This document describes a case of a 40-year-old woman presenting with symptoms of decreased urine output, abdominal pain, fever, and leg swelling. Her lab work showed signs of anemia and hypothyroidism. Her history revealed amenorrhea for 18 years and issues with lactation after her third delivery. She was diagnosed with Sheehan's syndrome, also known as postpartum pituitary necrosis, likely due to postpartum hemorrhage 18 years prior which caused necrosis of her pituitary gland. She required hormone replacement therapy for her cortisol, thyroid, and other deficiencies.

1. INTERESTING CASE OF ANAEMIA
S.DHANRAJ PG M2
DR.SUNDARAMURTHY’S UNIT

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

8. • INVESTIGATIONS
• CBC – HB 7.6 SR. ELECTROLYTES
TC 4500 Na-129
DC N70L27E3 K-3.7
ESR 15/35 CL-98
PCV 24 HCO3-23
MCV 83 URINE
MCH 26 ALB-NIL
MCHC 31 SUG-NIL
RBC 2.8LAC DEP-1-3PUS CELLS
PLATLETS 1L
• RFT- SUGAR 203
UREA 12
CREATININE 0.8

9. • USG– N STUDY
• CXR- PA – N STUDY
• ECG -- WNL
• ECHO -- N LV FUNCTION
• FEVER PROFILE AND BLOOD CULTURE--
NEGATIVE

10. • CLINICALLY , suspected
MYXEDEMA PRECOMA
TFT SENT and
 started on ELTROXIN 100mcg
WITH steroids

11. TFT results– FT3 - 0.37pg/ml(2.3 to 4.2pg)
FT4 – 0.41ng/dl(0.6 to 2ng)
TSH – 2.572miu/ml(1 to 5miu/ml)
ELTROXIN dose stepped up

12. INVESTIGATIONS
• 5/4/2013
Urine spot PCR– 23/13
p.smear– microcytic hypochromic anaemia
Wbc—N
Platelets– adequate
No immature cells/haemoparasite

13. • Reticulocyte count – 1.5% (0.5-1.5%)
•
• Se LDH 190 U/L (135-220)
• Coomb’s test: negative
• Serum iron: 48 (50 to 150mcg/dl)
• TIBC: 380 (300-360 mcg/dl)
• Serum ferritin : 28 (30 to100mcg/dl)

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

15. • PROLACTIN – 0.6ng/ml (4.7 to 23.3 ng)
• LH – 0.99miu/ml
( Follicular phase:2.4-12.6
Ovulation phase:14-95.6
Luteal phase: 1-11.4 mIU/ml)
• FSH – 3.14 miu/ml
( Follicular phase: 3.5-12.5
Ovulation phase: 4.7-21.5
Luteal phase: 1.7-7.7 mIU/ml)
• CORTISOL – 0.42mcg/dl ( 6.2 – 19.4 mcg/dl)
• ACTH – 3.07pg/ml (7.2 – 63.3 pg/ml)

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

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

26. PRESENTATION

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

32. THANK YOU