The pituitary gland increases in size during normal pregnancy. Prolactinoma management during pregnancy focuses on controlling tumor size. Generally, patients are counseled to discontinue dopamine (DA) agonists when pregnancy is confirmed and only resume if necessary during the pregnancy. Studies do not demonstrate an increase in adverse maternal/fetal outcomes if therapy is continued during the first 6 weeks and long-term studies of children up to 12 years of age have not stated any demonstrable issues. Bromocriptine has been preferred during pregnancy due to the larger clinical experience with the medication, but there is increasing data that cabergoline has a similar safety profile. Systemic reviews of cabergoline use antepartum demonstrate methodologic heterogeneity limiting generalizability and suggest a lower live birth rate but no increase in congenital malformation, preterm birth, or low birth rate. This case describes a prolactinoma patient with a high-risk tumor causing internal carotid artery (ICA) compression who had 2 successful pregnancies while being maintained on cabergoline therapy.
The patient is a 37-year-old woman with a macroprolactinoma (19x10x14mm) diagnosed at age 22 (initial prolactin level of ~4000ng/ml). She was treated with cabergoline. Her prolactin normalized and tumor shrank to 3mm in size. The patient was lost to follow up and cabergoline treatment ceased for 5 years. She represented with galactorrhea and amenorrhea. Repeat evaluation off therapy demonstrated tumor progression (size 2.2x1.2x1.6cm) including cavernous sinus invasion with ICA compression, hypogonadism and a prolactin level 580 ng/ml. Cabergoline therapy was resumed and prolactin normalized with modest tumor shrinkage. She desired pregnancy and had been seen by fertility specialists and briefly treated with letrozole. She ended up conceiving without reproductive assistance. She was maintained on cabergoline (1.75mg / week) throughout the pregnancy due to concerns for tumor progression and potential further compression of her ICA. She gave birth to a healthy baby girl via cesarian. After 1 year she became pregnant again on cabergoline and had a healthy son delivered via cesarian. She remains on cabergoline 1.5mg/week with her most recent prolactin being 4.6 ng/ml and MRI demonstrating stability.
This case contributes to broadening literature regarding the safety of cabergoline use during pregnancy in high risk prolactinomas.
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