effects, hypothyroidism and polycystic ovary syndrome should be excluded before investigating for prolactin-secreting pituitary tumours. Prolactinomas are mainly diagnosed in women aged 20-40 years. They present with clinical features of hyperprolactinaemia (galactorrhoea, gonadal dysfunction), and more rarely with large tumours, headache and visual field loss due to optic chiasm compression. Medical therapy with dopamine agonists is the treatment of choice for both micro- and macroprolactinomas. Tumour shrinkage and restoration of gonadal function are achieved in the majority of cases with dopamine agonists. A trial of withdrawal of medical therapy may be considered in many patients with close follow-up. Pituitary surgery and radiotherapy currently have very limited indications. Pregnancies in patients with prolactinomas need careful planning and close monitoring.

Hyperprolactinemia and prolactinomas

Any process interfering with dopamine synthesis, its transport to the pituitary gland, or its action at the level of lactotroph dopamine receptors can cause hyperprolactinemia. As described in this article, considering the complexity of prolactin regulation, many factors could cause hyperprolactinemia, and hyperprolactinemia can have clinical effects not only on the reproductive axis. Once any drug effects are excluded, prolactinomas are the most common cause of hyperprolactinemia. The most frequent symptom is hypogonadism in both genders. Medical and surgical therapies generally have excellent results, and most prolactinomas are well controlled or even cured in some cases.

Parity, pregnancy and neonatal outcomes in women treated for hyperprolactinaemia compared with a control group

OBJECTIVE

Infertility is a common problem in women with hyperprolactinaemia. There are limited data on the fertility and pregnancy course among these women. The objective was to study parity, pregnancy and neonatal outcomes in women with hyperprolactinaemia as compared with a control group.

DESIGN

Register study.

PATIENTS

Two hundred and seventy-one female patients treated for primary hyperprolactinaemia were identified in the hospital record archives between 1974 and 2002. For each patient four comparison subjects, matched by sex, birth year and county of residence were identified in the Register of Population. Data were retrieved from the Swedish medical birth register and were analysed using logistic regression and analysis of variance. Measurements Parity, maternal age at first delivery, weeks of gestation, induction of labour, caesarean delivery, multiple birth, Apgar score, birth weight, length, sex, congenital malformations, neonatal care.

RESULTS

One hundred and sixty-two deliveries in the hyperprolactinaemia group and 1220 deliveries in the control group were analysed.

PATIENTS

with hyperprolactinaemia were significantly older at their first pregnancy than their controls: 29.0 (+/- 4.4) and 27.2 (+/- 4.8) years, respectively (P = 0.0002). Furthermore, parity was inversely associated with hyperprolactinaemia status (P for trend = 0.0009). The odds of having three or more children were threefold lower among the patients (OR 0.31 (95% CI 0.16, 0.60)). There were no differences between patients and controls with respect to pregnancy complications, delivery or neonatal outcome variables.

CONCLUSIONS

We found no evidence of increased risk of pregnancy complications or adverse pregnancy outcomes in women with treated hyperprolactinaemia. However, the patients were older at their first pregnancy and had a reduced overall parity.

Advances in the treatment of prolactinomas

Prolactinomas account for approximately 40% of all pituitary adenomas and are an important cause of hypogonadism and infertility. The ultimate goal of therapy for prolactinomas is restoration or achievement of eugonadism through the normalization of hyperprolactinemia and control of tumor mass. Medical therapy with dopamine agonists is highly effective in the majority of cases and represents the mainstay of therapy. Recent data indicating successful withdrawal of these agents in a subset of patients challenge the previously held concept that medical therapy is a lifelong requirement. Complicated situations, such as those encountered in resistance to dopamine agonists, pregnancy, and giant or malignant prolactinomas, may require multimodal therapy involving surgery, radiotherapy, or both. Progress in elucidating the mechanisms underlying the pathogenesis of prolactinomas may enable future development of novel molecular therapies for treatment-resistant cases. This review provides a critical analysis of the efficacy and safety of the various modes of therapy available for the treatment of patients with prolactinomas with an emphasis on challenging situations, a discussion of the data regarding withdrawal of medical therapy, and a foreshadowing of novel approaches to therapy that may become available in the future.

Current treatment issues in female hyperprolactinaemia

High prolactin levels can occur as a physiological condition in females who are pregnant or lactating. As a pathological condition, hyperprolactinaemia is associated with gonadal dysfunction, infertility and an increased risk of long-term complications including osteoporosis. The most frequent cause of persistent hyperprolactinaemia is the presence of a micro- (<10mm diameter) or macroprolactinoma (>/=10mm). These pituitary tumours may produce an excessive amount of prolactin or disrupt the normal delivery of dopamine from the hypothalamus to the pituitary; prolactin secretion from the pituitary is inhibited by dopamine released from neurones in the hypothalamus. Medications including anti-psychotics can induce hyperprolactinaemia, while idiopathic hyperprolactinaemia accounts for 30-40% of cases. The prevalence of hyperprolactinaemia is difficult to establish as not all sufferers are symptomatic or concerned by their symptoms and may remain undiagnosed. Symptoms of hyperprolactinaemia include signs of hypogonadism, with oligomenorrhoea, amenorrhoea and galactorrhoea frequently observed. Pharmacological intervention should be considered the first line therapy and involves the use of dopamine agonists to reduce tumour size and prolactin levels. Bromocriptine has the longest history of use and is a well-established, inexpensive, safe and effective therapy option. However, bromocriptine requires multiple daily dosing and some patients are resistant or intolerant to this therapy. The two newer dopamine agonists, quinagolide and cabergoline, provide more effective and better tolerated treatments compared with bromocriptine and may offer effective therapies for bromocriptine-resistant or intolerant patients. Quinagolide can be used until pregnancy is confirmed and may result in improved compliance in females wishing to become pregnant. For patients with hyperprolactinaemia, pregnancy is safe and can frequently be beneficial, inducing a decrease in prolactin levels. There does not appear to be any increased risk of abortion, malformations or multiple births in pregnancies achieved with bromocriptine and this dopamine agonist can be used safely during pregnancy. Surgery should be considered only in certain circumstances, and for the majority of patients, dopamine agonists will be sufficient to alleviate symptoms and restore normal prolactin levels.

Pituitary gland and pregnancy

The hypothalamic-pituitary-adrenal axis is central to mammalian reproductive function, including conception, pregnancy maintenance, parturition, and breastfeeding. Pregnancy is associated with substantial physiologic changes within this endocrine axis to meet the demands of pregnancy, which include support of the fetus (volume support, nutritional and oxygen supply, clearance of fetal waste), protection of the fetus (from starvation, drugs, toxins), preparation of the uterus for labor, and protection of the mother from potential cardiovascular injury at delivery. This article reviews the anatomy, embryology, and physiology of the pituitary. The effect of pregnancy on pituitary structure and function, in health and disease, also is discussed.

Timing and special concerns regarding endocrine surgery during pregnancy

Pregnancy may occur in the setting of endocrine diseases or be the first time these diseases manifest clinically. Management of pregnancy in these circumstances is challenging and requires a high degree of vigilance on the part of the treating physicians. The best outcome is achieved by a multidisciplinary approach consisting of endocrinology, obstetrics, anesthesiology, and endocrine surgery.

Pituitary and adrenal disorders complicating pregnancy

PURPOSE OF REVIEW

Confidential enquiries of maternal deaths in the UK for 1997-1999 revealed that the number of indirect deaths from medical conditions exacerbated by pregnancy was greater than deaths from conditions directly caused by pregnancy. Indirect maternal deaths accounted for 36% of all deaths. Although neoplastic disorders of the pituitary and adrenal glands are very rare during pregnancy, they can be potentially fatal. The rarity of these disorders may pose difficulty in formulating an optimum plan of management. Biochemical tests that can be performed in the non-pregnant state may be of little value during pregnancy. The presence of a fetus may also influence the type and timing of intervention.

RECENT FINDINGS

A few case reports have been reported in the literature, but unfortunately no large series to develop guidelines or protocols. However, endoscopic surgical procedures have recently been used in their management with good outcomes. New drugs such as octreotide and lanreotide are increasingly being used during pregnancy. Although too soon to assess the safety of these new treatments, results so far have been very encouraging.

SUMMARY

Awareness of these potentially fatal neoplastic disorders of the pituitary and adrenal glands, coupled with early diagnosis and appropriate treatment, may help improve maternal and fetal outcomes. Advances in imaging techniques and endoscopic procedures are also likely to change clinical practice. Various new treatment options are being reported in the literature, but they are not supported by randomized, controlled trials. Further research is needed to determine their safety and efficacy during pregnancy.

PRL-secreting pituitary adenomas in pregnancy

Dopamine-agonists have significantly increased the number of pregnancies in women with micro- and macro-prolactinomas, as ovulation can be restored in the great majority of these patients. Thus, the main questions regard the possible consequences of high estrogen levels on tumor volume and the possible effects of D2-agonists on fetal development. While the risk of tumor increase is low in patients with prolactin secreting micro-adenoma (MIP), in PRL secreting macro-adenoma (MAP) patients the possibility of tumor growth is enhanced and influenced by previous treatment. Moreover, while it is well known that the exposition for only the first 4 weeks to bromocriptine (BRC) therapy does not affect the outcome of pregnancy, data on the use of BRC during the whole gestation are limited to just over 100 cases. Female pregnant patients with MIP, therefore, must be reassured and medical therapy suspended, with successive clinical follow-up. In the case of pregnant MAP subjects, the best approach from pre-pregnancy debulking, dopamine-agonist therapy interruption and BRC therapy continuation must be agreed on with the patient, and a careful follow-up instituted.

Medical management of prolactin-secreting pituitary adenomas

Prolactinomas are a common cause of reproductive/sexual dysfunction. Once other causes of hyperprolactinemia have been excluded with a careful history and physical examination, routine chemistries, a pregnancy test and a TSH, imaging with MRI or CT will delineate the size and extent of the tumor. Medical therapy is the initial treatment of choice. When infertility is the primary indication for treatment, bromocriptine use has an extensive safety experience and is preferred. However, for other indications, cabergoline appears to be more efficacious and better tolerated. Transsphenoidal surgery remains an option, especially for patients with microadenomas, when medical therapy is ineffective.

Disorders of prolactin secretion

Prolactinomas are a common cause of reproductive/sexual dysfunction. Once other causes of hyperprolactinemia have been excluded with a careful history and physical examination, routine chemistries, and an assay for TSH, MR imaging, or CT will delineate the size and extent of the tumor. Medical therapy is the initial treatment of choice. When infertility is the primary indication for treatment, bromocriptine use has an extensive safety record and is preferred. For other indications, cabergoline seems to be more efficacious and better tolerated. Transsphenoidal surgery remains an option, especially for patients with microadenomas, when medical therapy is ineffective.

Medical treatment of prolactinomas

Prolactinomas are a common cause of reproductive and sexual dysfunction. Once other causes of hyperprolactinemia have been excluded with a careful history, physical examination, routine chemistries, and a TSH, MR imaging or computerized tomography will delineate the size and extent of the tumor. Medical therapy is the initial treatment of choice. When infertility is the primary indication for treatment, bromocriptine use has an extensive safety experience and is preferred. For other indications, however, cabergoline appears to be more efficacious and better tolerated. Transsphenoidal surgery remains an option, especially for patients with microadenomas, when medical therapy is ineffective.

Pituitary diseases in pregnancy

Pituitary adenomas are the most common pituitary disorder affecting pregnancy, and prolactinomas are the most common of the hormone-secreting pituitary adenomas. Hyperprolactinemia must be corrected to allow ovulation and fertility. Bromocriptine has been shown to be safe for use during early gestation. There is less than a 2% risk of microprolactinoma enlargement during pregnancy but a greater than 15% risk of symptomatic enlargement of a macroprolactinoma. Treatment options for patients with macroadenomas include stopping bromocriptine when pregnancy is diagnosed and reinstituting with tumor enlargement, continuous bromocriptine throughout pregnancy, and prepregnancy tumor debulking by surgery. The diagnosis of acromegaly may be difficult to make during pregnancy and relies, in part, on the persistence of the normal pulsatile secretion of growth hormone and loss of this secretory characteristic with a tumor. The growth hormone oversecretion may exacerbate tendencies to gestational diabetes, fluid retention, and hypertension. Treatment for acromegaly and other tumors generally may be deferred until after delivery. There are rare reports of enlargement of clinically nonfunctioning and growth hormone secreting tumors during pregnancy, and surveillance is needed. Tumors may need to be differentiated from lymphocytic hypophysitis. Patients with chronic hypopituitarism usually will need treatment with gonadotropins or pulsatile GnRH to become pregnant and may need increased steroid coverage during labor and delivery. Hypopituitarism developing during pregnancy is usually caused by lymphocytic hypophysitis and usually also will require steroid replacement therapy. Hypopituitarism arising postpartum may be caused by either lymphocytic hypophysitis or Sheehan's syndrome, and the latter may present as an acute or chronic syndrome. Borderline diabetes insipidus may manifest during pregnancy because of increased vasopressin degradation caused by markedly increased levels of placental vasopressinase. Treatment with desmopressin usually is satisfactory. Patients presenting with either anterior or posterior pituitary insufficiency in the peripartum period should always be evaluated for function of the other portion of the pituitary.

Pregnancy in Parkinson's disease: a review of the literature and a case report

Pregnancy is rare in Parkinson's disease (PD). In the literature on studies of antiparkinsonian drugs in animals during pregnancy, there are reports on malformations of the skeletal and circulatory system. However, the majority of studies in animals have not shown any teratogenicity. Amantadine has been teratogenic in rats and selegiline has caused neurochemical and behavioral alterations in rats when coadministered with clorgyline. The published experience with humans consists of 35 pregnancies among 26 women suffering from PD, including this report, and a number of cases treated with antiparkinsonian agents for other reasons. With the exception of the majority of the cases where amantadine was used, complications have been rare. However, there are indications that suggest a possible risk of a woman's parkinsonism worsening in connection with pregnancy. We also report the case of a woman with PD who was treated with L-dopa-benserazide during an uncomplicated pregnancy and gave birth to a healthy boy without experiencing any worsening of her PD.

Evaluation and Management of Pituitary Tumors During Pregnancy

OBJECTIVE

To review the recommended management of pituitary tumors that occur in pregnant patients.

METHODS

Studies from the literature and personal experience are summarized, and guidelines for optimal maternal and fetal outcome are suggested.

RESULTS

Tumors are the most common pituitary disorder affecting pregnant patients. Hyperprolactinemia must be corrected to allow ovulation and fertility. Bromocriptine has been shown to be safe for use during early gestation. Patients have less than a 2% risk of microprolactinoma enlargement during pregnancy but approximately a 16% risk of symptomatic enlargement of a macroprolactinoma. Treatment options for patients with macroadenomas include discontinuing bromocriptine therapy when pregnancy is confirmed and reinstituting this treatment if the tumor enlarges; continuous bromocriptine therapy throughout the pregnancy; and prepregnancy surgical debulking of the tumor. The diagnoses of acromegaly and Cushing's disease are difficult to make during pregnancy. The hormone oversecretion in these conditions may exacerbate tendencies to gestational diabetes, fluid retention, and hypertension. Cushing's syndrome should be treated during pregnancy, but treatment for acromegaly and other tumors may be deferred. Rare reports have described enlargement of clinically nonfunctioning and growth hormone-secreting tumors during pregnancy, and surveillance is needed. Tumors may need to be distinguished from lymphocytic hypophysitis.

CONCLUSION

Physicians should be aware of the normal pituitary changes during pregnancy and the major clinical and laboratory findings associated with pituitary tumors for optimal management of pregnant patients.

Adverse effects of fertility drugs

Ovulation-induction agents are commonly used in the treatment of infertility in patients with or without ovulatory disturbances. These agents include clomifene, bromocriptine, gonadotrophin preparations and gonadotrophin-releasing hormone (GnRH) and its analogues. Each agent is associated with its own specific adverse effects. Although many of these adverse effects are benign and self-limited, some, in particular those effects associated with gonadotrophins, may be life-threatening. Commonly noted adverse effects encountered with the use of pharmacological agents to treat infertility include the following. Clomifene has been associated with hot flushes, multiple gestation, visual disturbances, cervical mucus abnormalities and luteal phase deficiency. Similarly, most of the adverse symptoms associated with bromocriptine are short-lived, such as nausea and postural hypotension. On the other hand, gonadotrophin therapy, even when used appropriately, may lead to the ovarian hyperstimulation syndrome (which is occasionally life-threatening) and a high incidence of multiple gestation. Pulsatile GnRH therapy maybe accompanied by similar adverse effects to those of gonadotrophins, but with a far lower incidence. With regards to the long term safety of these medications, the relationship between fertility drugs and epithelial ovarian cancer is controversial, and causality has yet to be proven. Indeed, a working knowledge of the many adverse effects associated with these medications is essential to any physician prescribing ovulation induction agents, in order to ensure maximum patient safety, compliance and understanding.

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.

Developmental toxicity of the dopamine agonist pergolide mesylate in CD-1 mice. I: Gestational exposure

Pergolide was given by oral gavage to mated CD-1 female mice at doses of 0, 1, 20, or 60 mg/kg/day on gestation days (GD) 6-15. Animals assigned to the teratology segment were killed on GD 18 for evaluation of maternal organ weights, and fetal viability, weights and morphology. Animals assigned to the postnatal segment were allowed to deliver and physical development and behavioral performance of the progeny were monitored until weaning. Maternal organ weights were collected at termination after weaning. One F1 offspring per sex per litter was maintained for postweaning physical, behavioral and reproductive assessments and for terminal examinations and organ weight evaluations. No adverse effects of pergolide treatment were found in the 1 mg/kg/day group. Dose-related hyperactivity, chewing and squinting that were consistent with dopaminergic stimulation occurred following dosing in the 20 and 60 mg/kg/day groups; F0 body weights and food consumption were reduced during the initial phase of treatment in the 60 mg/kg/day group. Gravid uterine weights and fetal weights were decreased in the 60 mg/kg/day group of the teratology segment, but there was no indication of teratogenicity in any group. Mammary inflammation, attributed to increased progeny suckling, occurred during the second week postpartum in a few postnatal segment females of the 20 and 60 mg/kg/day groups. Mean negative geotaxis performance was delayed slightly, but mean progeny survival and body weights were not affected. Although after weaning the F1 offspring from the treatment-derived groups tended to weigh more than controls and to perform more effectively in the active avoidance task, these findings were attributed to unusually low values obtained in the control group. Startle amplitudes were increased significantly in the males from the 60 mg/kg/day treatment-derived group. These dose-related maternal and developmental findings were all consistent with the mixed D1/D2 agonist properties of pergolide mesylate, and suggest that only very high doses may result in persistent effects on the developing central dopaminergic systems.

Bromocriptine in pregnancy: safety aspects

Since Bromocriptine is used to restore fertility in hyperprolactinemic women, its safety in pregnancy and the offspring was investigated in a stepwise approach: (i) the first survey in pregnancy was based on spontaneous reporting, (ii) the second investigation was conducted at 33 clinics as an intensive monitoring project and, (iii) the third study consisted in a full examination of children up to the age of 9 years who had been exposed to Bromocriptine in utero. The data collated in this program includes information on 2587 pregnancies in 2437 women treated with Bromocriptine during some stage of gestation, and follow-up examinations for 988 infants. The results show that the use of Bromocriptine in the treatment of infertility in women is not associated with an increased risk of spontaneous abortion, multiple pregnancy or the occurrence of congenital malformation in their progeny. Moreover, exposure to this drug in utero has no adverse influence on the postnatal development.

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.

The safety of bromocriptine in hyperprolactinaemic female infertility: a literature review

The dopamine agonist bromocriptine has been widely used to facilitate pregnancy in hyperprolactinaemic women, with a success rate of 80% in relevant cases. Neither the inappropriate hyperprolactinaemia consequent upon bromocriptine withdrawal after conception nor the relative hypoprolactinaemia caused by treatment throughout gestation appears to affect adversely the course and outcome of pregnancy or the endocrine status of the fetus. No teratogenic effect of bromocriptine has been evidenced in humans, and no disturbances in the physical, psychomotor, and intellectual development of the offspring have been observed. Pituitary-tumor enlargement during closely supervised pregnancies very rarely leads to severe and irreversible complications; both the re-institution of bromocriptine treatment in the event of tumor enlargement and its preventive use throughout pregnancy have been shown to be effective measures. It is interesting, moreover, that a reduction of hyperprolactinaemia, compared with pregestational levels, may be seen after bromocriptine-facilitated pregnancies.