What special considerations are needed for a pregnant patient with a history of pituitary microadenoma and hyperprolactinemia who has stopped her medication, such as dopamine agonists (e.g. bromocriptine or cabergoline), due to pregnancy?

Management of Pregnant Patient with Pituitary Microadenoma and Hyperprolactinemia

For pregnant patients with pituitary microadenoma and hyperprolactinemia who have stopped dopamine agonist medication during pregnancy, close monitoring for tumor expansion is essential, but routine reinitiation of medication is not recommended unless there are signs of significant tumor growth or visual field compromise. 1

Assessment of Current Status

• The patient's "swelling" at the end of pregnancy is likely normal physiologic edema of pregnancy rather than a complication of her pituitary condition
• For patients with microadenomas (tumors <1cm):
  • Risk of significant tumor growth during pregnancy is only about 1-2% 2
  • Symptomatic tumor expansion is rare with microadenomas
  • The standard practice is to discontinue dopamine agonists once pregnancy is confirmed 1, 3

Monitoring Recommendations During Late Pregnancy

• Visual field assessment should be performed if the patient reports:

  • Persistent headaches
  • Visual disturbances (blurred vision, visual field defects)
  • Symptoms of increased intracranial pressure

• Physical examination should focus on:

  • Visual field testing (confrontation test at minimum)
  • Assessment of cranial nerve function
  • Evaluation of physiologic vs. pathologic edema

Postpartum Management

• Prolactin levels naturally increase during pregnancy and lactation
• Do not measure prolactin levels during pregnancy or while breastfeeding as they will be physiologically elevated
• After delivery:
  • If the patient wishes to breastfeed, allow her to do so without restarting medication
  • If not breastfeeding, check prolactin levels 6-8 weeks postpartum
  • Consider restarting dopamine agonist therapy only if:
    • Prolactin remains significantly elevated after lactation ceases
    • Symptoms of hyperprolactinemia return (amenorrhea, galactorrhea)
    • There is evidence of tumor growth on imaging

MRI Considerations

• MRI is not routinely indicated during pregnancy unless there are concerning symptoms
• Consider postpartum MRI (after breastfeeding cessation) to reassess tumor size compared to pre-pregnancy baseline
• The FDA label for bromocriptine notes that effective treatment leads to reduction in hyperprolactinemia and often resolution of visual impairment 3

Medication Considerations if Needed

• If reinitiation of therapy becomes necessary postpartum:
  • Cabergoline is generally better tolerated than bromocriptine 1, 4
  • Initial dose of cabergoline is 0.25 mg twice weekly, with titration by 0.25 mg twice weekly at 4-week intervals 1
  • Maximum dose typically up to 1 mg twice weekly 1
  • If breastfeeding is desired, discuss risks/benefits of medication vs. breastfeeding

Potential Complications to Monitor

• Rare but serious postpartum complications with dopamine agonists include:

  • Hypertension
  • Seizures
  • Stroke
  • Myocardial infarction 3

• The FDA label specifically warns that bromocriptine "should not be used during the postpartum period in women with a history of coronary artery disease and other severe cardiovascular conditions unless withdrawal is considered medically contraindicated" 3

Long-term Follow-up

• After pregnancy and breastfeeding completion:
  • Resume monitoring prolactin levels
  • Consider gradual dose reduction if prolactin remains normal for ≥6 months 1
  • Some patients (20-30%) may achieve remission after pregnancy 5
  • Monitor prolactin levels every 3 months for the first year after discontinuation, then every 6 months for the second year 1

The patient's current swelling is most likely normal pregnancy-related edema and not related to her pituitary condition. Given the low risk of tumor expansion with microadenomas during pregnancy, no special intervention is needed unless she develops visual symptoms or severe headaches.