Pituitary tumor in pregnancy

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Pituitary tumor in pregnancy

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• In pregnancy the normal pituitary gland enlarges.
  This is mainly due to an increase in the number
  and size of the lactotrophic cells.
• This increase in pituitary size does not result
  in visual field changes

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• Several distinct types of tumors can occur in the
  pituitary gland.
• Pituitary adenomas derived from adenohypophyseal
  cells are the most common in pregnancy.

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Lactotroph adenoma (Pituitary adenoma) during
pregnancy
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• Pituitary adenomas are often classified on the
  basis of size
• Microadenomas lt 10mm in diameter
• Macroadenomas gt 10mm in diameter
• The risks to the mother
• adenoma size
• The potential risks to the fetus
• treatment

Gonzalez, JG, Elizondo, G, Saldivar, D, Nanez, H.
Pituitary gland growth during normal pregnancy
an in vivo study using magnetic resonance
imaging. Am J Med 1988 85217.
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Risks to the mother

• Increase in adenoma size cause neurologic
  symptoms, most importantly visual impairment
• Theoretical basis -- hyper-estrogenemia causes
  lactotroph hyperplasia

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Microadenomas

• The risk of a clinically important increase in
  the size of a lactotroph microadenoma during
  pregnancy is small

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Macroadenomas

• The outcome is substantially worse in women with
  macroadenomas
• In a 1979 survey, 46 women with lactotroph
  macroadenomas were followed during 56
  pregnancies. Symptoms occurred in 20 (36
  percent)
• headache 5
• headache and visual impairment 14
• diabetes insipidus 1

Gemzell, C, Wang, CF. Outcome of pregnancy in
women with pituitary adenoma. Fertil Steril 1979
31363.
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Potential risks to the fetus

• One potential risk to the fetus results from
  dopamine agonist treatment of hyperprolactinemia
  in order to permit ovulation and thereby
  conception
• spontaneous abortions , extrauterine pregnancies,
  and minor or major malformations

Ricci, E, Parazzini, F, Motta, T, et al.
Pregnancy outcome after cabergoline treatment in
early weeks of gestation. Reprod Toxicol 2002
16791.
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TREATMENT DURING PREGNANCY

• When a dopamine agonist is needed to lower the
  serum prolactin concentration to permit
  ovulation, we recommend bromocriptine rather than
  cabergoline, because of the greater certainty
  that it does not cause birth defects

Casanueva, FF, Molitch, ME, Schlechte, JA, et al.
Guidelines of the Pituitary Society for the
diagnosis and management of prolactinomas. Clin
Endocrinol (Oxf) 2006 65265.
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Early administration does not harm

• Bromocriptine during the first month of pregnancy
  does not harm -- sufficient data are available
• however, insufficient data are available about
  the use of bromocriptine later in pregnancy

Schade, R, Andersohn, F, Suissa, S, et al.
Dopamine agonists and the risk of cardiac-valve
regurgitation. N Engl J Med 2007 35629.
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Microadenomas (1)

• Risk is very small
• Should not be a deterrent to becoming pregnant
• Bromocriptine or cabergoline will likely be
  effective
• Should be given bromocriptine or cabergoline
  before pregnancy in whatever dosage is necessary
  
• Bromocriptine should be discontinued as soon as
  pregnancy has been confirmed

Turkalj, I, Braun, P, Krupp, P. Surveillance of
bromocriptine in pregnancy. JAMA 1982 247 1589
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Microadenomas (2)

• During the pregnancy, the woman should be seen
  every three months and asked about headaches and
  changes in vision.
• If no symptoms occur, serum prolactin can be
  measured two months after delivery or cessation
  of nursing, and if it is similar to the
  pretreatment value, the drug can be resumed.

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Macroadenomas (1)

• Relatively higher risk of clinically important
  tumor enlargement during pregnancy
• If the adenoma does not elevate the optic chiasm,
  treatment with bromocriptine or cabergoline
  should reduce the chance of enlargement during
  pregnancy

Ahmed, M, Al-Dossary, E, Woodhouse, NJY.
Macroprolactinomas with suprasellar extension
effect of bromocriptine withdrawal during one or
more pregnancies. Fertil Steril 1992 58492.
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Macroadenomas (2)

• Once adenoma has shrinked, the woman can attempt
  to become pregnant the dopamine agonist should
  be discontinued when pregnancy has been
  confirmed.
• Monitoring during pregnancy should be similar to
  that described above for women with microadenomas

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• If the adenoma has enlarged to a degree that
  could account for the symptoms, the woman should
  be treated with bromocriptine throughout the
  remainder of the pregnancy.

Konopka, P, Raymond, JP, Merceron, RE, Seneze, J.
Continuous administration of bromocriptine in the
prevention of neurological complications in
pregnant women with prolactinomas. Am J Obstet
Gynecol 1983 146935.
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• If the adenoma does not respond to
  bromocriptine, cabergoline may be successful
• If cabergoline is not successful, transsphenoidal
  surgery could be considered

Liu, C, Tyrrell, JB. Successful treatment of a
large macroprolactinoma with cabergoline during
pregnancy. Pituitary 2001 4179.
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• Surgery for persistent visual symptoms in the
  third trimester should be deferred until delivery
  if possible
• If the adenoma is very large or elevates the
  optic chiasm, pregnancy should be strongly
  discouraged until the adenoma has been treated by
  transsphenoidal surgery

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summary

• A perceived a change in vision should be assessed
  by a neuroophthalmologist
• MRI should be performed if an abnormality
  consistent with a pituitary adenoma is confirmed.
  

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• Pregnancy should also be discouraged in a woman
  whose macroadenoma is unresponsive to
  bromocriptine and cabergoline, even if it is not
  elevating the optic chiasm, until the size has
  been greatly reduced by transsphenoidal surgery,
  because medical treatment would not likely be
  effective if the adenoma enlarges during
  pregnancy.

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Breast feeding

• Not increase the risk of lactotroph adenoma
  growth
• Dopamine agonist treatment should be withheld
  until breastfeeding is completed.
• Breastfeeding is contraindicated in women who
  have neurologic symptoms at the time of delivery
  (suggesting tumor growth), because they should be
  treated with a dopamine agonist.

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Thanks for your attention!