Impact of pregnancy on pituitary disorders

Czech version

Authors: J. Marek
Authors‘ workplace: III. interní klinika 1. lékařské fakulty UK a VFN v Praze, přednosta prof. MU Dr. Štěpán Svačina, DrSc., MBA
Published in: Vnitř Lék 2013; 59(6): 472-477
Category: 80th birthday prof. MUDr. Karla Horkého, DrSc., FACP (Hon.)

Overview

In pregnancy, the volume of pituitary increases by multiplication of lactotopic and gonadotropic cells and developing placenta is the source of numerous hormones and enzymes that significantly affect and alter the function of the endocrine system. This naturally has an impact on the course of pituitary disorders and their treatment. The most common disorders of pituitary gland, which we can meet in pregnancy, are adenomas, particularly prolactinomas, and functionless adenomas. During pregnancy we avoid the treatment of microprolactinomas, but in macroprolactinomas where there is the risk of their enlargement by stimulation of placental estrogens, we administer preventively the dopaminergic agonists. Patients with acromegaly usually do not need the treatment during pregnancy, unless there is a danger to damage the visual pathway or heavy headaches occur. ACTH‑ secreting adenomas (Cushing‘s disease) in pregnancy are rare, they are difficult to diagnose but existing hypercortisolism is very dangerous to fetus and may damage even mother. Large functionless adenomas, unless treated before pregnancy, may damage the visual pathway. The volume of the enlarged pituitary gland in pregnancy and sometimes even of the functionless adenoma adenoma, may be reduced by cabergoline, so that the urgent neurosurgery in pregnancy is very rare. A typical disease that occurs primarily in pregnant women is autoimmune lymphocytic hypophysitis. Diagnosis is established on the basis of headaches and symptoms and signs of the deficits of adrenocorticotropic and thyreotropic function usually in the last third of pregnancy or in the first six months after birth, using a specific image in magnetic resonance. Treatment is limited to hormone replacement. It is also possible to meet pregnant women with deficient pituitary functions. In hypocortical women with exception of strains like as pregnancy vomiting, doses of hydrocortisone replacement usually do not change until birth. Childbirth, however, must be secured by increasing the doses of corticosteroids. Careful replacement of thyroid hormones in hypothyroid women is very important for the development of fetus. In women treated with growth hormone its administration during pregnancy may be omitted because the placental growth hormone takes over its function. Desmopressin dose for diabetes insipidus in pregnancy is unchanged – desmopressin is resistant to placental vasopressinases. However, their effects may cause manifestation of partial diabetes insipidus, which was compensated so far.

Key words:
pituitary – pregnancy – prolactinoma – acromegaly – Cushing’s disease – lymphocytic hypophysitis – hypopituitarism

Sources

1. Gonzales JG, Elizondo G, Saldivar N et al. Pituitary gland growth during normal pregnancy: an in vivo study using magnetic resonance imaging. Am J Med 1988; 85: 217– 220.

2. Chayep‑ Billon‑ Grand C, Billon‑ Grand R, Oulton S et al. Exploration par IRM de l’hypophyse au cours de la grossesse. In: Caron P (ed). Pathologie hypophysaire et grossesse. Paris: Springer‑ Verlag 2007: 21– 32.

3. Karaca Z, Tanriverdi F, Uluhizarci K et al. Pregnancy and pituitary disorders. Eur J Endocrinol 2010; 162: 453– 475.

4. Evain‑Brion D. Le placenta: une glande endocrine transitoire. Conséquences sur la fonction antéhypophysaire au cours de la grossesse. In: Caron P (ed). Pathologie hypophysaire et grossesse. Paris: Springer‑ Verlag 2007: 11– 20.

5. Marek J. Hyperprolaktinemie v praxi. Intern Med 2008; 10: 39– 43.

6. Marek J. Hypofyzární adenomy – kam směřuje léčba na počátku 21. století? Vnitř Lék 2010; 56: 690– 694.

7. Ježková J, Marek J. Diagnosis and treatment of prolactinomas. Expert Rev Endcocrinol Metab 2009; 4: 135– 142.

8. Ježková J, Hána V, Kršek M et al. Use of the Leksell gamma knife in the treatment of prolactinoma pacients. Clin Endocr 2009; 70: 732– 741.

9. Casanueva FF, Molitch ME, Schlechte JA et al. Guidelines of the Pituitary Society for the diagnosis and management of prolactinomas. Clin Endocrinol 2006; 65: 265– 273.

10. Molitch ME. Prolactinoma in pregnancy. Best Pract Res Clin Endocrinol Metab 2011; 25: 885– 896.

11. Colao A, Abs R, Bárcena DG et al. Pregnancy outcomes following cabergoline treatment: extended results from a 12‑year observational study. Clin Endcorinol 2008; 68: 66– 71.

12. Lebbe M, Hubinot C, Bernard P et al. Outcome of 100 pregnancies initiated under treatment with cabergoline in hyperprolactinaemic women. Clin Endocrinol 2010; 73: 236– 242.

13. Ono M, Miki N, Amano K et al. Individualized high‑dose cabergoline therapy for hyperprolactinemic infertility in women with micro‑ and macroprolactinomas. J Clin Endocrinol Metab 2010; 95: 2672– 2679.

14. Stalldecker G, Mallea‑ Gil MS, Guitelamn M et al. Effects of cabergoline on pregnancy and embryo‑ fetal development: retrospective study on 103 pregnancies and review of the literature. Pituitary 2010; 13: 345– 350.

15. Shahzad H, Sheikh A, Sheikh L. Cabergoline therapy for macroprolactinoma during pregnancy: a case report. BMC Res Notes 2012; 5: 606– 609.

16. Webster J. A comparative review of the tolerability profiles of dopamine agonists in the treatment of hyperprolactinaemia and inhibition of lactation. Drug Saf 1996; 14: 228– 238.

17. Bronstein MD, Salgado LR, Rosa N et al. Medical management of pituitary adenomas: the special case of management of the pregnant woman. Pituitary 2002; 5: 99– 107.

18. Grynberg M, Salenave S, Young J et al. Female gonadal function before and after treatment of acromegaly. J Clin Endocrinol Metab 2010; 95: 4518– 4525.

19. Kaltsas GA, Androulakis II, Tziveriotis K et al. Polycystic ovaries and the polycystic ovary syndrome phenotype in women with active aćromegaly. Clin Endocrinol 2007; 67: 917– 922.

20. Cheng S, Grasso L, Martinez‑ Orozco JA et al. Pregnancy in acromegaly: experience from two referral centers and systematic review of the literature. Clin Endocrinol 2012; 76: 264– 271.

21. Frankenne F, Closet J, Gomez F et al. The physiology of growth hormones (GHs) in pregnant women and partial characterization of the placental GH variant. J Clin Endocrinol Metab 1988; 66: 1171– 1180.

22. Herman‑ Bonert V, Seliverstov M, Melmed S. Pregnancy in acromegaly: successful therapeutic outcome. J Clin Endocrinol Metab 1998; 83: 727– 731.

23. Verhaeghe J. Does the physiological acromegaly of pregnancy benefit the fetus? Gynecol Obstet Invest 2008; 66: 217– 226.

24. Caron P, Brousssard S, Bertherat J et al. Acromegly and pregnancy: a retrospective multicenter study of 59 pregnancies in 46 women. J Clin Endocrinol Metab 2010; 95: 4680– 4687.

25. Cozzi R, Attanasio R, Barausse M. Pregnancy in acromegaly: a one‑ center experience. Eur J Endocrinol 2006; 155: 279– 284.

26. Lau SL, McGrath S, Avain‑Brion D et al. Clinical and biochemical improvement in acromegaly during pregnancy. J Endocrinol Invest 2008; 31: 255– 261.

27. Cheng V, Faiman C, Kennedy L et al. Pregnancy and acromegaly: a review. Pituitary 2012; 15: 59– 63.

28. Sahli R, Christ E. Schwangerschaft während aktiver Akromegalie. Dtsch Med Wochenschr 2008; 133: 2328– 2331.

29. Caron P, Gerbeau C, Pradayrol L. Maternal‑ fetal transfer of octreotide. N Engl J Med 1995; 333: 601– 602.

30. Brian SR, Bidlingmaier M, Wajnrajch P et al. Treatment of acromegaly with pegvisomant during pregnancy. Maternal and fetal effects. J Clin Endocrinol Metab 2007; 92: 3374– 3377.

31. Qureshi A, Kalu E, Ramanathan G et al. IVF/ ICSI in a woman with active acromegaly: successful outcome following treatment with pegvisomant. J Assist Reprod Genet 2006; 23: 439– 442.

32. Lekarev O, New MI. Adrenal disease in pregnancy. Best Pract Res Clin Endocrinol Metab 2011; 25: 959– 973.

33. Kalantaridou SN, Makrigiannakis A, Mastorakos G et al. Roles of reproductive corticotropin‑releasing hormone. Ann N Y Acad Sci 2003; 997: 129– 135.

34. Bertherat J. Syndrome de Cushing et grossesse. In: Caron P (ed). Pathologie hypophysaire et grossesse. Paris: Springer‑ Verlag 2007: 43– 48.

35. Buescher MA, McClamrock HD, Adashi EY. Cushing syndrome in pregnancy. Obstet Gynecol 1992; 79: 130– 137.

36. Mellor A, Harvey RD, Pobereskin LH et al. Cushing’s disease treated by trans‑sphenoidal selective adenomectomy in mid‑ pregnancy. Br J Anaesth 1998; 80: 850– 852.

37. Hána V, Dokoupilová M, Marek J et al. Recurrent ACTH‑ independent Cushing’s syndrome in multiple pregnancies and its treatment with metyrapone. Clin Endocrinol 2001; 54: 277– 281.

38. Berwaerts J, Verhelst J, Mahler C et al. Cushing’s syndrome in pregnancy treated by ketoconazole: case report and review of the literature. Gynecol Endocrinol 1999; 13: 175– 182.

39. Lindsay JR, Nieman LK. The hypothalamic‑ pituitary‑adrenal axis in pregnancy: challenges in disease detection and treatment. Endocrine Rev 2005; 26: 775– 799.

40. Gabalec F, Beranek M, Netuka D et al. Dopamine 2 receptor expression in various pathological types of clinically non‑functioning pituitary adenomas. Pituitary 2012; 15: 222– 226.

41. Molitch ME. Pituitary disorders during pregnancy. Endocrinol Metab Clin N Am 2006; 35: 99– 116.

42. Bellastella A, Bizzarro A, Coronella C et al. Lymphocytic hypophysitis: a rare or underestimated disease? Eur J Endocrinol 2003; 149: 363– 376.

43. Karaca Z, Kelestimur F. Pregnancy and other pituitary disorders (including GH deficiency). Best Pract Res Clin Endocr Metab 2011; 25: 897– 910.

44. Chabre O. Traitement de l’insuffisance hypophysaire pendant la grossesse. In: Caron P (ed). Pathologie hypophysaire et grossesse. Paris: Springer‑ Verlag 2007: 33– 42.

45. Horáček J, Jiskra J, Límanová Z et al. Doporučení pro diagnostiku a léčbu onemocnění štítné žlázy v těhotenství a pro ženy s poruchou fertility. Diab Metab Endokrinol Výživa 2013; 16: 38– 61.

46. Daniel A, Ezzat S, Greenblau E. Adjuvant growth hormone for ovulation induction with gonadotropins in the treatment of a woman with hypopituitarism. Case Rep Endocrinol 2012; Epub 2012 Jul 31.

47. Homburg R, Levy T, Ben‑ Rafael Z. Adjuvant growth hormone for induction of ovulation with gonadotropin‑relasing hormone agonist and gonadotropins in polycystic ovary syndrome: a randomized, double‑blind, placebo controlled trial. Hum Reprod 1995; 10: 2550– 2553.

48. Curran AJ, Peacey SR, Shalet SM. Is maternal growth hormone essential for a normal pregnancy? Eur J Endocrinol 1998; 139: 54– 58.

49. Wiesli P, Zwimpfer C, Zapf J et al. Pregnancy‑induced changes in insulin‑like growth factor I (IGF‑I), insulin‑like factor binding protein 3 (IGFBP‑ 3), and acid‑ labile subunit (ALS) in patients with growth hormone (GH) deficiency and excess. Acta Obstet Gynecol Scand 2006; 85: 900– 905.

50. Bichet DG, Winiszewski P. Insuffisance posthypophysaire au cours de la grossesse. In: Caron P (ed). Pathologie hypophysaire et grossesse. Paris: Springer‑ Verlag 2007: 43– 48.