Pituitary non-functioning macroadenomas: If and when to recommend surgery

Cârșote, Mara; Valea, Ana; Dumitrașcu, Mihai Cristian; Albu, Simona Elena; Şandru, Florica; Pharmacy, Bucharest; Pharmacy, Cluj-Napoca

doi:10.37897/rmj.2019.4.25

Cited by 2 publications

(4 citation statements)

References 13 publications

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“…As previously mentioned, gestational DM correlates with a higher risk of different materno-fetal outcomes in the general population [ 85 , 86 , 87 ]. Specific reports on the acromegalic population include isolated cases of macrosomia, ureteral stenosis, unilateral congenital cataract, craniosynostosis and microcephaly [ 78 , 95 , 120 ].…”

Section: Pregnancy Outcome and Materno-fetal Complicationsmentioning

confidence: 97%

“…We do not have enough data to sustain a different evolution and management during pregnancy with respect to gestational DM overt previously (secondary) DM/pre-DM which is generally found in 10–70% of all cases, neither between prior known, secondary HBP (which is expected to worsen) overt gestational HBP; the decision of intervention should be made from an individual perspective, but close surveillance is required and periodic checkups of glucose profiles are mandatory [ 83 , 84 ]. The risk of gestational diabetes is 15% with regard to the general population; there is a higher risk of fetal outcomes such as: macrosomia, stillbirth, large for gestational age (or small), lower APGAR, respiratory distress syndrome, neonatal hypoglycemia and jaundice, respective of maternal outcomes: preterm birth, need of cesarean section, or developing type 2 DM later in life [ 33 , 85 , 86 , 87 ]. The pathogenesis involves beta pancreatic cell dysfunction (anomalies of insulin secretion) and insulin resistance, but also a dysregulation of the IGF system, mostly higher levels of IGF1 and IGF2, and reduced IGFBP1 and IGFBP4 (IGF Binding Protein); IGF1 and IGF2 are essentially important for glucose transport to the fetus [ 33 , 85 , 86 ].…”

Section: Cardio-metabolic Features In Pregnant Females With Acromegalymentioning

confidence: 99%

“…The risk of gestational diabetes is 15% with regard to the general population; there is a higher risk of fetal outcomes such as: macrosomia, stillbirth, large for gestational age (or small), lower APGAR, respiratory distress syndrome, neonatal hypoglycemia and jaundice, respective of maternal outcomes: preterm birth, need of cesarean section, or developing type 2 DM later in life [ 33 , 85 , 86 , 87 ]. The pathogenesis involves beta pancreatic cell dysfunction (anomalies of insulin secretion) and insulin resistance, but also a dysregulation of the IGF system, mostly higher levels of IGF1 and IGF2, and reduced IGFBP1 and IGFBP4 (IGF Binding Protein); IGF1 and IGF2 are essentially important for glucose transport to the fetus [ 33 , 85 , 86 ].…”

Section: Cardio-metabolic Features In Pregnant Females With Acromegalymentioning

confidence: 99%

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Approach of Acromegaly during Pregnancy

et al. 2022

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Acromegaly-related sub/infertility, tidily related to suboptimal disease control (1/2 of cases), correlates with hyperprolactinemia (1/3 of patients), hypogonadotropic hypogonadism—mostly affecting the pituitary axis in hypopituitarism (10–80%), and negative effects of glucose profile (GP) anomalies (10–70%); thus, pregnancy is an exceptional event. Placental GH (Growth Hormone) increases from weeks 5–15 with a peak at week 37, stimulating liver IGF1 and inhibiting pituitary GH secreted by normal hypophysis, not by somatotropinoma. However, estrogens induce a GH resistance status, protecting the fetus form GH excess; thus a full-term, healthy pregnancy may be possible. This is a narrative review of acromegaly that approaches cardio-metabolic features (CMFs), somatotropinoma expansion (STE), management adjustment (MNA) and maternal-fetal outcomes (MFOs) during pregnancy. Based on our method (original, in extenso, English—published articles on PubMed, between January 2012 and September 2022), we identified 24 original papers—13 studies (3 to 141 acromegalic pregnancies per study), and 11 single cases reports (a total of 344 pregnancies and an additional prior unpublished report). With respect to maternal acromegaly, pregnancies are spontaneous or due to therapy for infertility (clomiphene, gonadotropins or GnRH) and, lately, assisted reproduction techniques (ARTs); there are no consistent data on pregnancies with paternal acromegaly. CMFs are the most important complications (7.7–50%), especially concerning worsening of HBP (including pre/eclampsia) and GP anomalies, including gestational diabetes mellitus (DM); the best predictor is the level of disease control at conception (IGF1), and, probably, family history of 2DM, and body mass index. STE occurs rarely (a rate of 0 to 9%); some of it symptoms are headache and visual field anomalies; it is treated with somatostatin analogues (SSAs) or alternatively dopamine agonists (DAs); lately, second trimester selective hypophysectomy has been used less, since pharmaco-therapy (PT) has proven safe. MNA: PT that, theoretically, needs to be stopped before conception—continued if there was STE or an inoperable tumor (no clear period of exposure, preferably, only first trimester). Most data are on octreotide > lanreotide, followed by DAs and pegvisomant, and there are none on pasireotide. Further follow-up is required: a prompt postpartum re-assessment of the mother’s disease; we only have a few data confirming the safety of SSAs during lactation and long-term normal growth and developmental of the newborn (a maximum of 15 years). MFO seem similar between PT+ve and PT-ve, regardless of PT duration; the additional risk is actually due to CMF. One study showed a 2-year median between hypophysectomy and pregnancy. Conclusion: Close surveillance of disease burden is required, particularly, concerning CMF; a personalized approach is useful; the level of statistical evidence is expected to expand due to recent progress in MNA and ART.

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Section: Pregnancy Outcome and Materno-fetal Complicationsmentioning

confidence: 97%

Section: Cardio-metabolic Features In Pregnant Females With Acromegalymentioning

confidence: 99%

Section: Cardio-metabolic Features In Pregnant Females With Acromegalymentioning

confidence: 99%

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Approach of Acromegaly during Pregnancy

et al. 2022

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“…The low number of cases found between 2012 and 2022, however, suggests the rarity of the disease. The clinical presentation of patients with PA in pregnancy and PP is similar to the clinical presentation of non-pregnant patients with PA with sudden and severe headache; nausea and vomiting; visual disturbances including a decrease in visual acuity; and signs and symptoms of cranial nerve palsies such as visual field defects, ptosis, anisocoria, and diplopia [14,39,[98][99][100][101][102]. Presentation with hypocortisolism occurred in one of the patients with PA in pregnancy [91].…”

Section: Integrating Pa In Pregnancy and Pp To The Larger Frame Of Pasmentioning

confidence: 87%

Challenges of Pituitary Apoplexy in Pregnancy

Gheorghe

Trandafir

Stanciu

et al. 2023

JCM

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Our purpose is to provide new insights concerning the challenges of pituitary apoplexy in pregnancy (PAP) and the postpartum period (PAPP). This is a narrative review of the English literature using a PubMed search. The inclusion criteria were clinically relevant original studies (January 2012–December 2022). Overall, we included 35 original studies: 7 observational studies (selected cases on PA) and 28 case reports, including 4 case series (N = 49; PAP/PAPP = 43/6). The characteristics of PAP patients (N = 43) are as follows: maternal age between 21 and 41 (mean of 27.76) years; 21/43 subjects with a presentation during the third trimester (only one case during first trimester); average weak of gestation of 26.38; most females were prim gravidae; 19 (out of 30 patients with available data on delivery) underwent a cesarean section. Headache remains the main clinical feature and is potentially associated with a heterogeneous panel (including visual anomalies, nausea, vomiting, cranial nerve palsies, diabetes insipidus, photophobia, and neck stiffness). Pre-pregnancy medication included dopamine agonists (15/43) and terguride (1/43) in addition to subsequent insulin therapy for gestational diabetes (N = 2) and type 1 diabetes mellitus (N = 1). Overall, 29/43 females received the conservative approach, and 22/43 women had trans-sphenoidal surgery (TSS) (and 10/22 had the initial approach). Furthermore, 18/43 patients had a pituitary adenoma undiagnosed before pregnancy. Most PA-associated tumors were prolactinomas (N = 26/43), with the majority of them (N = 16/26) being larger than 1 cm. A maternal–fetal deadly outcome is reported in a single case. The characteristics of PAPP patients (N = 6) are as follows: mean age at diagnosis of 33 years; 3/6 subjects had PA during their second pregnancy; the timing of PA varied between 5 min and 12 days after delivery; headache was the main clinical element; 5/6 had no underlying pituitary adenoma; 5/6 patients were managed conservatively and 1/6 underwent TSS; pituitary function recovered (N = 3) or led to persistent hypopituitarism (N = 3). In conclusion, PAP represents a rare, life-threatening condition. Headache is the most frequent presentation, and its prompt distinction from other conditions associated with headache, such as preeclampsia and meningitis, is essential. The index of suspicion should be high, especially in patients with additional risk factors such as pre-gestation treatment with dopamine agonists, diabetes mellitus, anticoagulation therapy, or large pituitary tumors. The management is conservative in most cases, and it mainly includes corticosteroid substitution and dopamine agonists. The most frequent surgical indication is neuro-ophthalmological deterioration, although the actual risk of pituitary surgery during pregnancy remains unknown. PAPP is exceptionally reported. To our knowledge, this sample–case series study is the largest of its kind that is meant to increase the awareness to the benefit of the maternal–fetal outcomes from multidisciplinary insights.

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Pituitary non-functioning macroadenomas: If and when to recommend surgery

Cited by 2 publications

References 13 publications

Approach of Acromegaly during Pregnancy

Approach of Acromegaly during Pregnancy

Challenges of Pituitary Apoplexy in Pregnancy

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