Preconception counselling for women with acromegaly: More questions than answers

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.

MANAGEMENT OF ENDOCRINE DISEASE: Acromegaly and pregnancy: a contemporary review

“…Contemporary experience has usually shown a rather stable clinical course of disease activity during pregnancy in most patients (2,3,4,5,38,46,50,51). Such favorable outcome is likely to reflect the overall improvement in both diagnosis and treatment of patients with acromegaly in the last decades.…”

“…Although the overall risks of metabolic and/or visual deterioration are usually acceptable, they are highest among patients with poor pre-pregnancy control of disease (3), with acromegaly diagnosed during pregnancy (59,68), and in those with pituitary adenomas closer to the optic chiasm (45). Tumor expansion, usually asymptomatic, has been observed after interruption of treatment in patients with recent shrinkage of the tumor with somatostatin analogs (2,50).…”

“…Although octreotide crosses placental barrier and placenta has somatostatin receptors that bind octreotide (78), no serious adverse fetal outcomes have been detected in nearly 50 (2,3,4,5,7,36,38,47,48,50,51,55,57,63,79,80,81,82,83,84) cases of transient exposure (mostly in first trimester) nor in a much smaller number of continuous exposure to somatostatin analogs (SA) and/or dopaminergic agonists (4,64,73,75,78,85,86,87). Notwithstanding, concerns about low birth weight associated to fetal exposure to SA either alone or, as more often reported, in combination with dopaminergic agonists (DA) have been raised by a large retrospective study and by few case reports (3,4,85,88).…”

Two successful pregnancies in a woman with active acromegaly

“…Treatment, such as surgical intervention or radiotherapy may also cause hypopituitarism. Although pregnancy in acromegalic patient is unusual, it is considered generally safe (3)(4)(5)(6)(7)(8). It commonly occurs after successful surgical intervention or during pharmacological treatment, when satisfying disease control has been achieved (3, 7, 9, 10).…”

“…Somatostatin analogues are known to cross the placental barrier, but in most cases of foetal exposure there were no adverse maternal of foetal outcomes (3,8,9,10,20,(24)(25)(26)(27). Notwithstanding, cases of small-for-gestational-age infants were reported (3,7,10).…”