Gebelik ve Hipofiz Hastalıklar
Özet
Gebelik sürecinde hipofiz bezinde meydana gelen fizyolojik büyüme ve laktotrop hücre artışı, endokrin aksların değerlendirilmesini ve hastalıkların teşhisini karmaşıklaştırmaktadır. Doğurganlık çağında en sık görülen hipofiz tümörü olan prolaktinomaların gebelik öncesi kontrolü, fetal riskleri ve tümör büyüme oranlarını belirgin düzeyde düşürürken, gebelik süresince semptom takibi ön plana çıkmaktadır. Akromegali ve Cushing hastalığı gibi nadir görülen durumlar ise hem fizyolojik değişimlerle örtüşen biyokimyasal baskılanmalar nedeniyle zor teşhis edilmekte hem de gestasyonel diyabet, preeklampsi ve preterm doğum gibi ciddi maternal ve fetal morbiditelerle ilişkilendirilmektedir. Hipopituitarizm ve lenfositik hipofizit olgularında levotiroksin, hidrokortizon ve desmopresin replasman tedavilerinin gebelik trimesterlerine göre dinamik olarak optimize edilmesi kritik önem arz etmektedir. Post-partum nekrozla karakterize Sheehan sendromu laktasyon yetersizliği ile kendini gösterirken, hayati risk taşıyan hipofizer apoplekside acil glukokortikoid müdahalesi gerekmektedir. Son olarak, plasental vazopresinaz aktivitesinin tetiklediği geçici diabetes insipidus, karaciğer patolojileriyle de ilişkili olabileceğinden multi-disipliner bir yaklaşımla izlenmelidir.
Physiological pituitary enlargement and lactotroph hyperplasia during pregnancy complicate the biochemical and radiological evaluation of specific endocrine pathologies. Prolactinomas, the most prevalent pituitary tumors in reproductive-aged women, require meticulous pre-pregnancy management to mitigate symptomatic tumor growth, while subsequent management focuses heavily on clinical monitoring rather than routine prolactin measurement. Rare conditions like acromegaly and Cushing's disease share overlapping clinical features with normal gestation, presenting diagnostic challenges due to altered endocrine axes and posing heightened risks for gestational diabetes, preeclampsia, and preterm delivery. In cases of hypopituitarism and lymphocytic hypophysitis, timely and dynamic adjustments of levothyroxine, hydrocortisone, and desmopressin replacement doses across trimesters are paramount to secure favorable neurocognitive and fetal outcomes. Postpartum pituitary necrosis, or Sheehan's syndrome, characteristically manifests as lactation failure, whereas acute pituitary apoplexy remains a life-threatening emergency necessitating immediate glucocorticoid administration and neurosurgical evaluation. Additionally, gestational diabetes insipidus induced by placental vasopressinase expression mandates a multi-disciplinary approach to rule out severe hepatic disorders and ensure structured peripartum hydration.
Referanslar
Molitch ME. Pregnancy and Endocrine Disorders. Endocrinol Metab Clin North Am. 2019 Sep;48(3):xv-xvi. doi: 10.1016/j.ecl.2019.06.001. PMID: 31345530.
Gonzalez JG, Elizondo G, Saldivar D, Nanez H, Todd LE, Villarreal JZ. Pituitary gland growth during normal pregnancy: an in vivo study using magnetic resonance imaging. Am J Med. 1988 Aug;85(2):217-20. doi: 10.1016/s0002-9343(88)80346-2. PMID: 3400697.
Motivala S, Gologorsky Y, Kostandinov J, Post KD. Pituitary disorders during pregnancy. Endocrinol Metab Clin North Am. 2011 Dec;40(4):827-36. doi: 10.1016/j.ecl.2011.08.007. Epub 2011 Sep 23. PMID: 22108282.
Mortimer AM, Bradley MD, Likeman M, Stoodley NG, Renowden SA. Cranial neuroimaging in pregnancy and the post-partum period. Clin Radiol. 2013 May;68(5):500-8. doi: 10.1016/j.crad.2012.08.024. Epub 2012 Oct 10. PMID: 23063171.
Kaiser UB. Hyperprolactinemia and infertility: new insights. J Clin Invest. 2012 Oct;122(10):3467-8. doi: 10.1172/jci64455. PMID: 23193578; PMCID: PMC3461927.
Molitch ME. Pregnancy and the hyperprolactinemic woman. N Engl J Med. 1985 May 23;312(21):1364-70. doi: 10.1056/NEJM198505233122106. PMID: 3887166.
Karaca Z, Tanriverdi F, Unluhizarci K, Kelestimur F. Pregnancy and pituitary disorders. Eur J Endocrinol. 2010 Mar;162(3):453-75. doi: 10.1530/EJE-09-0923. Epub 2009 Nov 24. Erratum in: Eur J Endocrinol. 2010 Jun;162(6):1167. PMID: 19934270.
Melmed S, Casanueva FF, Hoffman AR, et al. Diagnosis and treatment of hyperprolactinemia: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2011;96(2):273–88.
Türkiye Endokrinoloji ve Metabolizma Derneği(TEMD) Hipofiz Hastalıkları Tanı, Tedavi ve İzlem Kılavuzu-2019.
Woodmansee WW. Pituitary Disorders in Pregnancy. Neurol Clin. 2019 Feb;37(1):63-83. doi: 10.1016/j.ncl.2018.09.009. PMID: 30470276.
Chanson P, Vialon M, Caron P. An update on clinical care for pregnant women with acromegaly. Expert Rev Endocrinol Metab. 2019 Mar;14(2):85-96. doi: 10.1080/17446651.2019.1571909. Epub 2019 Jan 30. PMID: 30696300.
Katznelson L, Laws ER Jr, Melmed S, et al. Endocrine Society. Acromegaly: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2014 Nov;99(11):3933-51. doi: 10.1210/jc.2014-2700. Epub 2014 Oct 30. PMID: 25356808.
Brue T, Amodru V, Castinetti F. MANAGEMENT OF ENDOCRINE DISEASE: Management of Cushing's syndrome during pregnancy: solved and unsolved questions. Eur J Endocrinol. 2018 Jun;178(6):R259-R266. doi: 10.1530/EJE-17-1058. Epub 2018 Mar 9. PMID: 29523633.
Chanson P. Other Pituitary Conditions and Pregnancy. Endocrinol Metab Clin North Am. 2019 Sep;48(3):583-603. doi: 10.1016/j.ecl.2019.05.005. Epub 2019 Jun 18. PMID: 31345525.
Vila G, Fleseriu M. Fertility and Pregnancy in Women With Hypopituitarism: A Systematic Literature Review. J Clin Endocrinol Metab. 2020 Mar 1;105(3):dgz112. doi: 10.1210/clinem/dgz112. PMID: 31652320.
Joshi MN, Whitelaw BC, Carroll PV. MECHANISMS IN ENDOCRINOLOGY: Hypophysitis: diagnosis and treatment. Eur J Endocrinol. 2018 Sep;179(3):R151-R163. doi: 10.1530/EJE-17-0009. Epub 2018 Jun 7. PMID: 29880706.
Chrisoulidou A, Boudina M, Karavitaki N, Bili E, Wass J. Pituitary disorders in pregnancy. Hormones (Athens). 2015 Jan-Mar;14(1):70-80. doi: 10.1007/BF03401382. PMID: 25885105.
Keleştimur F. Sheehan's syndrome. Pituitary. 2003;6(4):181-8. doi: 10.1023/b:pitu.0000023425.20854.8e. PMID: 15237929.
Capatina C, Inder W, Karavitaki N, Wass JA. Management of endocrine disease: pituitary tumour apoplexy. Eur J Endocrinol. 2015 May;172(5):R179-90. doi: 10.1530/EJE-14-0794. Epub 2014 Dec 1. PMID: 25452466.
Ananthakrishnan S. Gestational diabetes insipidus: Diagnosis and management. Best Pract Res Clin Endocrinol Metab. 2020 Sep;34(5):101384. doi: 10.1016/j.beem.2020.101384. Epub 2020 Feb 27. PMID: 32205050.
