Managing the challenges of pregnancy in a case of recurrent macroprolactinoma: A balancing act

Prolactinomas are the most common pituitary adenomas and are usually microadenomas; however, macroprolactinomas (>4 cm) may lead to significant hyperprolactinemia and mass effects. Dopamine agonists (DAs) are the first-line therapy, while surgery is reserved for cases with resistance to medical treatment or visual compromise. A 27-year-old woman with recurrent macroprolactinoma, previously treated with transsphenoidal pituitary surgery five years earlier, presented with secondary amenorrhea, primary subfertility, and persistent headache. Menstrual cycles did not resume after surgery, and headaches persisted. Treatment with cabergoline resulted in a marked reduction in serum prolactin levels, although tumor size showed minimal regression. Five months later, she presented with nausea and vomiting and was found to be pregnant. Cabergoline therapy was continued throughout pregnancy. Serial clinical evaluations demonstrated no tumor enlargement or deterioration in visual function. The patient delivered a healthy infant by cesarean section. In the postpartum period, menstrual cycles resumed and headache severity improved. Management of macroprolactinomas during pregnancy is challenging due to the risk of tumor enlargement. In this case, continued cabergoline therapy effectively prevented tumor progression. Close monitoring with clinical assessment, visual field testing, and imaging was essential. This case illustrates that pregnancy in patients with macroprolactinomas requires vigilant monitoring. Continuation of cabergoline throughout pregnancy was safe and resulted in favorable maternal and neonatal outcomes. • Pregnancy in macroprolactinoma risks tumor expansion and apoplexy. • Cabergoline is an effective option during pregnancy. • Close monitoring with MRI and visual field testing is essential.