Prolactinoma The pituitary gland increases in size by

Prolactinoma • The pituitary gland increases in size by 50 – 70% in pregnancy due to normal lactotroph hyperplasia, which in rare cases causes symptoms in pregnancy The presence of an adenoma, called a prolactinoma, in the pituitary gland will further increase its size and cause symptoms.

• This adenoma, or cyst, increases the production of prolactin, which is the hormone that initiates lactation. There are two types of adenoma: • Microadenoma: accounts for 90% of cases in pregnancy. They are <10 mm in diameter • rarely grow significantly • regressing spontaneously.

• Macroadenoma: accounts for 10% of cases in pregnancy. • They are >10 mm in diameter • more likely to expand cause symptoms of headache and visual disturbance. • progress to pituitary apoplexy or diabetes insipidus. • With both types of adenoma there is a risk of infertility and treatment is with

• dopamine agonists, which cause sidee�ects of : • 1 -nausea, vomiting • 2 - postural hypotension, • 3 - constipation • 4 -nasal congestion • 5 - Raynaud's phenomenon

• Pre-conception care ; • -management depends upon the size of the adenoma which might involve a trial of discontinuing the dopamine agonist or changing to bromocriptine. • - In some cases, surgery might be afempted prior to conception to reduce the bulk size of the adenoma

• -Once pregnant, the woman should be referred to a specialist unit as this is a high-risk pregnancy. • - Antenatal care, however, can be shared with the community midwife and medical/obstetric team. • -At the initial visit the midwife should take particular note of past surgery and current medication when undertaking the woman's history. • - At each subsequent visit the woman should be asked about headache and visual symptoms.

• -It is the medical team who will determine the type and dose of dopamine agonist and perform monthly visual perimetry to detect early signs of compression on the optic chiasma • -If there are indications of adenoma expansion, a magnetic resonance imaging (MRI) scan should be performed urgently and bromocriptine commenced. • -In most cases the intrapartum care can be facilitated by the midwife, however if the adenoma is expanding the woman is likely to have a preterm induction of labour. • -The obstetric team may advise an elective instrumental birth to avoid a rise in intracranial pressure during the second stage of labour

• -In the postnatal period the woman is advised to report any symptoms. An MRI scan might be ordered by the medical team and prolactin levels measured aher 3 weeks, by which time the values should have returned to their prepregnancy levels. • -Follow-up appointments should be made with the specialist medical team who will evaluate the symptoms when determining the recommencement of pre-pregnancy treatment with dopamine agonists.

• The midwife should consult with the doctor and pharmacist for suitable alternative medication if the woman wishes to breastfeed her baby as dopamine agonists are usually contraindicated. • - Furthermore, the woman will require specialist contraception advice as oestrogen contained within the oral contraceptive pill might further increase the size of the adenoma and consequently is contraindicated