A triplet pregnancy after gonadotropin-releasing hormone pulsatile infusion therapy in a postoperative case of growth hormone-producing pituitary macroadenoma.
Intravenous GnRH pulsatile infusion therapy (10 micrograms/pulse, 90-min interval) was conducted in an acromegalic patient from whom 2/3 of a GH-producing pituitary macroadenoma had been removed. Before infusion therapy, plasma levels of GH and PRL were 10-20 and 15-25 ng/ml, respectively, while those of LH and FSH were subnormal without intrinsic fluctuations. Ovulation was induced after 13 days of infusion which was terminated on the 23rd day of therapy. Luteal function was supported by hCG (5,000 IU per dose) which was given 4 times from the 23rd to the 31st day of the treatment cycle. Triplet pregnancy was diagnosed ultrasonographically within 7 weeks of gestation. Although GH and PRL levels increased gradually as the gestational period progressed and plasma levels of GH and PRL of 32-55 and 30-67 ng/ml, respectively, were detected after 30 weeks of gestation, neither adverse signs related to the enlargement of the residual pituitary tumor nor manifestation of acromegaly was observed. The immunoreactive somatomedin-C levels during this period were not greater than those in normal pregnant women. Caesarean section was performed at 34 weeks and 3 normal healthy infants were delivered. Detailed analyses of hormonal changes throughout the period of GnRH pulsatile infusion and subsequent luteal phase revealed that the triplet pregnancy had been induced by the GnRH therapy itself and that hCG stimulation did not play any critical role. The residual tumor mass secreted increasing amounts of GH during the latter period of pregnancy but the somatomedin-C levels were not associated with this elevation. Therefore, the clinical as well as the hormonal findings strongly suggested that the GH secreted in increasingly large amounts by the residual tumor mass during pregnancy was defective in certain biological properties.