2. • 40 YRS OLD MRS.SARASU CAME WITH
C/O on 4/4/13
Decreased urine output – 15 days
-- gradual
-- 300ml/day
Abdominal pain -- 6 months
-- pricking,more towards
epigastric region,not radiating or referred,not assoc. with
any other symptoms
Fever -- on and off,10 days
-- low grade
intermittent, not assoc. with
chills,rigor,rash,bleeding tendency
3. • Leg swelling -- 15 days
-- bilateral,upto knee
No h/o abdominal distention
No h/o constipation
No h/o chest pain/ breathlesness
No h/o jaundice
h/o hair fall +
h/o easy fatigueability+
h/o loss of apetite
No h/o contact
No h/o trauma
No h/o loc, no h/o drug intake
4. • PAST HISTORY
Not a known DM/SHT/CAD
No previous admissions
• MENSTRUAL HISTORY
amenorrhea for 18 yrs
5. EXAMINATION
Drowsy
Temperature (98.4 F )
dehydrated,
Severe pallor,facial puffiness
Dry coarse skin,sparse hair in scalp
Hoarse voice
b/l pedal edema+
no clubbing,no palpable lymphadenopathy
6. CVS – s1s2+
RS -- B/L normal breath sounds
P/A– epigastric tenderness+
-- no organomegaly
CNS – drowsy ,responding to oral commands
-- Examination: able to move all four limbs
-- delayed DTR
VITALS : BP-90/60mmHg;
PR- 60/min
7. • She was initially suspected as a case of
? Chronic kidney disease with encephalopathy
and fever under evaluation
14. • 7/4/13
patient started showing improvement
FURTHER INVESTIGATIONS
With TFT results (low t3, t4, normal TSH)
a pituitary cause of hypothyroid was
suspected and
PROCEEDED FOR workup for endocrine
insufficiency
16. • Patient was continued with Levothyroxine
and steroids
• Patient improved dramatically
17. ON PROBING
She gave
• h/o post partum haemorrhage at 3rd delivery
• Lactation failure after 3rd delivery
• Amenorrhea for 18 years
• PROCEEDED WITH MRI BRAIN
18.
19.
20.
21. FINAL DIAGNOSIS
• EMPTY SELLA SYNDROME probably due to
POSTPARTUM PITUITARY NECROSIS
(SHEEHAN’S SYNDROME)
22. INVESTIGATIONS NOT DONE
• Stimulation and provocative tests
• Posterior pituitary hormones assay
• Autoimmune work up----primary hypophysitis
(lymphocytic, granulomatous)
• Secondary hypophysitis—(infections,
sarcoidosis, takayasu)
• Haematological malignancy
23. SHEEHAN’S SYNDROME
- Postpartum hypopituitarism caused by
necrosis of the pituitary gland
- It is usually the result of severe
hypotension or shock caused by
massive hemorrhage during or
after delivery
- Usually presents as anterior pituitary
hormone deficiency
- Evolves slowly and is diagnosed late
24. - most common cause of hypopituitarism in
developing countries
- prevalence to be about 3% for women
above 20 years of age
- average time between the previous
obstetric event and diagnosis of SS was 6
to 13 years
25. MECHANISM
• Ischemic pituitary necrosis due to
severe postpartum hemorrhage
• Vasospasm, thrombosis and
vascular compression of the
hypophyseal arteries
• Autoimmunity
29. SYMPTOMS
• CORTICOTROPIN DEFICIENCY can cause
weakness, fatigue, hypoglycemia, or dizziness.
• GONADOTROPIN DEFICIENCY will often cause
amenorrhea, oligomenorrhea, hot flashes, or
decreased libido.
• GROWTH HORMONE DEFICIENCY causes many
vague symptoms including fatigue, decreased quality of
life, and decreased muscle mass.
• Difficulty breast-feeding or an inability to breast-feed
• HYPOTHYROIDISM
• Some women live for years with pituitary
insufficiency, can present as ADRENAL CRISIS triggered
by extreme physical stressors, such as severe infection
or surgery.
30. TREATMENT
Hormone replacement
• Hydrocortisone or prednisolone is replaced first
because thyroxine therapy can exacerbate
glucocorticoid deficiency and theoretically induce
an adrenal crisis.
• thyroxine replacement
• gonadotropin replacement
• Replacement of growth hormone is necessary in
children with hypopituitarism but is controversial
in adults.
31. REPLACEMENT
• ACTH -- Hydrocortisone
Cortisone acetate
Prednisone
• TSH – L-Thyroxine
• FSH/LH -- Females
Conjugated estrogen (0.65–1.25 mg qd for 25 days)
Progesterone (5–10 mg qd) on days 16–25
For fertility: Menopausal gonadotropins, human CG
Males
Testosterone enanthate
• GH -- Adults: Somatotropin (0.1–1.25 mg SC qd)
Children: Somatotropin [0.02–0.05 (mg/kg per day)]
• VASOPRESSIN