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MICROADENOMA AND PREGNANCY

AR DALAL*, AK SHUKLA**, CV HEGDE***, P RANKA****
*Prof. and HOD; **Resident; ***Prof. and HOU; ****Lecturer, Nair Ch. Hospital, Mumbai 400 008.

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A case of pituitary microadenoma who presented with irregular menstrual cycles is described in whom initiation of oral bromocryptine failed to result in resumption of normal menses and conception. She underwent transsphenoidal excision of pituitary microadenoma as well as was continued on bromocryptine, conceived within 2 months postsurgery. She was continued on bromocryptine and prednisolone. She delivered by caesarean section, a male child 2.6 kg. This case highlights that in case of tumours not responding to dopamine agonists surgery is an interesting alternative to be considered instead of longterm medical treatment.[1]

INTRODUCTION

Hyperprolactinaemia is a frequent cause of anovulatory sterility, although spontaneous pregnancy may occur occasionally. Dopaminergic treatment is highly effective for both idiopathic and tumoral hyperprolactinaemia. If the only cause of infertility is chronic anovulation due to hyperprolactinaemia, a 60-80% pregnancy rate can be achieved.[2] These results mean that surgical treatment is still needed for few cases that are not responding to dopaminergic treatment.

CASE REPORT

Mrs. RSK, a 26 yr old housewife married since 8 yrs a case of primary infertility came to OPD at Nair Hospital with complaints of irregular and scanty cycles since 8 months. On examination all findings were in normal limits. There was no obvious thyroid swelling but there was bilateral galactorrhoea. All secondary sexual characters were well developed. Patient was already investigated. All the investigations were within normal limits except S. Prolactin which was 130 ng/ml. Patient had undergone premenstrual dilatation and curretage with diagnostic laparoscopy in 1996. Findings were normal. Histopathology of endometrium showed proliferative phase indicating anovulatory cycles. CT Skull in 1996 showed pituitary microadenoma, perimetry was normal. Patient was started on tab. bromocryptine 2.5 mg per day which was increased to 7.5 mg per day. Patient was lost to followup for 2 yrs but took bromocryptine irregularly. As patient was not responding to bromocryptine, surgical mode of management was considered. MRI was done on 4200 which showed microadenoma with haemorraghic component in the left aspect of the pituitary gland (Fig. 1). Patient was explained the need of bromocryptine even after surgery as well the chances of recurrence.

Transsphenoidal excision of pituitary microadenoma was done in Dec. 2000. Patient was started on prednisolone and bromocryptine. She missed her menses in Feb. 2001. Last S. Prolactin levels were 23 ng/ml on 10.2.01. Bromocryptine was omitted. Ultrasound done on 7.3.01 showed live single intrauterine pregnancy of 7 wks. Patient followed regularly her S. T3, T4, TSH and Prolactin were repeated at 3 monthly intervals. Patient had a fullterm caesarean section on 25.10.01 male child 2.6 kg cried immediately with apgar score of 8,9,9. Wound healing was good. She had flat nipples, needed help in breast feeding. She was discharged on 8th day after surgery and was advised to continue prednisolone at least for 2 more months.

Fig 1: Showing microadenoma with haemorraghic component in left aspect of pituitary gland.

DISCUSSION

Hyperprolactinaemia is a frequent cause of amenorrhoea, infertility and galactorrhoea in young women and a pituitary microadenoma is the most common cause of spontaneous hyperprolactinaemia.[2] Hyperprolactinaemia is seen in 15% of anovulatory women. 30% to 80% of women with hyperprolactinaemia will have galactorrhoea. It is postulated that abnormal release of prolactin produce a rise in hypothalamic dopamine which may interfere with gonadotrophin release by altering the secretion of norepinephrine. It also interferes with midcycle LH surge and directly inhibits ovarian steroidogenesis.

The indications for treatment of hyperprolactinaemia are[3]

1. The presence of significant symptoms, such as infertility, ovulatory dysfunction or galactorrhoea in women.

2. The presence of significant signs such as visual field defects or cranial nerve palsies.

3. Abnormal test results including visulisation of pituitary mass or lesion or detection of osteopenia.

Management options available are:

1. Medical management with dopamine receptor agonists such as bromocryptine, methysergide bromocryptine.[4,6]

2. Radiation : this is not the primary mode of therapy as radiation may damage the surrounding normal pituitary tissue causing diabetes insipidus and also damage to the optic nerve.

3. Surgery : Transsphenoidal microsurgical resection of prolactinomas for tumours that do not respond to medical therapy.

Gammaknife radiosurgery as a primary treatment for pituitary adenomas may be safe and effective.[5]

Medical treatment is the initial treatment of choice but Transsphenoidal surgery remains an option especially for patients with microadenoma when medical therapy is ineffective.[6]

REFERENCES

1.Nomikos P, Buchfelder M. Current management of prolactinomas. J Neurooncol 2001; 54 : 139-50.

2.Seri O. Progress in management of hyperprolactinaemia. N Engl J Med 1994; 331 : 942-44.

3.Olive D. Indications for hyperprolactinaemia therapy. J Reprod Med 1999; 44 (12 suppl) : 1091-4.

4.Webster J. Dopamine agonists therapy in hyperprolactinaemia. J Reprod Med 1999; 44 (12 suppl) : 1105-10.

5.Zhang N, Pan L. Gamma Knife radiosurgery as a primary surgical treatment for hypersecreting pituitary adenomas. Stereotact Funct Neurosurg 2000; 75 (2-3) : 123.

6.Molitch ME. Medical treatment of prolactinomas. Endocrinol Met Clin North Am 1999; 28 (1) : 143-69.

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