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Vialon M, Grunenwald S, Mouly C, Vezzosi D, Bennet A, Caron P. First-generation somatostatin receptor ligands and pregnancy: lesson from women with acromegaly. Endocrine 2020; 70:396-403. [PMID: 32734551 DOI: 10.1007/s12020-020-02430-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/18/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Few data are available on the risks of first-generation somatostatin receptor ligands (SRLs) during pregnancy in women treated for acromegaly. Current recommendations suggest the withdrawal of treatment at diagnosis of pregnancy. The aims of this literature review were to evaluate the teratogenic effects and the potential impact of SRLs on maternal and fetal outcomes by comparing acromegalic patients treated or not during pregnancy. PATIENTS AND METHODS This study concerns 141 pregnancies in 127 women with acromegaly: 67 pregnancies in 62 women treated with SRLs during pregnancy and 74 pregnancies in 65 women not medically treated during pregnancy. A second analysis was then realized comparing women treated during 1st trimester only (36 pregnancies) and women treated longer (20 pregnancies). RESULTS One malformation (ureteral stenosis) was reported in a newborn of a woman treated with SRL during pregnancy. No difference was found concerning maternal outcomes (gestational diabetes, hypertension, headaches, and delivery mode) and fetal outcomes (birth term, height, and weight). These results were also confirmed for the second analysis. CONCLUSIONS This review of the literature did report one malformation without being able to prove a specific link with the first-generation SRL treatment. No significant impact on maternal and fetal outcomes is related to first-generation SRL treatment in women with acromegaly. The number of pregnancies is still low and more data are necessary to conclude on the total safety of this treatment during gestation. In the meantime, based on the nonthreatening data from this review of literature, SRL treatment can be continued and/or reintroduced during pregnancy if necessary (mainly for persistent headaches) in women with acromegaly.
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Affiliation(s)
- Magaly Vialon
- Department of Endocrinology and Metabolic Diseases, CHU Larrey, 24 chemin de Pouvourville, TSA 30030, 31059, Toulouse Cedex, France
| | - Solange Grunenwald
- Department of Endocrinology and Metabolic Diseases, CHU Larrey, 24 chemin de Pouvourville, TSA 30030, 31059, Toulouse Cedex, France
| | - Céline Mouly
- Department of Endocrinology and Metabolic Diseases, CHU Larrey, 24 chemin de Pouvourville, TSA 30030, 31059, Toulouse Cedex, France
| | - Delphine Vezzosi
- Department of Endocrinology and Metabolic Diseases, CHU Larrey, 24 chemin de Pouvourville, TSA 30030, 31059, Toulouse Cedex, France
| | - Antoine Bennet
- Department of Endocrinology and Metabolic Diseases, CHU Larrey, 24 chemin de Pouvourville, TSA 30030, 31059, Toulouse Cedex, France
| | - Philippe Caron
- Department of Endocrinology and Metabolic Diseases, CHU Larrey, 24 chemin de Pouvourville, TSA 30030, 31059, Toulouse Cedex, France.
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Vialon M, Grunenwald S, Mouly C, Vezzosi D, Bennet A, Gourdy P, Caron PJ. Gestational diabetes and acromegaly: Single-centre experience of 14 pregnancies. Clin Endocrinol (Oxf) 2019; 91:805-809. [PMID: 31520541 DOI: 10.1111/cen.14097] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/06/2019] [Accepted: 09/10/2019] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The prevalence of gestational diabetes (GD) in women with acromegaly is rarely reported. The aims of this study were to evaluate the prevalence of GD in acromegalic women submitted to a systematic screening for GD and then to compare women with or without GD. PATIENTS AND METHODS We studied 14 pregnancies in 11 women (34.0 ± 3.6 years) treated with somatostatin analogues after a pituitary surgery (n = 6) or as primary (n = 5) therapy, and treatment was discontinued at the time of pregnancy diagnosis for 13 pregnancies. One woman was diagnosed with acromegaly during pregnancy and was treated with octreotide LAR between 12 and 18 weeks of gestation. Before pregnancy, no women had diabetes mellitus, and GH/IGF-1 hypersecretion was uncontrolled in 6 women. RESULTS Gestational diabetes was diagnosed during 7 pregnancies (50%) in 6 women (one woman had GD during her 2 pregnancies), according to fasting blood glucose (n = 5) or to an oral glucose tolerance test (n = 2). Before pregnancy, IGF-1 was not controlled in 4 GD+ and in 2 GD- women. Women with GD were not significantly older and had increased pregestational BMI (P = .02), with a more frequent family history of type 2 diabetes, no personal history of GD but of macrosomia for one patient. CONCLUSION The prevalence of GD in our women is higher than that reported in the literature, probably resulting from the systematic GD screening and to the age of women. Therefore, routine screening of GD should be considered in women with acromegaly, particularly in those with risk factors for GD and with uncontrolled IGF-1 levels before pregnancy.
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Affiliation(s)
- Magaly Vialon
- Service d'Endocrinologie, Maladies métaboliques et Nutrition, Pôle Cardio-Vasculaire et Métabolique, CHU Larrey, Toulouse, France
| | - Solange Grunenwald
- Service d'Endocrinologie, Maladies métaboliques et Nutrition, Pôle Cardio-Vasculaire et Métabolique, CHU Larrey, Toulouse, France
| | - Céline Mouly
- Service d'Endocrinologie, Maladies métaboliques et Nutrition, Pôle Cardio-Vasculaire et Métabolique, CHU Larrey, Toulouse, France
| | - Delphine Vezzosi
- Service d'Endocrinologie, Maladies métaboliques et Nutrition, Pôle Cardio-Vasculaire et Métabolique, CHU Larrey, Toulouse, France
| | - Antoine Bennet
- Service d'Endocrinologie, Maladies métaboliques et Nutrition, Pôle Cardio-Vasculaire et Métabolique, CHU Larrey, Toulouse, France
| | - Pierre Gourdy
- Service de Diabétologie, Maladies Métaboliques et Nutrition, Pôle Cardio-Vasculaire et Métabolique, CHU et Université de Toulouse, Toulouse, France
| | - Philippe J Caron
- Service d'Endocrinologie, Maladies métaboliques et Nutrition, Pôle Cardio-Vasculaire et Métabolique, CHU Larrey, Toulouse, France
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Chanson P, Vialon M, Caron P. An update on clinical care for pregnant women with acromegaly. Expert Rev Endocrinol Metab 2019; 14:85-96. [PMID: 30696300 DOI: 10.1080/17446651.2019.1571909] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 01/16/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION As pregnancy is rare in women with acromegaly, only case reports and few series have been published. AREAS COVERED All case reports and publications dealing with pregnancy in patients with acromegaly were collated. Information concerning the effects of acromegaly on pregnancy outcomes, the impact of pregnancy on GH/IGF-I measurements, acromegaly comorbidity and pituitary adenoma size, the effects of treatment of acromegaly on fetus outcomes were retrieved and analyzed. EXPERT COMMENTARY Based on the small number of reported cases, pregnancy is generally uneventful, except for a potential increased incidence of gestational hypertension and diabetes mellitus. Medical therapy of acromegaly (dopamine agonists, somatostatin analogs, growth hormone-receptor antagonists) is generally interrupted before or at diagnosis of pregnancy. In very rare patients with a pituitary adenoma, particularly a macroadenoma that has not been surgically treated before pregnancy, or if a surgical remnant persists, or when acromegaly is revealed during pregnancy, tumor volume may increase and cause symptoms through a mass effect. Close monitoring of clinical manifestations and imaging are necessary during pregnancy in these cases. In the rare cases of symptomatic tumor enlargement during pregnancy, medical treatment with dopamine agonists or eventually somatostatin analogs may be attempted before resorting to transsphenoidal surgery.
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Affiliation(s)
- Philippe Chanson
- a Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Mladies Rares de l'Hypophyse , Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre , Le Kremlin Bicêtre , France
- b Unité Mixte de Recherche S1185 Facultéde Médecine Paris-Sud , University Paris-Sud , Le Kremlin Bicêtre , France
- c Unit 1185, Institut National de la Santé et de laRecherche Médicale (INSERM) , Le Kremlin Bicêtre , France
| | - Magaly Vialon
- d Service d'Endocrinologie et des Maladies Métaboliques , Centre Hospitalier Universitaire de Toulouse, Hôpital Larrey , Toulouse , France
| | - Philippe Caron
- d Service d'Endocrinologie et des Maladies Métaboliques , Centre Hospitalier Universitaire de Toulouse, Hôpital Larrey , Toulouse , France
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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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Karaca Z, Yarman S, Ozbas I, Kadioglu P, Akturk M, Kilicli F, Dokmetas HS, Colak R, Atmaca H, Canturk Z, Altuntas Y, Ozbey N, Hatipoglu N, Tanriverdi F, Unluhizarci K, Kelestimur F. How does pregnancy affect the patients with pituitary adenomas: a study on 113 pregnancies from Turkey. J Endocrinol Invest 2018. [PMID: 28634705 DOI: 10.1007/s40618-017-0709-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Data regarding pregnancies in relation to pituitary tumors are limited. The effects of pregnancy on pituitary adenomas and the effects of adenoma itself (hormonal activity, mass effects and pituitary insufficiency) and/or treatment on the ongoing gestation and developing fetus were evaluated. METHODS The study was a retrospective study. A questionnaire involving questions regarding medical history before index gestation, history of related pregnancy, result of index gestation and postpartum follow-up of the patients was filled by the investigator in one of the eight Referral Endocrinology Centers from Turkey. RESULTS One hundred and thirteen (83 prolactinoma, 21 acromegaly, 8 NFPA and 1 plurihormonal pituitary adenoma) pregnancies of 87 (60 prolactinoma, 19 acromegaly, 7 NFPA and 1 plurihormonal pituitary adenoma) patients were reviewed. The clinically important pregnancy-related tumor growth of pituitary adenomas was found to be low in previously treated adenomas. Prolactinomas were more likely to increase in size during pregnancy especially if effective prior treatment was lacking. The risk of hypopituitarism is also minimal due to pituitary adenomas during pregnancy. The results of pregnancies did not differ in patients who were on medical treatment or not for prolactinomas and acromegaly during gestation. Neural tube defect and microcephaly associated with maternal cabergoline use; Down syndrome and corpus callosum agenesis associated with maternal bromocriptine use; unilateral congenital cataract, craniosynostosis and microcephaly associated with maternal acromegaly were detected for the first time. CONCLUSION Medical treatment can be safely done stopped in patients with prolactinoma and acromegaly when pregnancy is confirmed and reinstituted when necessary. Prospective studies may help to determine the effects of medical treatment during gestation on the mother and fetus.
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Affiliation(s)
- Z Karaca
- Department of Endocrinology, Erciyes University Medical School, 38039, Kayseri, Turkey
| | - S Yarman
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - I Ozbas
- Department of Endocrinology, İstanbul University Cerrahpaşa Medical School, Istanbul, Turkey
| | - P Kadioglu
- Department of Endocrinology, İstanbul University Cerrahpaşa Medical School, Istanbul, Turkey
| | - M Akturk
- Department of Endocrinology, Gazi University Medical School, Ankara, Turkey
| | - F Kilicli
- Department of Endocrinology, İstanbul Medipol University Medical School, Istanbul, Turkey
| | - H S Dokmetas
- Department of Endocrinology, İstanbul Medipol University Medical School, Istanbul, Turkey
| | - R Colak
- Department of Endocrinology, Ondokuz Mayis University Medical School, Samsun, Turkey
| | - H Atmaca
- Department of Endocrinology, Ondokuz Mayis University Medical School, Samsun, Turkey
| | - Z Canturk
- Department of Endocrinology, Kocaeli University Medical School, Kocaeli, Turkey
| | - Y Altuntas
- Department of Endocrinology, Şişli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - N Ozbey
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - N Hatipoglu
- Department of Pediatric Endocrinology, Erciyes University Medical School, Kayseri, Turkey
| | - F Tanriverdi
- Department of Endocrinology, Erciyes University Medical School, 38039, Kayseri, Turkey
| | - K Unluhizarci
- Department of Endocrinology, Erciyes University Medical School, 38039, Kayseri, Turkey
| | - F Kelestimur
- Department of Endocrinology, Erciyes University Medical School, 38039, Kayseri, Turkey.
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Abucham J, Bronstein MD, Dias ML. MANAGEMENT OF ENDOCRINE DISEASE: Acromegaly and pregnancy: a contemporary review. Eur J Endocrinol 2017; 177:R1-R12. [PMID: 28292926 DOI: 10.1530/eje-16-1059] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/24/2017] [Accepted: 03/09/2017] [Indexed: 12/16/2022]
Abstract
Although fertility is frequently impaired in women with acromegaly, pregnancy is apparently becoming more common due to improvement in acromegaly treatment as well as in fertility therapy. As a result, several studies on pregnancy in patients with acromegaly have been published in recent years adding new and relevant information to the preexisting literature. Also, new GH assays with selective specificities and the knowledge of the expression of the various GH genes have allowed a better understanding of somatotrophic axis function during pregnancy. In this review, we show that pregnancy in women with acromegaly is generally safe, usually with tumoral and hormonal stability. Although the paucity of data limits evidence-based recommendations for preconception counseling and pregnancy surveillance, controlling tumor size and hormonal activity before pregnancy is highly recommended to ensure better outcomes, and surgical control should be attempted when feasible. Treatment interruption at pregnancy confirmation has also proven to be safe, as drugs are not formally allowed to be used during pregnancy. Drug exposure (somatostatin analogs) during early or whole pregnancy might increase the chance of a lower birth weight. Aggressive disease is uncommon and may urge individual decisions such as surgery or drug treatment during pregnancy or lactation.
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Affiliation(s)
- Julio Abucham
- Neuroendocrinology UnitEscola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, Brazil
| | - Marcello D Bronstein
- Division of Endocrinology and MetabolismNeuroendocrinology Unit, University of São Paulo, São Paulo, Brazil
| | - Monike L Dias
- Endocrinology UnitUniversidade Federal de Goiás, Goiânia, Brazil
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Abstract
INTRODUCTION Acromegaly is a rare disorder in which, due to the high incidence of secondary hypogonadism, pregnancies are relatively rare. However, some women with acromegaly do get pregnant, which brings along questions about medication, complications and follow-up. This review tries to address these issues and provide the reader with practical information. METHODS This review summarizes published data. CONCLUSIONS Acromegaly is a disorder that is characterized by changes in growth hormone (GH), insulin-like growth factor-1 (IGF-1) and insulin concentrations and actions. All these hormones are important in pregnancy as well. In principle, the fetal-placental collaboration between mother and child more-or-less takes over the control over GH and IGF-1, not only in normal physiology but also to a certain extend in acromegaly. When medication for the high GH levels or actions is continued during pregnancy, both dopamine agonists, somatostatin analogs and GH receptor antagonists have been used and the available data suggest that there are no adverse consequences on mother or fetus to date. However, it is strongly advised to stop any medical intervention during pregnancy until more data are available on the safety of these compounds. Also, medical treatment is not needed as tumor size and disease activity are not reported to escape.
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Affiliation(s)
- Ammar Muhammad
- Rotterdam Pituitary Centre, Erasmus University MC, Rotterdam, The Netherlands
| | - Sebastian J Neggers
- Rotterdam Pituitary Centre, Erasmus University MC, Rotterdam, The Netherlands
| | - Aart J van der Lely
- Rotterdam Pituitary Centre, Erasmus University MC, Rotterdam, The Netherlands.
- Section of Endocrinology, Department of Medicine, Erasmus University MC, P.O. Box 2040, 3000 AC, Rotterdam, The Netherlands.
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Haliloglu O, Dogangun B, Ozcabi B, Kural HU, Keskin FE, Ozkaya HM, Pamukcu FC, Bektas E, Poyraz BC, Buber H, Evliyaoglu O, Kadioglu P. General health status and intelligence scores of children of mothers with acromegaly do not differ from those of healthy mothers. Pituitary 2016; 19:391-8. [PMID: 27033692 DOI: 10.1007/s11102-016-0717-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE To determine the physical status and intelligence scores of children of acromegalic mothers and to compare them with those of children from mothers without acromegaly. METHODS Six women with acromegaly who became pregnant under follow-up between 2010 and 2014 and their 16 children (group A) were assessed and compared with 16 children of healthy women (group B) and 15 children of women with prolactinoma (group C). The physical examinations of children were performed by the department of pediatric endocrinology and intelligence quotient (IQ) testing was undertaken by adult and pediatric psychiatry departments, using appropriate scales for their ages. RESULTS Six of the 16 children (girls/boys: 7/9) were born after the diagnosis of acromegaly. Five of the 6 pregnancies occured when the patients were taking somatostatin analogs, none continued taking the drugs during pregnancy. The mean IQ of groups A, B, and C were 106.4 ± 12.5, 105.3 ± 12.5, and 103.2 ± 16.1 respectively (p > 0.05). The mean ages, birth percentiles, recent weight and height standard deviation scores were similar between groups (p > 0.05). Two siblings from group A and 1 child from group B were large for gestational age at birth. At recent follow-up, two children from group A were found tall for their age and one from group C was short for his age and was placed under the care of pediatric endocrinology clinic. CONCLUSIONS Pregnancies in acromegaly seems to be uneventful and the general health status and IQ scores of children from women with and without acromegaly were found similar.
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Affiliation(s)
- Ozlem Haliloglu
- Division of Endocrinology-Metabolism and Diabetes, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Burak Dogangun
- Department of Pediatric Psychiatry, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Bahar Ozcabi
- Division of Endocrinology, Department of Pediatrics, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Hanife Ugur Kural
- Department of Pediatric Psychiatry, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Fatma Ela Keskin
- Division of Endocrinology-Metabolism and Diabetes, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Hande Mefkure Ozkaya
- Division of Endocrinology-Metabolism and Diabetes, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Fatma Colkesen Pamukcu
- Department of Pediatric Psychiatry, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Elif Bektas
- Department of Pediatric Psychiatry, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Burc Cagri Poyraz
- Department of Psychiatry, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Hakan Buber
- Division of Endocrinology-Metabolism and Diabetes, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Olcay Evliyaoglu
- Division of Endocrinology, Department of Pediatrics, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Pinar Kadioglu
- Division of Endocrinology-Metabolism and Diabetes, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey.
- Pituitary Center, Istanbul University, Istanbul, Turkey.
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Assal A, Malcolm J, Lochnan H, Keely E. Preconception counselling for women with acromegaly: More questions than answers. Obstet Med 2015; 9:9-14. [PMID: 27512484 DOI: 10.1177/1753495x15598699] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND AIMS Approximately 174 pregnancies in acromegaly have been reported. Our objectives were to identify the key challenges of preconception counselling in this population. METHODS Case series of three acromegalic women with desire for pregnancy. Issues were identified from chart review and discussion with attending physicians. Literature review of acromegaly and pregnancy was conducted. RESULTS Important issues identified included: impact of acromegaly on fertility, management of acromegaly in the peripartum period, screening for associated conditions, risk of progression of acromegaly/tumour growth during pregnancy, impact of acromegaly on pregnancy outcomes, surveillance during pregnancy, method of delivery and impact on neonatal outcomes and breastfeeding. CONCLUSIONS Pregnancy can be safely achieved in patients with acromegaly. There is little evidence to guide recommendations around conception and pregnancy surveillance. Patients can be reassured that in most situations, pregnancy proceeds without complication and that medical treatment can be used during pregnancy if necessary.
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Affiliation(s)
- Angela Assal
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Janine Malcolm
- Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, Division of Endocrinology and Metabolism, University of Ottawa, Ottawa, Canada
| | - Heather Lochnan
- Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, Division of Endocrinology and Metabolism, University of Ottawa, Ottawa, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, Division of Endocrinology and Metabolism, University of Ottawa, Ottawa, Canada
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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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Maiza JC, Castillo-Ros S, Matta M, Bennet A, Caron P. Tamoxifen enhances the control of acromegaly treated with somatostatin analog lanreotide. Pituitary 2012; 15 Suppl 1:S23-7. [PMID: 21221819 DOI: 10.1007/s11102-010-0287-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We present the case of a 51-year old female patient with acromegaly that was resistant to somatostatin analogs and dopamine agonists. The patient was diagnosed with breast cancer requiring treatment with the anti-estrogen tamoxifen. Prior to initiating the treatment with tamoxifen, the IGF-I level was very high at 415% of the upper limit of normal for the patient's age and sex. During the tamoxifen treatment, the level of IGF-I dropped spectacularly down to normal levels. This observation highlights the effect of an anti-estrogen treatment in certain female patients with acromegaly.
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Affiliation(s)
- Jean-Christophe Maiza
- Department of Endocrinology and Metabolic Diseases, CHU Larrey, 24 Chemin de Pourvouville, TSA 30030, 31059, Toulouse Cedex 9, France
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Abstract
To review the literature regarding the diagnosis and management of acromegaly during pregnancy. A systematic literature search was performed using MEDLINE including hand-searching reference lists from original articles. The diagnosis of acromegaly during pregnancy is made difficult due to the physiologic changes in pituitary GH secretion and IGF-1 production resulting from placental GH secretion and the inability of commercial assays to discriminate between pituitary and placental GH. Most patients with acromegaly during pregnancy do not have an increase in tumor size, metabolic complications are uncommon, and neonatal outcome is largely unaffected. IGF-1 levels tend to be stable in such patients possibly due to the high estrogen levels causing GH resistance. Dopamine agonists, somatostatin analogues, and a GH receptor antagonist have been reported to be safe during pregnancy. Patients with visual field defects should be considered for surgery, but in most cases this can be safely postponed until after delivery. Overall, pregnancy in acromegaly is uneventful and newborns unaffected. Dopamine agonists and somatostatin analogues have not been associated with major adverse effects to the fetus; however, more data are needed to validate their safety.
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Affiliation(s)
- Vicky Cheng
- Endocrinology and Metabolism Institute, Cleveland Clinic, 9500 Euclid Ave, Desk F20, Cleveland, OH 44195, USA
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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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Kasuki L, Neto LV, Takiya CM, Gadelha MR. Growth of an aggressive tumor during pregnancy in an acromegalic patient. Endocr J 2012; 59:313-9. [PMID: 22240890 DOI: 10.1507/endocrj.ej11-0306] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Pregnancy in acromegalic patients is a rare event, but is usually uneventful, with stable GH and IGF-I levels and no tumor enlargement. Medical treatment can usually be withdrawn without problems and although no major adverse event has been reported, the suspension of drug treatments is generally recommended. No case report exists in the literature regarding evolution of a somatotropinoma with invasiveness markers throughout pregnancy. We report a case of an acromegalic patient who was submitted to surgery and treated with octreotide LAR maintaining a stable residual tumor and an IGF-I close to the normal levels. Her tumor presented with a high Ki-67 (11.6%) and a low aryl hydrocarbon receptor-interacting protein (AIP) expression. When she became pregnant, octreotide LAR was withdrawn, and despite remaining asymptomatic during pregnancy, tumor growth occurred with compression of surrounding structures. In conclusion, pregnancy in acromegalic patients has usually a favorable prognosis with no tumor growth. However, in the presence of high Ki-67 labeling index and low AIP expression, tumor enlargement may occur and somatostatin analogue treatment throughout the pregnancy should be considered.
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Affiliation(s)
- Leandro Kasuki
- Serviço de Endocrinologia, Hospital Universitário Clementino Fraga Filho, Rio de Janeiro, Brazil
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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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Maffei P, Tamagno G, Nardelli GB, Videau C, Menegazzo C, Milan G, Calcagno A, Martini C, Vettor R, Epelbaum J, Sicolo N. Effects of octreotide exposure during pregnancy in acromegaly. Clin Endocrinol (Oxf) 2010; 72:668-77. [PMID: 19769624 DOI: 10.1111/j.1365-2265.2009.03706.x] [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: 11/29/2022]
Abstract
BACKGROUND Only six women who were treated with somatostatin analogues (SSAs) throughout their pregnancies have been described so far. The influence of SSAs on the course of pregnancy and newborn outcomes remains largely unknown. Many aspects of SSAs pharmacokinetics in mother and foetus have not yet been defined. METHODS AND FINDINGS We report a case study on the effects of octreotide on uterine artery blood flow, octreotide concentrations in biological fluids of mother and newborn, and somatostatin (SST) receptor expression and binding at the level of the maternal-foetal barrier tissues in an acromegalic woman treated with short-acting octreotide throughout her pregnancy. An acute decrease in uterine artery blood flow was observed after octreotide injections, without affecting the pregnancy course, delivery, or foetal development. Octreotide concentrations were high in maternal serum and colostrum and lower in umbilical cord serum, amniotic fluid, and newborn serum. All SST receptor subtypes can be expressed in placental tissue but their binding profile was weak both in the placenta and umbilical cord. The child was healthy and developed normally up to age 6 from an anthropometric, metabolic, and endocrine point of view. We reviewed all published reports on pregnancy SSA exposure and outcomes were compared to a time-matched group of acromegalic women not exposed to SSA. No significant effect on the mother or foetus was observed. CONCLUSIONS Short-acting octreotide appears not to affect the function of the maternal-foetal barrier or foetal development, except for the occurrence of acute, reversible, and clinically irrelevant haemodynamic changes. These data support the feasibility and safety of treatment with short-acting octreotide in acromegalic women during pregnancy and excludes major matters of concern about the effects of this medication on pregnancy itself and its outcome.
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Affiliation(s)
- Pietro Maffei
- Department of Medical and Surgical Sciences, University of Padua, Italy.
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Shimatsu A, Usui T, Tagami T, Kuzuya H, Takahashi JA. Suppressed levels of growth hormone and insulin-like growth factor-1 during successful pregnancy in persistent acromegaly. Endocr J 2010; 57:551-3. [PMID: 20371983 DOI: 10.1507/endocrj.k10e-069] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Pregnancy is a rather rare event in acromegaly because fertility is often reduced during active disease. Previous reports of pregnancy in acromegalic patients showed that the pituitary growth hormone (GH) level was unaffected and the insulin-like growth factor (IGF)-1 level was elevated during the second and third trimesters. We describe here a case of persistent acromegaly that showed suppressed levels of GH and IGF-1 during pregnancy. The suppression of GH secretion and IGF-1 may be due to increased estrogen or other factors circulating in mid- to late pregnancy.
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Affiliation(s)
- Akira Shimatsu
- Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.
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Bibliography. Current world literature. Diabetes and the endocrine pancreas II. Curr Opin Endocrinol Diabetes Obes 2007; 14:329-57. [PMID: 17940461 DOI: 10.1097/med.0b013e3282c3a898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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