Anterior Pituitary Dysfunction - Tutorial

Question 1

Case Study:
34F - 3 months post-partum after delivery of her first baby and is exhausted. Was active during pregnancy, not anymore. Had a difficult labour requiring forceps delivery and lost a lot of blood during delivery. She had a blood transfusion, her periods have not returned after delivery. She has struggled to breastfeed. She bursts into tears during the consultation.

What is your differential diagnosis?

Answer 1

Post-natal depression - tired, tearful
Sheenan’s syndrome - due to excessive blood loss during labour
Anaemia - due to blood loss, tiredness
Hypothyroidism - tiredness

Question 2

What questions would you like to ask her next to narrow down the differential diagnoses?

Answer 2

Have you noticed any weightloss?
Why was the delivery of your baby / labour difficult?
Are you planning to have more children?
When was the last time you successfully breastfed?
Is the issue with milk production or baby latching onto the breast? (build up of pressure and leakage from the breast determines whether she is producing breast milk)
Do you have any other autoimmune conditions?
Do you feel down / depressed? How do you feel about your baby?
Do feel persistently sad / low mood? Do you have any frightening thoughts?

Question 3

More History:
Breastfeeding issue is milk production. 3kg below pre-pregnancy weight with no effort. Her mood is ok. She feels really tired, all day every day, even if she has a good night’s sleep.
She has a good support network at home.
No family history of autoimmune disease eg coeliac, thyroid disease, type 1 diabetes. BMI of 22kg/m2.

Now that you have this further information, are there certain diagnoses which you think may be more likely?

Answer 3

Sheehan’s Syndrome most likely - explains all her symptoms: tiredness, lack of lactation, weightloss, etc.
Could still be anaemia
Less likely it’s hypothyroidism, no family history of autoimmune conditions
Less likely to be post-partum depression as her mood is okay, not stressed etc.
Her BMI is in a healthy range - but returning to below her pre-pregnancy weight with no effortis indicative of weightloss
She’s not tired from lack of sleep as the baby sleeps through the night

Question 4

Her blood test results come back and they show: 
Haemoglobin			130 g/L 	(115 – 165)
Mean cell volume		89 fl		(80-100)
Oestradiol			<70 pmol/l	(>200) 
LH				        0.5 U/l		(2-10 U/L)
FSH				0.8 U/l		(1.5 – 10 U/L) 
Prolactin			<50 miU/L	(<500 IU/L)
fT4				        6.9 pmol/L	(9-23) 
TSH				0.09 mU/L	(0.3 – 4.2) 
9AM cortisol	        75nmol/L	(>350 nmol/L)

Work through these blood results and describe what is normal or abnormal about them:

How do the clinical examination findings and blood results change your differential diagnosis?

Answer 4

All the anterior pituitary hormones are below the normal range
Mean cell vol is within the same range
Hb is good, not anaemic

Probably not anaemia due to the Hb being within the correct range
Most likely to be Sheehan’s Syndrome - all her anterior pituitary hormones are low, so likely due to the major blood loss during delivery that caused apoplexy

Question 5

What treatment is given to Sheehan Syndrome’s patients?

Answer 5

Hormone replacement therapy
Oestrogen plus progesterone monthly (LH and FSH if she wants more kids)
fT4 replacement - (clinically you don’t replace TSH) e.g. levo-thyroxine
Replace cortisol, and must take steroids every day, and wear the bracelet alerting she is on steroids