Acromegaly and pregnancy

Lisa Tramble, RN

Women living with a chronic disease often face unique challenges that do not generally affect men. One important issue involves the decision to start a family while being treated for a medical condition. Questions such as "Can I even get pregnant?", "Can I still take my medication when I'm pregnant?", and "Will I pass my condition to my child?" often arise in women on therapy for a medical condition who want to have children. It can be challenging to live with acromegaly, and since it affects growth hormone levels, it causes extra concern for women as normal hormonal function is important for achieving and maintaining pregnancy.

The following article will discuss several questions that women living with acromegaly may have when considering having children. These questions regarding acromegaly and pregnancy include understanding how acromegaly can affect a women's ability to become pregnant, how pregnancy can affect acromegaly, and the typical course of treatment for women with acromegaly of childbearing age. As with all decisions regarding acromegaly management, please speak with an endocrinologist about any questions you may have about acromegaly and pregnancy.

How does acromegaly affect a woman's fertility?

A women's ability to become pregnant is controlled by several hormones that are released, or secreted, by the pituitary gland. These hormones include the gonadotropins: luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Other hormones produced in the pituitary gland play supporting roles during the pregnancy; prolactin helps the body produce milk for breastfeeding, and growth hormone (GH) and IGF-1 (insulin-like growth factor-1) help the ovaries respond to LH and FSH.

Acromegaly is caused by a benign tumour, or adenoma, on the pituitary gland. The adenoma secretes GH into the bloodstream, resulting in excess GH, and consequently, excess IGF-1. This adenoma may also cause less LH and FSH to be made and released by the pituitary gland, a condition called hypogonadism. There are generally three reasons why hypogonadism occurs, 1) too much prolactin is secreted by the pituitary gland (hyperprolactinemia), 2) the adenoma presses on the pituitary gland, making it difficult for the pituitary gland to release hormones, or 3) the excess GH and IGF-1 interferes with hormone production by the pituitary gland (1). Some women with acromegaly may experience a loss of periods, loss of sex drive, infertility, and/or the inability to breastfeed because of hypogonadism. It is possible to restore LH and FSH levels to normal by treating acromegaly with surgery, radiation or medical therapy, and thereby increase the chances of a woman with acromegaly to become pregnant.

Can pregnancy increase tumour size and elevate hormone levels further?

The pituitary gland generally grows larger during a normal pregnancy; therefore, there is some concern for women with acromegaly who want to have children. The adenomas of most women observed in clinical studies on acromegaly and pregnancy did not grow any larger when these women became pregnant (2). However, there were a few cases where pregnancy caused an increase in adenoma size, and resulted in the return of typical symptoms related to acromegaly, such as headaches, an increase in hand and feet size, etc. There were also some women with acromegaly who experienced vision problems during pregnancy due to the increased size of the adenoma putting pressure on the optic nerve. Generally, pregnancy has no effects on GH and IGF-1 secretion in women with acromegaly.

How can acromegaly affect the pregnancy and pregnancy outcomes?

There is a possibility that metabolic and cardiovascular complications of acromegaly could affect the mother and fetus. Some studies have shown that a small group of mothers with acromegaly were diagnosed with diabetes during pregnancy, having not been previously diagnosed with this condition (2),(3). This condition is called gestational diabetes, and is often treated with special dietary measures during the pregnancy (4). Most studies show that the majority of mothers with acromegaly do not develop metabolic complications during their pregnancies (2),(5).

Some mothers with acromegaly are also at risk for developing hypertension and coronary artery disease, leading to a potential risk to the fetus (2),(3). However, studies have shown that these potential complications do not have a detrimental effect on the fetus in the majority of pregnant mothers with acromegaly.

Most of the studies of acromegaly and pregnancy indicate that mothers have a very low risk of passing their condition to their infant (2),(3),(4). No major birth defects were observed in these studies, and a greater than normal birth weight at delivery was reported in a few cases. With careful observation and treatment, most mothers with acromegaly are able to deliver a healthy, full-term infant (2).

What are the effects of treatment on pregnancy outcomes?

There is very limited clinical data on the effect of using somatostatin analogues, dopamine agonists, and/or GH antagonists during pregnancy; therefore, they are not recommended during pregnancy. Limited clinical data does show that these medical therapies have no major negative effect on pregnancy and pregnancy outcomes. However, medical therapy should only be used if clearly needed, and the potential benefit justifies the potential risk to the mother and fetus (6),(7),(8). Similarly, it is not recommended to use medical therapy for acromegaly while breastfeeding.

The impact of having transsphenoidal surgery to treat acromegaly while pregnant has not been studied in detail. A few cases of fetal problems have been reported due to the effects of anaesthesia during the surgery and not specifically due to the transsphenoidal surgery itself (9).

Treatment of women with acromegaly of childbearing age

Although no two acromegaly cases are the same, there are a set of steps that healthcare professionals generally follow when treating women with acromegaly who want to become pregnant. The three general steps taken are: 1) get prolactin and growth hormone levels down to as normal as possible to help fertility and conception, 2) prevent adenoma growth during pregnancy, and 3) ensure the delivery of a healthy, full-term infant (2). Women with acromegaly can consider transsphenoidal surgery prior to conception to treat the pituitary adenoma because the procedure has little risk of hindering their fertility further. Similarly, medical treatment can be used to control GH and IGF-1 levels, but the use of medication should be stopped two months prior to planned pregnancy, and once pregnancy is confirmed (4). Women who have transsphenoidal surgery do not generally need to use medical treatment during their pregnancy. Those who have not had surgery and only medical treatment should only continue medical treatment during pregnancy if absolutely necessary, and if the potential benefits outweigh the potential risks to the mother and fetus (4). Pregnant mothers with acromegaly should also be observed for potential vision problems throughout the pregnancy (2),(4).

Despite the fact that acromegaly can affect a woman's ability to become pregnant and maintain a pregnancy, modern day medicine can help women with acromegaly who want to start a family. Transsphenoidal surgery and medical treatment are valid options for women with acromegaly prior to a planned pregnancy. Pregnant women with acromegaly are then closely monitored to ensure their adenomas do not grow. Overall, the majority of research studying acromegaly and pregnancy suggests that with close observation and treatment, most women with acromegaly are able to deliver healthy, full-term infants. As with all decisions regarding acromegaly management, please speak with an endocrinologist about any questions you may have about acromegaly and pregnancy.

References

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