How are prolactinomas treated during pregnancy?

Updated: Mar 25, 2018
  • Author: Venkatesh Babu Segu, MD, MBBS, DM; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Answer

During pregnancy, a physiologic doubling occurs in the volume of a normal pituitary gland. Moreover, prolactin levels increase by 10-fold during this period.

When a woman with prolactinoma presents with infertility and is proceeding with medical treatment for hyperprolactinemia, the patient is advised to use mechanical (barrier) methods of contraception until her menstrual cycles resume and the first few cycles have occurred, so that accurate dating of pregnancy can be performed. BEC is the preferred medical treatment in this situation because of its long safety record. The drug can be discontinued after the first skipped period; despite BEC's safety record, this precaution is taken to prevent unwanted fetal exposure to the agent. To date, however, increased rates of spontaneous abortion, ectopic pregnancy, or teratogenic effects have not been reported with BEC therapy. [36]

Clinical experience with cabergoline-induced pregnancies in approximately 600 patients suggests no excess risk of miscarriage or fetal malformation. [28]

Most women with microprolactinomas do not show significant increases in tumor size during pregnancy. Tumor progression rates of 1-5% have been reported in these patients. In contrast, women with macroadenomas show significant tumor enlargement (15-35%) during gestation, secondary to the hormonal stimulation of lactotrophs.

The treatment of pregnant women with prolactinomas must be tailored to the individual patient. In women with microadenomas, as well as in the subgroup of women who have intrasellar macroadenomas without significant suprasellar or parasellar extension, BEC can usually be safely discontinued upon conception, and the patient can be monitored clinically for symptoms of tumor enlargement. Periodic monitoring of PRL levels and VFs is not usually required in these patients.

In women with larger macroadenomas, a definitive, individualized plan is made only after thorough discussions with the patient. Options include the following:

  • Discontinuation of BEC at conception and careful monitoring of PRL levels and VFs, with or without MRI scan evidence of tumor enlargement

  • Prepregnancy transsphenoidal surgery with debulking of the tumor, with the resultant risk of complications (see Complications)

  • Continuation of BEC throughout gestation, with the theoretical risk to the fetus


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