1. LOGO Management of lactotroph adenoma (prolactinoma) during pregnancy Dr seyed javadi

2. LOGO Goals of treatment The main goals of treatment for women with lactotroph adenomas considering pregnancy include:  Women with microadenomas – Lower serum prolactin into the normal range to allow spontaneous ovulation.  Women with macroadenomas – Administer dopamine agonists or perform transsphenoidal surgery to decrease adenoma size before attempting to conceive.dopamine  During pregnancy, monitor women for possible adenoma growth; growth that affects visual function should be treated with dopamine agonists or, if necessary, surgery (but only in the second trimester).dopamine

3. LOGO  Current data suggest that neither bromocriptine nor cabergoline use during the first month of pregnancy harms the fetus.bromocriptine cabergoline  However, few data are available about the risk of either drug later in pregnancy.

4. LOGO Choice of drug  Women who are especially concerned about the possibility of birth defects often choose bromocriptine.  Women who are more concerned about nausea from bromocriptine often choose cabergoline.

5. LOGO During pregnancy Women with lactotroph adenomas, in particular those with macroadenomas, should be monitored closely during pregnancy. The approach outlined here is consistent with the 2011 Endocrine Society Clinical Practice Guidelines on the diagnosis and treatment of hyperprolactinemia.

6. LOGO Monitoring Patients should be seen at routine intervals and asked about headaches and changes in vision (as indicators of potential adenoma growth).  Women with microadenomas should be seen every three months.  Women with macroadenomas should also be seen at least every three months, and more often the larger the adenoma.

7. LOGO Serum prolactin  During normal pregnancy, serum prolactin concentrations increase to as high as 400 ng/mL. Women with lactotroph adenomas may experience an increase in serum prolactin to pre-treatment levels.  We do measure prolactin in women with both macro- and microadenomas every three months during pregnancy, as we find it reassuring if the prolactin does not increase above 400 ng/mL. If the prolactin does increase to >400 ng/mL, we obtain visual field testing.

8. LOGO Visual field testing  For most pregnant women with lactotroph adenomas, routine visual field testing is not indicated. However, women who develop visual symptoms during pregnancy should have visual field testing.  In addition, women whose macroadenomas extend above the sella should undergo visual field testing before pregnancy and every three months during the pregnancy, even if the patient has no visual symptoms.  If a visual field defect consistent with a sellar mass is found (diminished vision in the temporal fields (bitemporal hemianopsia), an MRI should be performed.

9. LOGO Pituitary MRI  Routine pituitary MRIs are not indicated in women with lactotroph adenomas during pregnancy, because the risk of adenoma growth is very low. However, if a patient develops severe headaches or visual field abnormalities, pituitary MRI should be performed to assess adenoma size.

10. LOGO Treatment of enlarging adenoma  If the adenoma has enlarged to a degree that could account for the headaches and/or visual field defect, the woman should be treated with bromocriptine or cabergoline throughout the remainder of the pregnancy, and she should be seen at least once a month to re- evaluate symptoms and visual fields.bromocriptine cabergoline  This treatment will usually decrease the size of the adenoma and alleviate the symptoms.  We suggest using the same dopamine agonist the patient has taken and tolerated in the past. The advantage of bromocriptine is its safety record during pregnancy, while cabergoline is easier to tolerate and more likely to lower serum prolactin and shrink the adenoma.dopamine bromocriptine cabergoline

11. LOGO  If bromocriptine is used first and the adenoma does not respond, cabergoline should then be tried because it is more effective for decreasing adenoma size.bromocriptinecabergoline  If cabergoline is not successful in alleviating severely compromised vision after several weeks, we suggest transsphenoidal surgery in the second trimester.  In contrast, in the third trimester, surgery for persistent visual symptoms should be deferred until after delivery, if possible.

12. LOGO Pituitary apoplexy  Pituitary apoplexy refers to sudden hemorrhage into the pituitary, a rare event with potential serious neurologic and endocrine consequences.  In its most dramatic presentation, apoplexy causes the sudden onset of excruciating headache, diplopia due to pressure on the oculomotor nerves, and hypopituitarism.  All pituitary hormonal deficiencies can occur, but the sudden onset of corticotropin (ACTH) and therefore cortisol deficiency is the most serious because it can cause life-threatening hypotension. It should be treated with high dose hydrocortisone.hydrocortisone

13. LOGO Pituitary apoplexy  Apoplexy can occur in patients with pituitary micro- or macroadenomas, including women with lactotroph macroadenomas during pregnancy. Most patients who develop apoplexy were not known to have an adenoma previously, and when tissue is excised surgically, it is necrotic, so the cell type cannot be identified.

14. LOGO Breastfeeding and dopamine agonists  Breastfeeding increases serum prolactin concentrations, but does not appear to increase the risk of lactotroph adenoma growth. Therefore, breastfeeding is an option for women with micro- and macroadenomas that remained stable in size during pregnancy. Dopamine agonist therapy, which lowers serum prolactin and inhibits lactation, should be withheld until breastfeeding is completed.Dopamine  In contrast, breastfeeding is contraindicated in women who have visual field impairment after delivery because they should be treated with a dopamine agonist.dopamine

15. LOGO  Breastfeeding is not contraindicated in women who have lactotroph adenomas, but dopamine agonists should not be used during breastfeeding because they impair lactation. An exception is a woman who has visual field impairment, who should not breastfeed and should be treated with a dopamine agonist.dopamine

16. LOGO  Three months after delivery in women who do not breastfeed or after breastfeeding, the need for resumption of dopamine agonist treatment should be re-evaluated by measurement of the serum prolactin concentrationdopamine  Since 40 to 60 percent of women who were treated with dopamine agonists for lactotroph adenomas prior to pregnancy do not require them afterwards.