What to do if you have hyperprolactinemia in late pregnancy

What should we do if we have hyperprolactinemia in late pregnancy? The incidence of hyperprolactinemia has shown a clear increasing trend in recent years. The cause is unknown in most patients (idiopathic), and a few patients have pituitary microadenomas (diameter <1cm). Pituitary macroadenomas (diameter >1cm) are rare, and other intracranial tumors are even rarer.

1. Should patients with hyperprolactinemia stop taking bromocriptine immediately after becoming pregnant?

It depends on different situations. If the prolactin level is not too high before pregnancy (<50ng/ml or 1060mIU/L), especially if the prolactin level has dropped to normal and has been stable for a period of time after a long period of oral bromocriptine treatment (for example, more than half a year) before pregnancy, then bromocriptine can be stopped immediately once pregnancy is confirmed.

Although prolactin is not too high before pregnancy, if there is no strict treatment for a period of time, or if the side effects of bromocriptine cannot be tolerated and the medication is not taken regularly, or if the bromocriptine resistance treatment is not effective, prolactin will still be high before pregnancy. Because high prolactin can lead to luteal insufficiency and the risk of miscarriage, it is best to continue to use bromocriptine for treatment in the first 3 months of pregnancy, especially for pregnant women with a history of early spontaneous abortion due to hyperprolactinemia, they should continue to take bromocriptine orally to prevent miscarriage. The dosage of medication can be reduced during pregnancy (for example, halved) to keep the blood PRL at the corresponding normal level or slightly higher during pregnancy, that is, take the lowest effective dose continuously.

Bromocriptine is safe to use during pregnancy. The FDA (U.S. Food and Drug Administration) classifies bromocriptine as Class B during pregnancy (i.e. no adverse effects on the fetus were found in the study, and penicillin is Class B). This is also confirmed by a large number of clinical observations. Therefore, the use of bromocriptine during pregnancy has no adverse effects on the embryo or will not cause fetal malformations, so it can be used with confidence. However, it is also important to note that drug side effects are difficult to distinguish from early pregnancy reactions, such as nausea, dizziness, drowsiness, etc. If the reaction is particularly severe, you can stop the drug and observe.

2. For patients with pituitary tumors, will the tumor grow during pregnancy? If the pituitary tumor grows, do you need to resume taking medication? Generally, pituitary microadenomas (diameter <1cm) will not worsen during pregnancy, while macroadenomas (diameter >1cm) are at high risk of worsening during pregnancy, so patients with macroadenomas should actively treat before pregnancy and wait for a significant improvement before getting pregnant. Regardless of whether it is a microadenoma or a macroadenoma after treatment, you should pay attention to self-monitoring of the subjective symptoms of the pituitary tumor after pregnancy, such as headaches, changes in vision and other neurological symptoms. If you have these symptoms, you can do a pituitary magnetic resonance imaging (MRI) (note that you can only do MRI, not CT, because the latter has X-rays, which is not good for the fetus) to see if the pituitary tumor has increased significantly. Even if there are no symptoms, visual field and vision examinations should be performed in the early, middle and late stages of pregnancy.

If neurologic symptoms develop, if a pituitary tumor enlarges, or if prolactin rises more rapidly than normal during pregnancy, oral bromocriptine should be started immediately.

During normal pregnancy, prolactin gradually increases. In the first 3 months of pregnancy, blood PRL is <80ng/ml; in the second 3 months of pregnancy, blood PRL is <160ng/ml; in the third 3 months of pregnancy, blood PRL is <400ng/ml.

3. What indicators should be monitored when taking medication during pregnancy? When can patients who take medication during pregnancy stop taking medication? After taking medication during pregnancy, should the treatment effect be monitored? The monitoring should mainly focus on the following aspects: (1) Self-monitoring of neurological symptoms of pituitary tumors, such as headaches, vision changes, etc.;

(2) If there are neurological symptoms, or even if there are no symptoms, visual field and vision examinations should be performed in the early, middle and late stages of pregnancy; (3) If necessary, a pituitary magnetic resonance imaging (MRI) should be performed to see if the pituitary tumor has increased significantly; (4) Blood tests for prolactin should be performed regularly (for example, once a month) to see if the level is significantly higher than during normal pregnancy.

For pregnant women with unsatisfactory hyperprolactinemia, it is recommended to continue bromocriptine treatment in the first three months of pregnancy to prevent miscarriage; the risk of miscarriage is significantly reduced in the second and third trimesters of pregnancy. If the PRL is normal or only slightly elevated, you can consider stopping the medication for observation. For microadenomas, after medication treatment, if the subjective symptoms have disappeared for a period of time (>1 month), the visual field and visual acuity examination are normal, the MRI pituitary tumor has not increased significantly, and the blood PRL has dropped to the normal range of the corresponding stage of normal pregnancy for a period of time (>1 month), you can consider stopping the medication, but the above indicators still need to be monitored regularly. For macroadenomas, it is recommended to continue medication treatment throughout pregnancy until the end of the puerperium (42 days after delivery), and the blood PRL drops to normal, then consider stopping the medication for observation.

4. If you did not take medication during pregnancy, what would require you to continue taking medication after delivery?

If you do not take medication during pregnancy and your condition is relatively stable, it means that your condition is relatively mild. However, you still need to take blood samples regularly to monitor prolactin after delivery. If prolactin is significantly elevated after delivery, or if a pituitary tumor (even a microadenoma) is found, you still need to continue taking medication.

5. Can pregnant women who are taking medication breastfeed?

Taking bromocriptine does not affect breastfeeding. Bromocriptine has no adverse effects on the fetus and is also safe for the baby, so mothers who take the medicine can breastfeed.