Prolactinomas and Pregnancy

Abstract

Prolactinomas are the most frequent pituitary tumors. Treatment of infertility in such tumors usually is very successful. On the other hand, reports of pituitary tumor growth during pregnancy have been described since bromocriptine started to be used. Since then, dopamine agonists (DA) have been increasingly used as the first-choice treatment of prolactinomas, with surgery being reserved for resistance or persistent intolerance to DA or for special situations. More recently other DA, such as quinagolide and cabergoline have shown better tolerance than bromocriptine with similar or greater efficacy. Cabergoline is now the first choice drug but its use in pregnancy is still under evaluation. We followed 71 term pregnancies in women bearing microprolactinomas. Of the 22 patients with previous surgery, none presented symptoms of tumor growth. Of the 41 pregnant patients treated with bromocriptine alone, only one (2.4%) presented with headaches, which regressed with drug reintroduction. Fifty one term pregnancies in patients with macroprolactinomas were followed by us. Of those, 21 were in patients with previous surgery and none of them presented clinical evidence of tumor growth. On the other hand, of the 30 patients treated only with pre-gestational bromocriptine, 11 (37%) manifested complaints related to tumor growth. A non-hormonal contraceptive should be the use along with a DA drug until tumor shrinkage within sellar boundaries has been evidenced. After pregnancy has been confirmed, the DA can be withdrawn and the patient must be closely followed. If tumor expansion is suspected, confirmation can be made through MRI and by visual field testing. Reintroduction of bromocriptine in such cases can lead to tumor reduction and clinical improvement. Surgery can also be employed as treatment for symptomatic tumor growth in pregnancy.

Management of prolactinomas in Brazil: an electronic survey

“…Similar results have been reported with women who have taken cabergoline before and during pregnancy [32][33][34][35][36]. However, the number of pregnancies studied using cabergoline is still much smaller than for bromocriptine [30,31]. Accordingly, most respondents favored the use of bromocriptine instead of cabergoline for women with prolactinomas who wish to become pregnant.…”

“…The incidence of abortions, ectopic pregnancies or congenital malformations is no higher in infants born to mothers who conceived while taking bromocriptine than that in the general population [30,31]. Similar results have been reported with women who have taken cabergoline before and during pregnancy [32][33][34][35][36].…”

Expression of estrogen receptor alpha is associated with prolactin pituitary tumor prognosis and supports the sex-related difference in tumor growth

“…In another study (39), 12 patients had headaches and five unspecific visual disturbances without visual field defect, but none of them showed tumor enlargement in post partum MRI. In some patients with macroprolactinoma, post partum imaging investigation may reveal either tumor shrinkage or hemorrhage (41). In our experience, four patients operated on in an emergency setting for visual impairment had hemorrhagic PRL tumors proved by MRI, peroperative data, and histology, but low MKI67 index (J Trouillas, unpublished observations).…”

Pregnancy Induced Ocular Changes and Associated Risk of Ocular Medications

“…An untreated pituitary adenoma appears to increase the risk of miscarriage. 15,40 Asymptomatic patients should have visual field testing every 3 months to monitor tumour growth and compression of the visual pathways. Symptomatic pituitary adenomas require the combined efforts of an ophthalmologist, obstetrician, neurosurgeon, and endocrinologist to decide upon appropriate medical, surgical, or radiation treatment.…”