Prolactinoma in pregnancy, all are true except -

Macroadenoma > 1 cm is associated with bad prognosis Prolactinomas are prolactin secreting tumours of the pituitary It is a benign tumour They are the most common type of pituitary tumour0 They are .five times more common in women Prolactittomas are an impoant cause of infeility in women - They constitute about 1/3rd cases of infeility Treatment of prolactinomas restores feility - Women undergoing infeility t/t for prolactinoma gets pregnant However an impoant point to note is that pregnancy causes growth of prolactinomas -The rising estrogen levels during pregnancy have a marked stimulatory effect on normal lactotrophs. - Hyperophy and hyperplasia of the lactotrophs results in an upto 1.5 fold increase in pituitary size. - Such increase in size may also occur with prolactinomas mostly in the second and third trimesters. "About 1.2% microprolactinomas and about 24% of macro- prolactinomas increase in size during pregnancy". Management of prolactinoma in pregnancy Microprolactinoma -For women with microprolactinoma the subsequent risk of adenomas growth during pregnancy appears to be 1%, once the drug is discontinued - In these cases drug is discontinued once the patients is pregnant - Symptomatic follow up should be done each trimester, and treatment is reinitiated, only if symptoms of tumour growth develops. Macro prolactinoma For women with maeroprolactinoma there is 23% risk of tumour enlargement. - In these cases optimal choice of t/t is more difficult to determine. The patient should be advised to reduce the tumour size by medical treatment prior to pregnancy or at least responsiveness of the tumour to medical treatment should he established. - After conception bromocriptine may be stopped or continued during pregnancy depending on the aggressiveness of the tumour. - It symptoms of rumour appear of regrowth develops therapy is reinitiated. If medical t/t .fails surgery is recommended. Treatment during pregnancy - Treatment of women with lactotroph adenomas should begin before conception with advice to the woman and her paner about the risks of pregnancy to her and the .fetus. - The woman is then monitored during pregnancy and, if relevant, nursing. - The approach outlined here is consistent with the 2011 Endocrine Society Clinical Practice Guidelines on the diagnosis and treatment of hyperprolactinenzia. - When a dopamine agonist is needed to lower the serum prolactin concentration to permit ovulation, we suggest bromocriptine rather than cabergoline, because of the greater ceainty that it does not cause bih defects, as described above. However, if a woman cannot tolerate bromocriptine, we recommend cabergoline. Microadenomas A woman who has a lactotroph microadenoma should be told that the risk of clinically impoant enlargement of her adenoma during pregnancy is very small (1.2%) and that it should not be a deterrent to becoming pregnant. - She should also he told that bromocriptine or caber' oline will likely be effective if symptoms do occur. - If she is willing to take this risk, she should be given bromocriptine or cabergoline before pregnancy in whatever dose is necessary to lower her serum prolactin concentration to normal. - Bromocriptine is still the preferred drug Pr this purpose .for most women because of the greater experience with it. When the serum prolactin concentration is normal and menses have occurred regularly for a few months, the woman can attempt to become pregnant. Bromocriptine should be discontinued as soon as pregnancy has been confirmed, an approach that is safe given the lack of apparent toxicity during the first trimester. If the adenoma is not responsive to a dopamine agonist, ovulation can usually be induced by administration of other ovulation induction agents. During the pregnancy, the woman should be seen every three months and asked about headaches and changes in vision. If no symptoms occur, serum prolactin can be measured two months after delivery or cessation of nursing, and if it is similar to the pretreatment value, the drug can he resumed. Treatment is initiated during pregnancy when there is tumour growth or symptoms develop. Macroadenomas - A woman who has a lactotroph macroadenoma should be advised of the relatively higher risk of clinically impoant tumor enlargement during pregnancy (23%). - Advice and monitoring depend upon how large the adenoma is. If the adenoma does not elevate the optic chiasm - Treatment with bromocriptine or cabergoline for a sufficient period to shrink it substantially should reduce the chance of clinically impoant enlargement during pregnancy. Once this has occurred, the woman can attempt to become pregnant; the dopamine agonist should be discontinued when pregnancy has been confirmed. Monitoring during pregnancy should be similar to that described above for women with microadenomas. A perceived change in vision should be assessed by a neuroophthalmologist, and an MRI should be performed if an abnormality consistent with a pituitary adenoma is confirmed. If the adenoma has enlarged to a degree that could account for the symptoms, the woman should be treated with bromocriptine throughout the remainder of the pregnancy, which will usually decrease the size of the adenoma and allete the symptoms. - If the adenoma does not respond to bromocriptine, cabergoline may be successful. If cabergoline is not successful, transsphenoidal surgery could be considered in the second trimester if vision is severely compromised. In comparison, surgery for persistent visual symptoms in the third trimester should be deferred until delivery if possible. If the adenoma is very large or elevates the optic chiasm - Pregnancy should be strongly discouraged until the adenoma has been treated by transsphenoidal surgery, and perhaps postoperatively by radiation. - Postoperative treatment with bromocriptine or cabergoline may also be helpful in reducing adenoma size fuher and lowering the serum prolactin concentration to normal. - Such a regimen reduces the chance that symptomatic expansion will occur during pregnancy, but it may still occur. Pregnancy should also be discouraged in a woman whose macroadenoma is unresponsive to bromocriptine and cabergoline, even if it is not elevating the optic chiasm, until the size has been greatly reduced by transsphenoidal surgery, because medical treatment would not likely be effective if the adenoma enlarges during pregnancy. Breast feeding - Breast feeding does not 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. - However, dopamine agonist treatment should be withheld until breastfeeding is completed. - In contrast, breastfeeding is contraindicated in women who have neurologic symptoms at the time of delivery (suggesting tumor growth), because they should be treated with a dopamine agonist. We are unable to comprehend the option 'c' Prolactinomas are classified as macroprolactinomas only when they are > 10 mm or 1 cm. - May be , the correct option would have been prolactinoma > 10 mm are associated with worse prognosis. - Macroprolactinomas are definityly associated with worse prognosis during pregnancy. - "Approximately 23% macroprolactinomas increase in size during pregnancy as compared to 1-2 microprolactinomas". Increase in prolactin level associated with worse prognosis.???? We are not sure of this option Increased prolactin levels are definitely associated with worse prognosis in nonpregnant women whether, it retains the same prognostic significance during pregnancy is doubtful because during pregnancy there is significant increase in prolactin level. It becomes quite difficult to distinguish whether this elevation is due to tumour activity or pregnancy itself. Dewhurst says "Prolactin levels should not be checked as they increase by as much as 10 folds by 25th week of gestation". Williams obstetrics says "Serial serum prolactin levels are not recommended because of normal increase during pregnancy".