|Viernes, septiembre 19, 2014

Prolactinomas y Embarazo  

Dr. Germán Barón Castañeda, M.D.

Aproximadamente el 80% de las mujeres con hiperprolactinemia pueden lograr el embarazo después de un tratamiento adecuado. Inicialmente existió la duda de la posibilidad y crecimiento de los adenomas hipofisiarios durante un embarazo, por lo cual se recomendaba la cirugía antes de buscar el embarazo. En el caso de los macroadenomas la posibilidad de compresión es mayor, alrededor del 15%, por lo cual el seguimiento debe ser estrecho. El microprolactinoma tiene un riesgo de compresión supraselar muy bajo, menor al 2%, por lo cual el tratamiento con dopaminérgicos se debe suspender cuando se diagnostica el embarazo. La compresión del tumor contra las paredes hipofisiarias favorece los fenómenos de infarto hemorrágico y necrosis secundaria, motivo por el cual una gran cantidad de pacientes con microprolactinomas presentan mejoría después del parto. Si la mujer lo desea, puede llevar a cabo su lactancia en forma normal.

Cuando hay crecimiento del adenoma, generalmente la cefalea precede a la aparición de los trastornos visuales; no hay una característica clásica de esta cefalea, mientras que la alteración visual generalmente es una hemianopsia bitemporal.

El seguimiento durante el embarazo inicialmente consistía en realizar mensualmente niveles séricos de prolactina y campimetría visual, lo cual no ha demostrado utilidad. El seguimiento debe ser clínico buscando la aparición de síntomas. La evidencia de crecimiento del tumor con aparición de sintomatología, regresa en forma rápida cuando se inicia manejo con bromocriptina. La terminación del embarazo o la cirugía se indican solo en escasas oportunidades.

Aunque el tratamiento con bromocriptina disminuye los niveles de prolactina tanto en la madre como en el feto, no hay efectos adversos sobre el embarazo o el recién nacido. La prolactina del líquido amniótico es derivada del tejido decidual y su secreción es totalmente independiente de la dopamina, por lo cual no se altera con el manejo médico.

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