Category: Pituitary Disorders/Neuroendocrinology
Objective : Octreotide use in pregnancy has been a challenge for women with pituitary tumors given a limited number of cases in the literature. We report a patient with a growth hormone secreting pituitary adenoma who was exposed to OCT-LAR during early pregnancy, and experienced a successful pregnancy and neonatal outcome.
Methods : n/a
Case Presentation: A 27-year old woman was referred for management of a pituitary tumor discovered during evaluation for infertility. She reported frequent headache, excessive snoring, galactorrhea and weight gain. She had no physical features of acromegaly. Hormonal studies showed prolactin 59ng/mL (nl:2-29) and insulin like growth factor (IGF-1) 742.9 ng/mL (nl:87-368). OGTT failed to suppress growth hormone (GH): >4 ng/mL (nl < 1 ng/mL). MRI showed a 1.9 cm pituitary adenoma with right cavernous sinus extension and slight compression of the optic chiasm. She underwent transsphenoidal surgery. Six month follow-up MRI showed minimal residual tumor. Prolactin was normal, but IGF-1 was elevated at 402 ng/mL. GH suppression test failed. She began monthly OCT-LAR and later participated in a research study with low dose OCT-LAR and weekly Pegvisomant. IGF-1 levels normalized during the 6 month study. IGF-1 rose after stopping Pegvisomant at the end of the study. OCT-LAR was gradually increased to 30 mg monthly. She then unsuccessfully attempted pregnancy by ovulation induction. She planned for in vitro fertilization, but she became pregnant naturally. The final dose of OCT-LAR was at 4 weeks gestation. Her pregnancy was uneventful. She delivered a normal 9lb 10oz baby at term. Currently, she is planning for a second pregnancy while on treatment with OCT-LAR given its dosing convenience compared with short-acting octreotide.
Discussion : Guidelines state that OCT-LAR should be stopped 2 months before attempts to conceive since its safety in pregnancy is unclear, and the potential for fetal growth restriction exists. To our knowledge, the safe use of OCT-LAR in pregnancy has been reported in fewer than 10 cases. One case report described the use of OCT-LAR throughout three pregnancies with uneventful outcomes. A possible explanation is that most somatostatin receptors on the placenta are SST4 receptors (SSTR4). And since OCT-LAR has high affinity for SSTR2 and SSTR5 receptors, and low affinity for SSTR4 receptors, placental GH secretion would less likely be inhibited by octreotide.
Although further studies are needed, our case adds credence to the safety and feasibility of OCT-LAR use in early pregnancy. This is reassuring should a patient become pregnant within the month after an injection of OCT-LAR.
Wai Wai Lin– Endocrine Fellow, Creighton University School of Medicine, Omaha, Nebraska
Robert Anderson– Program Director, Fellowship in Endocrinology, Diabetes and Metabolism, 1. Creighton University School of Medicine 2. VA Nebraska-Western Iowa Healthcare System, Nebraska
Creighton University School of Medicine
Dr. Wai Wai Lin is a current endocrinology fellow at Creighton University School of Medicine in Omaha, Nebraska. She received her medical degree from University of Medicine (1) in Yangon, Myanmar. She did her residency training at Presence Saint Joseph Hospital, Chicago, Illinois. She is inspired by every aspect of endocrinology.
Program Director, Fellowship in Endocrinology, Diabetes and Metabolism
1. Creighton University School of Medicine 2. VA Nebraska-Western Iowa Healthcare System, Nebraska
Dr. Robert Anderson is an endocrinologist in Omaha, Nebraska and is affiliated with Creighton University Medical Center-Bergan Mercy. He received his medical degree from Northwestern University Feinberg School of Medicine. He finished his endocrinology fellowship in Mayo Clinic, Rochester, Minnesota. Currently, he is a chief, section of endocrinology in VA-Nebraska Western Iowa healthcare system and a program director of fellowship in endocrinology at Creighton University School of Medicine.