Many disease are envolved in this part of physiology, this thread is for us to talk about them and their treatment, so i wish everyone participates ........ I will start with Shehaan's Syndrome : which is panhypopituitarism due to reduced blood supply and ischemia of the the pituitary gland. It occurs as a complication of post partum hemorrhage after delivery, during the pregnancy period the pituitary enlarges due to increased hormonal demands in the body (FSH,,LH,,etc), so as its blood requirements increase, therefore with the hemorrhage, the blood supply decrease making the gland ischemic. as
Points to ponder 1) So what would be her first complaint ? How would she first present ? And how would you manage that ? 2) Assuming her pituitary problem gets worse down the line...how would she present or how would you spot the problem ( assuming ur prior knowledge of her Sheehan syndrome ) ? 3) worst case scenario - What if she lands into a life threatening crisis immediately following pregnancy ? How would you manage that ? Which hormone would you give her first ? Does the sequence matter ? This is open to anybody who wishes to answer but I wish the thread starter takes the lead (-:
I think it's worthwhile to discuss practical issues becos, the general stuff u will find in every book and in the era of ebooks ( and our hard-drives on the brink of bursting with them ), it's futile to just pick some excerpts and put it here wink)
Well, first it might be she might present with with amenorrehea and agalactorrehea , and loss of libido (but it might be asymptomatic in some cases) she would also have fatigue, bradycardia, Low Blood pressure, constipation, adrenal insufficiency, weight loss, and Hyponatremia... Sheehan syndrome may also appear acutely after delivery, mainly by hyponatremia. There are several possible mechanisms by which hypopituitarism can result in hyponatremia, including decreased free-water clearance by hypothyroidism, direct syndrome of inappropriate antidiuretic hormone (ADH) hypersecretion, decreased free-water clearance by glucocorticoid deficiency (independent of ADH). Treatment involves estrogen and progesterone hormone replacement therapy, which must be taken for the rest of your life. Thyroid and adrenal hormones also must be taken. HOPE THIS REPLY IS GOOD,,, WELCOMING TO LEARN MORE FROM U ?
Dear Xerxles, I see no more ans coming, so am going ahead and answering the questions I posed. Take all of this as a big brotherly advice, since I am senior to u and have seen it all and besides I want to see u do well (-: Since u had ur orals today in patho, u r in the right frame of mind to understand what I am saying. U said the examiner asked u just 2 questions and seemed to b in a hurry. Well, that's usually the case during vivas, since they hav to cover many students. So when u r asked something u shud b very specific....otherwise, if they r in a bad mood - they will make u repeat the year. U got 2 put urself in their shoes to understand this...today u r a student,...2 morrow u could be an examiner. Let's take the ex of what i asked u. First presentation for Sheehan's in a non-serious and serious case and the order of giving the hormones. U put the entire basket b4 me and asked me to pic what I want. U can argue that it is the way in the textbooks. Well, if I am an examiner in the exam, i don't want to search that basket. I want u to pick and choose from that basket 4 me. Our conventional textbooks don't do that...so u hav to think critically for which u hav to raise ur head after u read a few lines and think over it. U can't put ur head down and think...only mugging is possible that way. Now, let me explain this by elaborating on the questions I posed and the ans u gave. Sheehan's syndrome mild case. First sym. has to be agalactorhea becos - no prolactin, so no milk let down. (Amenorhea is always presnt atleast for 4 months following preg and u shud not mention it in the same breath as agalactorrhea )We hav to hav high clinical suspicion, becos we may just keep forcing/encouraging the mother to try harder but she just can't...it's beyond her since she has no prolactin...and the child can get quickly dehydrated. So if a wet nurse is available at the hospital..then immediate breast feeding can begin or else other artificial milk replacement should begin immediately ( no cow's milk until 1 year of age...check out why (-: ). the rest of the symptoms will manifest later ( based on severity ). Thyroid hormone def won't immediately manifest as we hav enough stores for at least a couple of weeks and it's secretion is based on body metabolic demands. TSH is responsible to replenish the stores, which will be hampered and take a couple of weeks to manifest....so even in an acute case of Sheehan, thyroid hormone def won't be immediate. Now let's see the acute case...the symptoms will be due to ACTH shut down...becos unlike TSH, ACTH is imp for both production stimulation and release of cortisol. Remember that Mineralocorticoid secretion (aldosterone) is independent of ACTH control and so will not be affected ( either short term or long term ). We use ACTH analogue only for diagnosis...so replacement in this case where the adrenal gland is intact is the same as in case of def due to congenital enzyme problems like 21 - hydroxylase def or Addison's disease i.e we hav to replace with synthetic corticosteroids ( permanently )...over time the adrenal cortex will shrink (cortisol secreting zone). Remember all this is relative and there is no absolute mild or clear cut severe case. The period post preg is stressful and a mild patient may also have some hypoglycemia due to cortisol def..which needs to be corrected either with steroids or iv glucose. Now about the order of giving the hormones....like I said, there is no immediate thyroid hormone def and if u giv thyroid hormones, then metabolism of cortisol will be accelerated and a mild case can become severe and a severe case may take a turn for the worse. sp. note 1 - Serum cortisol levels are not helpful in monitoring hormone replacement. It has to be titrated based on symptoms. sp. note 2 - All patients should be instructed about increasing glucocorticoid replacement during times of illness and should wear medical alert jewelry. As doctors we r among the most brilliant in socitey...but the way it's going these days ( pharma industry driven + advanced diagnostic tech )..we hav taken of our thinking caps. I will be glad if this discussion will make a difference to ur life. Wishing u all the very best in ur professional and personal life neo_star
