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Management of pituitary tumors in pregnancy

Abstract

Pituitary tumors, usually adenomas, account for about 10–15% of all intracranial tumors. Their treatment, which includes surgery, medicine or radiotherapy, either isolated or in combination, aims to halt tumor growth or achieve tumor shrinkage, as well as control hormone hypersecretion or ensure hormone replacement. Such approaches have made pregnancy possible for women with pituitary adenomas. Medical therapy with dopamine agonists is the treatment of choice for most patients with prolactinomas, with surgery reserved for individuals resistant to drugs. On the other hand, surgery before conception is indicated as a first-line approach in patients with acromegaly, Cushing disease or clinically nonfunctioning pituitary macroadenomas. In these patient populations, medical therapy with somatostatin analogues (acromegaly) or drugs that target the adrenal glands, such as metyrapone and ketoconazole (Cushing disease), should be reserved for those in whom surgery is unsuccessful or contraindicated.

Key Points

  • Improvements in medical and surgical treatment strategies have increased the numbers of pregnancies occurring in women with pituitary tumors

  • The overall management goals in pregnancy are effective hormonal and tumor control, avoidance of potential risks to the mother, as well as immediate and long-term consequences to the fetus

  • In patients with microprolactinomas, dopamine agonists are effective and safe for pregnancy induction; in those with macroprolactinomas, the decision for medical or surgical treatment depends on tumor characteristics and drug response

  • Once pregnancy is confirmed, dopamine agonists should be discontinued in patients with prolactinomas, except in selected cases, and reintroduced if tumor re-expansion occurs, whereas surgery is indicated in nonresponsive women

  • In pregnant women with acromegaly, somatostatin analogues should not be used unless absolutely necessary, for example, in cases of recurrent symptoms of substantial tumor growth (headaches or visual field defects)

  • Given the high rates of maternal and fetal morbidities in Cushing disease, pituitary surgery is the first choice, followed by medical treatment that targets the adrenal glands (metyrapone or ketoconazole)

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Figure 1: Growth hormone (GH) and insulin-like growth factor 1 (IGF-1) axis in nonpregnant women compared with healthy pregnancy and in pregnant women with acromegaly.
Figure 2: Therapeutic management of pregnant women with acromegaly.
Figure 3: Hypothalamic–pituitary–adrenal (HPA) axis during pregnancy.

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M. D. Bronstein declares an association with the following companies: Ipsen, Novartis, Pfizer (consultant, speaker and grant/research support). D. B. Paraiba declares an association with the following company: Ipsen (grant/research support). R. S. Jallad declares an association with the following company: Pfizer (speaker, grant/research support).

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Bronstein, M., Paraiba, D. & Jallad, R. Management of pituitary tumors in pregnancy. Nat Rev Endocrinol 7, 301–310 (2011). https://doi.org/10.1038/nrendo.2011.38

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