Introduction
Visual disturbances during pregnancy can be alarming and result in significant complications if not promptly addressed. One rare yet potentially serious cause is the presence of a pituitary adenoma, such as a prolactinoma. Despite their relative rarity, prolactinomas are the most common type of functioning pituitary tumor and can have considerable impact on a woman’s health during pregnancy. A case report, published in BMJ Case Reports on May 5, 2019, presents the peculiar instance of a 30-year-old pregnant woman who experienced visual loss, which was subsequently diagnosed as caused by a prolactinoma.
Keywords
1. Visual loss pregnancy
2. Prolactinoma pregnancy
3. Pituitary adenomas pregnancy
4. Endocrinological complications gestation
5. Neuro-ophthalmologic conditions pregnancy
Pregnancy is a state of considerable physiological upheaval, bringing about endocrinological, immunological, and metabolic shifts designed to support both the mother and the developing fetus. While most of these adaptations are benign and transient, some can precipitate pathologies that significantly affect maternal health. One such condition is visual loss due to prolactinomas, a potentially serious yet treatable cause, as reported in a recent case detailed in BMJ Case Reports (DOI: 10.1136/bcr-2018-228323).
Background on Prolactinomas
Prolactinomas are classified as hormone-secreting tumors that predominantly produce prolactin, a hormone that stimulates milk production in women after childbirth. Although relatively uncommon in the general population, these tumors are notably the most frequently encountered pituitary adenomas during pregnancy (Lambert & Williamson, 2013). The growth and function of prolactinomas are influenced by estrogen levels, which rise considerably throughout gestation. Recognizing and managing these tumors in pregnant women is of significant importance as they can lead to diverse complications, including visual impairment.
Reported Case of Visual Loss in Pregnancy
The case detailed by Caroline Annette Erika Bachmeier et al. (2019), involved a 30-year-old primigravida who presented with visual loss at 36 weeks and 5 days of gestation. The patient had no history of visual disturbances or neurological deficits prior to her pregnancy and had not undergone any vision-related interventions. Upon further investigation, including magnetic resonance imaging (MRI) and neuro-ophthalmologic evaluations, a diagnosis of a prolactinoma was established as the root cause of her visual symptoms.
Diagnostic Approach and Management
MRI remains a cornerstone in the diagnostic approach to pituitary adenomas, capable of defining the lesion’s size, extent, and impact on surrounding structures (Gonzalez et al., 1988). Neuroimaging, clinical assessment, and hormonal profiling are integral parts of establishing a diagnosis.
Treatment outcomes for prolactinomas can be favorable with appropriate intervention. In non-pregnant patients, dopamine agonists are the mainstay therapy, effectively reducing tumor size and prolactin levels (Randeva et al., 2000). However, managing prolactinomas during pregnancy involves careful consideration of both the mother and the fetus. Surgical intervention is reserved for patients who develop acute complications, such as rapidly progressive visual loss, not amenable to medical therapy. The preferred surgical approach is the transsphenoidal resection, which allows for tumor removal with minimal invasiveness.
Post-Delivery Follow-Up
Follow-up after delivery is vital as hormonal changes postpartum can lead to reactivation or growth of the adenoma. Monitoring prolactin levels and regular visual assessments is recommended to ensure no recurrence of symptoms (Von Versen-Höynck et al., 2004).
Incidence and Impact
The incidence of visual loss due to pituitary adenomas during pregnancy is low; however, the impact on the patient cannot be understated. It requires a multidisciplinary approach involving endocrinologists, obstetricians, and neuro-ophthalmologists to provide comprehensive care.
Discussion
Pregnancy induces hyperplasia and hypertrophy of lactotroph cells in the anterior pituitary, leading to an enlarged gland and increased prolactin synthesis (Sadovsky et al., 1977). The physiological adaptations in pregnancy can mimic pathologic enlargement of the pituitary gland, often complicating diagnosis (Heald et al., 2004). This similarity underscores the necessity for a high index of suspicion and a detailed understanding of the underlying pathophysiology when dealing with pregnant patients presenting with ocular symptoms.
The interplay between a pathologic condition, such as a prolactinoma, and a physiologic state, such as pregnancy, poses unique diagnostic and therapeutic challenges. The case presented by Bachmeier et al. illuminates the ability of prolactinomas to present initially or to exacerbate during pregnancy, with vision loss being a prominent and concerning symptom (Pivonello et al., 2014).
Conclusion
The case report by Bachmeier and colleagues stresses the significance of considering pituitary tumors, such as prolactinomas, in the differential diagnosis of visual disturbances during pregnancy. Early detection, multidisciplinary management, and regular follow-ups are crucial to ensure favorable outcomes for both the mother and the child. This case sheds light on the complex hormonal interplay characterizing pregnancy and the need for heightened clinical vigilance when encountering neuro-ophthalmologic conditions in pregnant patients.
References
1. Bachmeier, C. A. E., Snell, C., & Morton, A. (2019). Visual loss in pregnancy. BMJ Case Reports, 12(5), e228323. doi: 10.1136/bcr-2018-228323
2. Lambert, K., & Williamson, C. (2013). Review of presentation, diagnosis and management of pituitary tumours in pregnancy. Obstetric Medicine, 6(13), 13-19. doi: 10.1258/om.2012.120022
3. Gonzalez, J. G., Elizondo, G., Saldivar, D., Nanez, H., Todd, L. E., & Villarreal, J. Z. (1988). Pituitary gland growth during normal pregnancy: an in vivo study using magnetic resonance imaging. The American Journal of Medicine, 85(2), 217-220. doi: 10.1016/S0002-9343(88)80346-2
4. Randeva, H. S., Davis, M., Prelevic, G. M. (2000). Prolactinoma and pregnancy. BJOG, 107(10), 1064-1068. doi: 10.1111/j.1471-0528.2000.tb11101.x
5. Von Versen-Höynck, F., Schiessl, K., Morgenstern, B., & Hierl, T. (2004). [Primary diagnosis of hormone-secreting pituitary adenoma during pregnancy and after birth — a rare occurrence]. Z Geburtshilfe Neonatol, 208(4), 150-154. doi: 10.1055/s-2004-827221