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Twin Pregnancy in Woman with Panhypopituitarism: Case Report and Mini Review of Literature

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Twin Pregnancy in Woman with Panhypopituitarism: Case Report and Mini Review of Literature Case Report ISSN: 2574 -1241 DOI: 10.26717/BJSTR.2019.20.003470 Twin Pregnancy in Woman with Panhypopituitarism: Case Report and Mini Review of Literature Marianna Mariani*, Giulietta Micara, Lucia Merlino, Antonella Linari, Daniela Pietrangeli, Maria Grazia Piccioni, Chiara Di Tucci, Michele Carlo Schiavi and Oriana Capri Department of Gynaecology, Obstetrics and Urology, Italy *Corresponding author: Marianna Mariani, Department of Gynaecology, Obstetrics and Urology, Italy ARTICLE INFO Abstract Received: August 08, 2019 Panhypopituitarism is a condition of inadequate or absent production of pituitary hormones. These hormones play important roles in biological processes, including Published: August 14, 2019 metabolism, growth and development, and reproduction. Women with hypopituitarism may present amenorrhea, infertility and an increased risk of pregnancy complications, such as abortion, anemia, pregnancy-induced hypertension, placental abruption, Citation: Marianna M, Giulietta M, Lucia M, Antonella L, Daniela P, Maria Grazia P, premature birth and postpartum hemorrhage. We report a novel case of bichorionic- Chiara Di T, Michele Carlo S, Oriana Capri. biamniotic twin pregnancy obtained through Assisted Reproductive Technology (ART) Twin Pregnancy in Woman with Panhy- programs, in a woman with iatrogenic panhypopituitarism. Pregnancy was complicated popituitarism: Case Report and Mini Re- by diabetes insipidus, an elective cesarean delivery was performed at 35 weeks gestation view of Literature. Biomed J Sci & Tech and two healthy babies, a boy and a girl, were delivered. Pregnancy in women with Res 20(4)-2019. BJSTR. MS.ID.003470. endocrinologist, gynecologist and embryologist. Keywords: Assisted Reproductive Tech- pituitary insufficiency are uncommon and guarantee a good outcomes neurologist, nology; Infertility; Pregnancy; Diabetes Abbreviations: GH: Growth Hormone; FSH: Follicle-Stimulating Hormone; LH: Insipidus; Pituitary Gland Luteinizing; Hormone IGF-1: Insulin-Like Growth Factor-I; GHRT: Growth Hormone Replacement Therapy; ART: Assisted Reproductive Technology; WHO: World Health Organization; B-HCG: Beta-Human Chorionic Gonadotropin; ICSI: Intra Cytoplasmatic Sperm Injection; DI: Diabetes Insipidus; AVP: Antidiuretic Hormone Vasopressin Introduction The pituitary gland produces and secretes various hormones, fundamental in the regulation of endocrine function within the states, subfertility is present in a higher than normal prevalence [6] From this it can be seen that in female with GH-insufficient body, including metabolism, growth and development and repro- duction [1]. Hypopituitarism is a disorder characterized by the de- sexual maturation, in menstrual cycle and in reproductive ability because it leads to a deficient ovarian activity, causing problems in [7]. In literature there is discordance on utility of GH replacement in gland. Onset can be acute or insidious and the most common cause female with pan hypopituitarism. Some authors, for example, have ficiency of one or more of the hormones secreted by the pituitary in adulthood is a pituitary adenoma, or treatment with pituitary observed that the addiction of GH, increasing ovarian sensitivity to endogenous gonatropins, improve fertility and pregnancy Hormone (GH), Follicle-Stimulating Hormone (FSH) and Luteiniz- rate [4,8]. De Boer states that GH permits the recruitment of the surgery or radiotherapy, frequently affecting deficiencies of Growth dominant follicle from its cohort, stimulating ovulation [6]. Laron et al. observed, instead, ovulation and fertility in individual with ing Hormone (LH) [2]. Deficiency of pituitary hormones may affect - GH resistance [9]. During pregnancy, GH Replacement Therapy conception, pregnancy and delivery [3]. In particular, GH deficiency ry stimulating both directly the steroidogenesis and gametogene- (GHRT),can be stopped or continued at the same dose, or gradually play significant role to poor pregnancy rate; GH acts on the ova sis and indirectly through the release of gonadotropins and Insu- reduced but the literature demonstrated that the different GHRT lin-Like Growth Factor-I (IGF-1),that amplify the action of FSH and regimens do not affect pregnancy outcomes [10]. In women with LH on granulosa cells [4,5]. Panhypopituitarism spontaneous pregnancy, even if rare or Copyright@ Marianna Mariani | Biomed J Sci & Tech Res| BJSTR. MS.ID.003470. 15138 Volume 20- Issue 4 DOI: 10.26717/BJSTR.2019.20.003470 exceptional, is associated with high risk of abortions or fetal and maternal mortality [11]. Sperm Injection (ICSI). All three oocytes were fertilized. Two em- cle fluid, three of which were inseminated by Intra Cytoplasmatic bryos were transferred to the patient’s uterine cavity on the second Advances in fertility treatment has increased the hope of be- day. Unfortunately, serum b-hCG test 15 days after embryo transfer, coming pregnant in hypopituitary women, although only few cas- gave a negative result. Three months later, the patient began a sec- es of successful pregnancy and life birth have been published [3]. of menstrual cycle and a combination of Gonal F 37.5 UI/d (Serono, pituitary hormones plays an important role in the high number of ond ovulation induction protocol with Fertipeptil from the first day Fernanda’s prospective study has shown that the deficiency of the Rockland, MA, USA) and Menopur 75 UI/d from cycle day 2, for a cancelled cycles, due to low or absent ovarian response to stimula- total of 600 UI of Gonal F and 1200UI of Menoptur. Endometrial tion and consequently in low pregnancy rates [12]. Co- treatment thickness and the diameter of each follicle was controlled every 2 with Human growth hormone and gonadotropins may improve the days using transvaginal ultrasound. An endometrial scratch on cy- follicular response in a poor responder with Panhypopituitarism, cle day 10, during hormonal stimulation, was performed. At day 17 of hormonal stimulation, at a dose of 17B-estradiol of 1689 pg/ml, early stages of maturation [13-15]. Useful, moreover, seems to be to confirming the important role of GH, in follicular recruitment at an 18 mm leading follicle was detected and Ovitrelle 250 mcg was given. 36 hours later the patient underwent oocyte pick-up: four using thyroid hormones, glucocorticoids and bromocriptine in case restore the other hormonal deficiencies related to hypopituitarism, of hyperprolactinemia [15]. In summary, optimized hormonal re- inseminated by ICSI. placement and co-treatment with GH and estrogen may directly or oocytes were recovered from the aspirated follicle fluid and were indirectly increase the fertility of women with Panhypopituitarism Insemination led to fertilization of four oocytes. Five days but still pregnancy rate and achievement of live birth are poorly. later, two blastocysts were transferred to the uterus. Pregnancy Case Reports transfer. An ultrasound examination at 6 weeks of amenorrhea was confirmed with serum b-hCG test 14 days after embryo A 26-years-old white female was referred to our ART (assisted demonstrated two gestational sacs. Bichorionic biamniotic twin reproductive technology)-unit for treatment of primary infertility. She had transsphenoidal subtotal excision of pituitary gland for a continued hormone replacement therapy with hydrocortisone pregnancy was confirmed by first trimester ultrasound. Patient hemorrhagic adenoma at the age of 12, resulting in panhypopitu- (10mg/day), L-thyroxine (100 ug/day) and Liothyronine (5 mg/ day) but not GH replacement. No severe problems during the thyroid hormones and growth hormone substitution. At the age itarism. Pituitary insufficiency was treated with glucocorticoids, rest of the pregnancy were detected until week 35, when the of 16, menstrual cycle was established by estrogen and progestin patient showed a form of Diabetes Insipidus characterized by combined oral therapy. First cycle of ovulation induction was per- polyuria and polydipsia. Endocrinological advice, introduced a formed at the age of 25. Her 30 years old husband underwent right therapy with desmopressin (Minirin(®))and electrolyte and water orchidopexy, even though his semen analyses revealed normosper- balance. Therefore, depending on gestational age and completion mia (100 Million/ml, >55% motile sperm and 12% typical sperm of antenatal corticosteroid therapy for prophylaxis of respiratory morphology, according to WHO 2010 criteria) [16]. The female pa- distress syndrome, an elective cesarean delivery was performed at tient showed a good ovarian reserve (anti-Millerian hormone 5.2 35 weeks and 4 days of gestation. Two healthy babies, a boy and a ng/ml, antral follicular count > 5 in both ovaries). girl, were delivered (2234 g the boy and 2015 g the girl). Second Controlled ovarian stimulation was performed with gonadotro- twin (female) had a true knot of umbilical cord. - Discussion al cycle (Fertipeptil; Ferring Pharmaceuticals, Kiel, Germany) and pin- releasing hormone analogues from the first day of menstru Panhypopituitarism patients often do not get spontaneously human menopausal gonadotropin (Menopur; Ferring Pharmaceu- pregnant, but, now, thanks to the practices of assisted reproduction ticals, Kiel, Germany) containing both FSH and LH activity (1:1). they can reach ovulation and pregnancy. A literature review Daily subcutaneous gonadotropin administration started at men- was performed via an automated search for information on the strual cycle days 3. The initial dose varied from 75 IU/d to 150 IU/d. database: MEDLINE (Pub-Med)
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