RESUMEN
During pregnancy, the body undergoes a major adaptation process as a result of the interaction between mother, placenta and fetus. Major anatomical and histological changes are produced in the pituitary, with an increase of up to 40% in the size of the gland. There are wide variations in the function of the hypothalamus-pituitary-thyroid axis that effect iodine balance, the overall activity of the gland, as well as transport of thyroid hormones in plasma and peripheral metabolism of thyroid hormones. The incidence of goiter and thyroid nodules increases throughout pregnancy. The management of differentiated thyroid carcinoma should be individually tailored according to tumoral type and pregnancy stage. Given the effects of hypothyroidism on fetal development, both the diagnosis and appropriate therapeutic management of thyroid hypofunction are essential. The most important modification to the hypothalamus-pituitary-adrenal axis during pregnancy is the rise in serum cortisol levels due to an increase in cortisol-binding proteins. Although Cushing's syndrome during pregnancy is infrequent, both diagnosis and treatment of this disorder are especially difficult. Adrenal insufficiency during pregnancy does not substantially differ from that occurring outside pregnancy. However, postpartum pituitary necrosis (Sheehan's syndrome) is a well-known complication that occurs after delivery and, together with lymphocytic hypophysitis, constitutes the most frequent cause of adrenal insufficiency. The management of prolactinoma during pregnancy requires suppression of dopaminergic agonists and their reintroduction if there is tumoral growth. Notable among the neuropituitary disorders that can occur throughout pregnancy is diabetes insipidus, which occurs as a consequence of increased vasopressinase activity.
RESUMEN
Hypophysitis are a group of inflammatory lesions affecting the pituitary gland and pituitary stalk. These lesions should be included in the differential diagnosis of sellar masses. There are three types of primary hypophysitis: lymphocytic, granulomatous and xanthomatous. Lymphocytic hypophysitis is the most frequent form of chronic pituitary inflammation and is believed to have an autoimmune origin. This form characteristically affects women during the peripartum, with diverse types of pituitary deficiency, especially ACTH deficiency, and frequently there are other associated autoimmune processes. Lymphocytic hypophysitis can affect the anterior pituitary only, the infundibular stalk and posterior lobe of the pituitary (infundibuloneurohypophysitis), or the entire pituitary (panhypophysitis). Clinically, lymphocytic hypophysitis can manifest with compression symptoms, hypopituitarism, diabetes insipidus or hyperprolactinemia. The imaging technique of choice is magnetic resonance imaging, which helps to characterize the sellar lesion. Treatment includes replacement of the functional pituitary deficiency and the use of corticosteroids, generally at high doses. Surgical treatment is reserved for patients unresponsive to conservative therapy. Granulomatous hypophysitis can be of known etiology, whether infectious (currently highly infrequent) or non-infectious (ruptured Rathke's cyst, etc.). Granulomatous hypophysitis of unknown etiology is manifested by the presence of idiopathic granulomas. Xanthomatous hypophysitis is characterized by a histiocytic infiltrate with cystic characteristics on imaging. Secondary hypophysitis is due to pituitary inflammation caused by surrounding lesions or can form part of systemic diseases.
RESUMEN
Introducción: La macroprolactina (maPRL) es una variedad molecular de prolactina (PRL) de alto peso molecular y de actividad biológica cuestionable. El objetivo del presente estudio fue valorar la repercusión clínico-analítica de la presencia de maPRL en pacientes con hiperprolactinemia. Pacientes y método: Seleccionamos las muestras con concentraciones de PRL > 50 ng/ml (1.060 MU/l), tras la realización de la técnica de precipitación con polietilenglicol (PEG) 6000, consideramos que presentaban maPRL aquellas con valores de recuperación 50 ng/ml estudiados en un periodo de 24 meses, 22 presentaron maPRL (9,6%), todas mujeres con edad media de 32 años (12-48). El rango de PRL basal fue de 50,5 a 158 ng/ml. El motivo más frecuente de petición de PRL fueron las alteraciones menstruales (el 45% de los pacientes). Para valorar la repercusión clínica, evaluamos la PRL monomérica en estas pacientes y encontramos que en el 36,4% la maPRL se asociaba a aumento de PRL monomérica (grupo A) y en este grupo presentaba clínica hipogonadal el 87,5%. La maPRL se asociaba con concentraciones fisiológicas de PRL monomérica en el 63,6% (grupo B) y en este grupo presentaba clínica de amenorrea sólo 1 (7,14%) paciente, p < 0,05. De las 6 pacientes a las que se realizó estudio radiológico, 2 presentaron adenomas. Se trató con agonistas dopaminérgicos a 6 pacientes y en todas se normalizaron la clínica y los valores de hiperprolactinemia. Conclusiones: En nuestra serie, la presencia de maPRL sólo se acompañó de clínica de disfunción gonadal cuando se asoció a hiperprolactinemia monomérica. La maPRL aislada carece de significado clínico, pero es importante determinarla para evitar un manejo clínico innecesario
Introduction: Macroprolactin (maPRL) is a high molecular weight variant of prolactin (PRL) with reduced bioactivity. The purpose of the present study was to determine the clinical-laboratory repercussions of the presence of maPRL in patients with hyperprolactinemia. Patients and Method: A polyethylene glycol (PEG) precipitation test was used to detect the presence of maPRL in all consecutive samples with a prolactin concentration of > 50 ng/ml (1.060 MU/l). A recovery 50 ng/ml. All the patients with maPRL were women; the mean age was 32 years (12-48). Serum PRL levels ranged from 50.5-158 ng/ml. The most frequent reason for the initial PRL request was menstrual disturbance (45% patients). To study clinical repercussions, monomeric PRL was determined. The results showed that maPRL was associated with an increase of monomeric PRL levels in 36.4% of the patients (group A) and that 87.5% of patients in this group had hypogonadal symptoms. MaPRL was associated with physiological concentrations of monomeric PRL in 63.6% (group B) and only one patient in this group had amenorrhea (7.14%), p < 0.05. Of 6 patients who underwent neuroimaging, pituitary adenomas were identified in 2. Six patients were treated with dopamine agonists. In all 6 of these patients, symptoms and hyperprolactinemic values were resolved. Conclusions: Our results indicate that patients with maPRL only presented symptomatology suggestive of hyperprolactinemia when the monomeric PRL concentration was elevated. MaPRL has limited clinical repercussions but its determination in routine practice is important to avoid inappropriate management
