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Chanson P, Vialon M, Caron P. An update on clinical care for pregnant women with acromegaly. Expert Rev Endocrinol Metab 2019; 14:85-96. [PMID: 30696300 DOI: 10.1080/17446651.2019.1571909] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 01/16/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION As pregnancy is rare in women with acromegaly, only case reports and few series have been published. AREAS COVERED All case reports and publications dealing with pregnancy in patients with acromegaly were collated. Information concerning the effects of acromegaly on pregnancy outcomes, the impact of pregnancy on GH/IGF-I measurements, acromegaly comorbidity and pituitary adenoma size, the effects of treatment of acromegaly on fetus outcomes were retrieved and analyzed. EXPERT COMMENTARY Based on the small number of reported cases, pregnancy is generally uneventful, except for a potential increased incidence of gestational hypertension and diabetes mellitus. Medical therapy of acromegaly (dopamine agonists, somatostatin analogs, growth hormone-receptor antagonists) is generally interrupted before or at diagnosis of pregnancy. In very rare patients with a pituitary adenoma, particularly a macroadenoma that has not been surgically treated before pregnancy, or if a surgical remnant persists, or when acromegaly is revealed during pregnancy, tumor volume may increase and cause symptoms through a mass effect. Close monitoring of clinical manifestations and imaging are necessary during pregnancy in these cases. In the rare cases of symptomatic tumor enlargement during pregnancy, medical treatment with dopamine agonists or eventually somatostatin analogs may be attempted before resorting to transsphenoidal surgery.
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Affiliation(s)
- Philippe Chanson
- a Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Mladies Rares de l'Hypophyse , Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre , Le Kremlin Bicêtre , France
- b Unité Mixte de Recherche S1185 Facultéde Médecine Paris-Sud , University Paris-Sud , Le Kremlin Bicêtre , France
- c Unit 1185, Institut National de la Santé et de laRecherche Médicale (INSERM) , Le Kremlin Bicêtre , France
| | - Magaly Vialon
- d Service d'Endocrinologie et des Maladies Métaboliques , Centre Hospitalier Universitaire de Toulouse, Hôpital Larrey , Toulouse , France
| | - Philippe Caron
- d Service d'Endocrinologie et des Maladies Métaboliques , Centre Hospitalier Universitaire de Toulouse, Hôpital Larrey , Toulouse , France
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Hage M, Kamenický P, Chanson P. Growth Hormone Response to Oral Glucose Load: From Normal to Pathological Conditions. Neuroendocrinology 2019; 108:244-255. [PMID: 30685760 DOI: 10.1159/000497214] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 01/24/2019] [Indexed: 11/19/2022]
Abstract
The exact physiological basis of acute growth hormone (GH) suppression by oral glucose is not fully understood. Glucose-mediated increase in hypothalamic somatostatin seems to be the most plausible explanation. Attempts to better understand its underlying mechanisms are compromised by species disparities in the response of GH to glucose load. While in humans, glucose inhibits GH release, the acute elevation of circulating glucose levels in rats has either no effect on GH secretion or may be stimulatory. Likewise, chronic hyperglycemia alters GH release in both humans and rats nonetheless in opposite directions. Several factors influence nadir GH concentrations including, age, gender, body mass index, pubertal age, and the type of assay used. Besides the classical suppressive effects of glucose on GH release, a paradoxical GH increase to oral glucose may be observed in around one third of patients with acromegaly as well as in various other disorders. Though its pathophysiology is poorly characterized, an altered interplay between somatostatin and GH-releasing hormone has been suggested and a link with pituitary ectopic expression of glucose-dependent insulinotropic polypeptide receptor has been recently demonstrated. A better understanding of the dynamics mediating GH response to glucose may allow a more optimal use of the OGTT as a diagnostic tool in various conditions, especially acromegaly.
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Affiliation(s)
- Mirella Hage
- Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Institut National de la Santé et de la Recherche Médicale (Inserm) U1185, Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Peter Kamenický
- Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Institut National de la Santé et de la Recherche Médicale (Inserm) U1185, Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Service d'Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l'Hypophyse, Institut National de la Santé et de la Recherche Médicale (Inserm) U1185, Université Paris-Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France,
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Jallad RS, Shimon I, Fraenkel M, Medvedovsky V, Akirov A, Duarte FH, Bronstein MD. Outcome of pregnancies in a large cohort of women with acromegaly. Clin Endocrinol (Oxf) 2018; 88:896-907. [PMID: 29574986 DOI: 10.1111/cen.13599] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/15/2018] [Accepted: 03/16/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess the outcome of pregnancies in a large cohort of women with acromegaly. DESIGN AND METHODS This is a retrospective analysis of 31 pregnancies in 20 patients with acromegaly. RESULTS Twenty-seven pregnancies resulted in healthy offspring, and 4 resulted in abortion. Three patients underwent transsphenoidal surgery during pregnancy. IGF-1 levels remained elevated during pregnancy in 4 pregnancies and normalized in 23 cases. Fifteen cases were followed during pregnancy without any medical or surgical treatment, and 13 of these exhibited normal IGF-1 levels. Before or during pregnancy, somatostatin receptor ligands usage was not associated with higher risk for adverse outcomes. Arterial hypertension worsening (45%) and impairment of glucose levels (32%) were the most common complications during pregnancies. There were no maternal or neonatal deaths. One woman delivered twins. Two cases of congenital malformations and one with foetal macrosomia were observed. Caesarean delivery was performed in sixteen cases. CONCLUSION Our study confirms the impact of gestation on IGF-1 levels. However, it also indicates that acromegaly still holds an increased risk for worsening of comorbidities, especially in uncontrolled patients.
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Affiliation(s)
- R S Jallad
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - I Shimon
- Institute of Endocrinology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - M Fraenkel
- Endocrinology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - V Medvedovsky
- Endocrinology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - A Akirov
- Institute of Endocrinology, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - F H Duarte
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
- Endocrine Service, AC Camargo Cancer Center, São Paulo, Brazil
| | - M D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
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Abucham J, Bronstein MD, Dias ML. MANAGEMENT OF ENDOCRINE DISEASE: Acromegaly and pregnancy: a contemporary review. Eur J Endocrinol 2017; 177:R1-R12. [PMID: 28292926 DOI: 10.1530/eje-16-1059] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 02/24/2017] [Accepted: 03/09/2017] [Indexed: 12/16/2022]
Abstract
Although fertility is frequently impaired in women with acromegaly, pregnancy is apparently becoming more common due to improvement in acromegaly treatment as well as in fertility therapy. As a result, several studies on pregnancy in patients with acromegaly have been published in recent years adding new and relevant information to the preexisting literature. Also, new GH assays with selective specificities and the knowledge of the expression of the various GH genes have allowed a better understanding of somatotrophic axis function during pregnancy. In this review, we show that pregnancy in women with acromegaly is generally safe, usually with tumoral and hormonal stability. Although the paucity of data limits evidence-based recommendations for preconception counseling and pregnancy surveillance, controlling tumor size and hormonal activity before pregnancy is highly recommended to ensure better outcomes, and surgical control should be attempted when feasible. Treatment interruption at pregnancy confirmation has also proven to be safe, as drugs are not formally allowed to be used during pregnancy. Drug exposure (somatostatin analogs) during early or whole pregnancy might increase the chance of a lower birth weight. Aggressive disease is uncommon and may urge individual decisions such as surgery or drug treatment during pregnancy or lactation.
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Affiliation(s)
- Julio Abucham
- Neuroendocrinology UnitEscola Paulista de Medicina da Universidade Federal de São Paulo, São Paulo, Brazil
| | - Marcello D Bronstein
- Division of Endocrinology and MetabolismNeuroendocrinology Unit, University of São Paulo, São Paulo, Brazil
| | - Monike L Dias
- Endocrinology UnitUniversidade Federal de Goiás, Goiânia, Brazil
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Assal A, Malcolm J, Lochnan H, Keely E. Preconception counselling for women with acromegaly: More questions than answers. Obstet Med 2015; 9:9-14. [PMID: 27512484 DOI: 10.1177/1753495x15598699] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND AIMS Approximately 174 pregnancies in acromegaly have been reported. Our objectives were to identify the key challenges of preconception counselling in this population. METHODS Case series of three acromegalic women with desire for pregnancy. Issues were identified from chart review and discussion with attending physicians. Literature review of acromegaly and pregnancy was conducted. RESULTS Important issues identified included: impact of acromegaly on fertility, management of acromegaly in the peripartum period, screening for associated conditions, risk of progression of acromegaly/tumour growth during pregnancy, impact of acromegaly on pregnancy outcomes, surveillance during pregnancy, method of delivery and impact on neonatal outcomes and breastfeeding. CONCLUSIONS Pregnancy can be safely achieved in patients with acromegaly. There is little evidence to guide recommendations around conception and pregnancy surveillance. Patients can be reassured that in most situations, pregnancy proceeds without complication and that medical treatment can be used during pregnancy if necessary.
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Affiliation(s)
- Angela Assal
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Janine Malcolm
- Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, Division of Endocrinology and Metabolism, University of Ottawa, Ottawa, Canada
| | - Heather Lochnan
- Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, Division of Endocrinology and Metabolism, University of Ottawa, Ottawa, Canada
| | - Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, Division of Endocrinology and Metabolism, University of Ottawa, Ottawa, Canada
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Dias M, Boguszewski C, Gadelha M, Kasuki L, Musolino N, Vieira JGH, Abucham J. Acromegaly and pregnancy: a prospective study. Eur J Endocrinol 2014; 170:301-10. [PMID: 24247731 DOI: 10.1530/eje-13-0460] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
CONTEXT AND OBJECTIVE The interaction between pregnancy and acromegaly has been studied only retrospectively. We used prospective data to assess those interactions. DESIGN Prospective, interventional, multicentric study. PATIENTS TEN PREGNANCIES IN EIGHT ACROMEGALIC PATIENTS WERE INCLUDED ACCORDING TO THE FOLLOWING CRITERIA: previous diagnosis of acromegaly; and active acromegaly before pregnancy. Sellar magnetic resonance image (MRI), GH, and IGF1 measurements were carried out before pregnancy. The exclusion criterion was radiotherapy. INTERVENTION Withdrawal of pharmacological treatment (octreotide and/or cabergoline and/or pegvisomant) following pregnancy diagnosis. MAIN OUTCOME MEASURES Clinical/biochemical evaluations throughout pregnancy/puerperium and sellar MRI after delivery; and GH and IGF1 measurements before pregnancy. GH was measured by an interference-free IFMA assay during pregnancy and IGF1 by measured by Immulite 2000 assay in patients and 64 control pregnancies. RESULTS No tumor growth was observed. Nine deliveries were at term and one at 35 weeks (preeclampsia). All newborns were healthy. Mean IGF1 levels before and during pregnancy were similar, but increased significantly during puerperium. As IGF1 in controls increased after midgestation, the prevalence of controlled IGF1 rose significantly from 2/10 (<20 weeks) to 9/10 (>30 weeks). Diabetes mellitus and hypertension/preeclampsia developed in one patient in each group; both complications were nonsignificantly (P=0.06) associated with IGF1 >1.3 ULN before pregnancy. CONCLUSIONS Acromegaly control usually improved and tumor growth was not stimulated during pregnancy in spite of withdrawal of drug treatment. Drug treatment can be discontinued in most patients. Uncontrolled disease before pregnancy may pose a higher risk for diabetes and hypertension.
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Affiliation(s)
- Monike Dias
- Neuroendocrinology Unit, Division of Endocrinology, UNIFESP, Escola Paulista de Medicina da Universidade Federal de São Paulo, Rua Pedro de Toledo 910, 04039-002 São Paulo, Brazil
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Abstract
To review the literature regarding the diagnosis and management of acromegaly during pregnancy. A systematic literature search was performed using MEDLINE including hand-searching reference lists from original articles. The diagnosis of acromegaly during pregnancy is made difficult due to the physiologic changes in pituitary GH secretion and IGF-1 production resulting from placental GH secretion and the inability of commercial assays to discriminate between pituitary and placental GH. Most patients with acromegaly during pregnancy do not have an increase in tumor size, metabolic complications are uncommon, and neonatal outcome is largely unaffected. IGF-1 levels tend to be stable in such patients possibly due to the high estrogen levels causing GH resistance. Dopamine agonists, somatostatin analogues, and a GH receptor antagonist have been reported to be safe during pregnancy. Patients with visual field defects should be considered for surgery, but in most cases this can be safely postponed until after delivery. Overall, pregnancy in acromegaly is uneventful and newborns unaffected. Dopamine agonists and somatostatin analogues have not been associated with major adverse effects to the fetus; however, more data are needed to validate their safety.
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Affiliation(s)
- Vicky Cheng
- Endocrinology and Metabolism Institute, Cleveland Clinic, 9500 Euclid Ave, Desk F20, Cleveland, OH 44195, USA
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Karaca Z, Kelestimur F. Pregnancy and other pituitary disorders (including GH deficiency). Best Pract Res Clin Endocrinol Metab 2011; 25:897-910. [PMID: 22115165 DOI: 10.1016/j.beem.2011.07.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
The pituitary gland is one of the most affected organs with altered anatomy and physiology during pregnancy. Acromegaly is the second most common pituitary adenoma seen in relation to gestation after prolactinomas. Acromegaly should be treated before conception to prevent potential tumor growth in patients who desire fertility. Medical therapy can be ceased safely after confirmation of pregnancy in acromegalic patients, but octreotide may be used in selected cases with compressive signs. Other hormonal and non-functional tumors are rarer and have been presented as case reports. Sheehan's syndrome, which is one of the most common causes of hypopituitarism in developing countries, and lymphocytic hypophysitis are known to be associated with pregnancy. They usually result in hypopituitarism, sometimes with delays in diagnosis and difficulties in differential diagnosis. Pregnancy is not common among patients with hypopituitarism or pituitary adenomas due to altered gonadotroph functions. Ovulation induction is essential for fertility achievement, but the replacement of other deficient pituitary hormones, including GH, seems to play an important role in the preparation of the uterus for implantation of the embryo.
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Affiliation(s)
- Zuleyha Karaca
- Erciyes University Medical School, Department of Endocrinology, Kayseri, Turkey.
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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.
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Affiliation(s)
- Marcello D Bronstein
- Neuroendocrine Unit, Division of Endocrinology and Metabolism, Hospital das Clinicas, University of São Paulo Medical School, Avenida 9 de Julho 3858, 01406-100 São Paulo, SP, Brazil.
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Maffei P, Tamagno G, Nardelli GB, Videau C, Menegazzo C, Milan G, Calcagno A, Martini C, Vettor R, Epelbaum J, Sicolo N. Effects of octreotide exposure during pregnancy in acromegaly. Clin Endocrinol (Oxf) 2010; 72:668-77. [PMID: 19769624 DOI: 10.1111/j.1365-2265.2009.03706.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Only six women who were treated with somatostatin analogues (SSAs) throughout their pregnancies have been described so far. The influence of SSAs on the course of pregnancy and newborn outcomes remains largely unknown. Many aspects of SSAs pharmacokinetics in mother and foetus have not yet been defined. METHODS AND FINDINGS We report a case study on the effects of octreotide on uterine artery blood flow, octreotide concentrations in biological fluids of mother and newborn, and somatostatin (SST) receptor expression and binding at the level of the maternal-foetal barrier tissues in an acromegalic woman treated with short-acting octreotide throughout her pregnancy. An acute decrease in uterine artery blood flow was observed after octreotide injections, without affecting the pregnancy course, delivery, or foetal development. Octreotide concentrations were high in maternal serum and colostrum and lower in umbilical cord serum, amniotic fluid, and newborn serum. All SST receptor subtypes can be expressed in placental tissue but their binding profile was weak both in the placenta and umbilical cord. The child was healthy and developed normally up to age 6 from an anthropometric, metabolic, and endocrine point of view. We reviewed all published reports on pregnancy SSA exposure and outcomes were compared to a time-matched group of acromegalic women not exposed to SSA. No significant effect on the mother or foetus was observed. CONCLUSIONS Short-acting octreotide appears not to affect the function of the maternal-foetal barrier or foetal development, except for the occurrence of acute, reversible, and clinically irrelevant haemodynamic changes. These data support the feasibility and safety of treatment with short-acting octreotide in acromegalic women during pregnancy and excludes major matters of concern about the effects of this medication on pregnancy itself and its outcome.
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Affiliation(s)
- Pietro Maffei
- Department of Medical and Surgical Sciences, University of Padua, Italy.
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Prise en charge de l’acromégalie évolutive au cours de la grossesse. ANNALES D'ENDOCRINOLOGIE 2010; 71:60-3. [DOI: 10.1016/j.ando.2009.10.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Revised: 09/23/2009] [Accepted: 10/12/2009] [Indexed: 12/29/2022]
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