Hypopituitarism - Clinical Case Flashcards
A 34 year old woman sees her GP. She is three months post-partum after delivery of her first baby and is exhausted. This is particularly frustrating for her as before she was pregnant, she was very active and enjoyed going for a run a few times per week. She describes a difficult labour requiring forceps delivery and lost a lot of blood during delivery. She had a blood transfusion before discharge from the hospital so can’t understand why she feels so tired. Her periods have not returned after delivery. She has struggled to breastfeed and has ended up giving her baby formula milk, which she has also found very disappointing. She bursts into tears during the consultation.
Summary of issues:
* Tired
* No periods
* Difficulty breastfeeding
* Tearful
What is your differential diagnosis?
- Sheehan’s Syndrome
- Pituitary tumour
- Post-partum depression
- Anaemia
A 34 year old woman sees her GP. She is three months post-partum after delivery of her first baby and is exhausted. This is particularly frustrating for her as before she was pregnant, she was very active and enjoyed going for a run a few times per week. She describes a difficult labour requiring forceps delivery and lost a lot of blood during delivery. She had a blood transfusion before discharge from the hospital so can’t understand why she feels so tired. Her periods have not returned after delivery. She has struggled to breastfeed and has ended up giving her baby formula milk, which she has also found very disappointing. She bursts into tears during the consultation.
Summary of issues:
* Tired
* No periods
* Difficulty breastfeeding
* Tearful
What questions would you like to ask her next?
PCH:
* Any weight gain
* Ask about low libido
* Any headaches
* Ask about bitemporal hemianopia
PMH / FH:
* Thyroid disease
* Anaemia
* Period regularity before pregnancy
SH:
* Post - partum depression -> Psychological health
* Sleep wellness
A 34 year old woman sees her GP. She is three months post-partum after delivery of her first baby and is exhausted. This is particularly frustrating for her as before she was pregnant, she was very active and enjoyed going for a run a few times per week. She describes a difficult labour requiring forceps delivery and lost a lot of blood during delivery. She had a blood transfusion before discharge from the hospital so can’t understand why she feels so tired. Her periods have not returned after delivery. She has struggled to breastfeed and has ended up giving her baby formula milk, which she has also found very disappointing. She bursts into tears during the consultation.
Summary of issues:
* Tired
* No periods
* Difficulty breastfeeding
* Tearful
The baby had no difficulty latching on to the breast to feed, but she couldn’t produce much milk.
She has returned to 3kg below her pre-pregnancy weight without any effort at all.
Her mood is ok and she doesn’t seem particularly stressed about new motherhood. She feels really tired, all day every day, even if she has a good night’s sleep. The baby is sleeping through the night. She feels guilty about not breastfeeding her baby.
She has a good support network at home. Her husband is back at work (so no financial worries) but helps a lot in the evenings and her mum lives nearby and pops in every day to help. In fact, her mum encouraged her to speak to the doctor about how tired she was feeling.
No family history of autoimmune disease eg coeliac, thyroid disease, type 1 diabetes. On examination, she has a BMI of 22kg/m2.
Now that you have this further information, are there certain diagnoses which you think may be more likely?
Sheehan’s Syndrome (Post-Partum Pituitary Infarction)
A 34 year old woman sees her GP. She is three months post-partum after delivery of her first baby and is exhausted. This is particularly frustrating for her as before she was pregnant, she was very active and enjoyed going for a run a few times per week. She describes a difficult labour requiring forceps delivery and lost a lot of blood during delivery. She had a blood transfusion before discharge from the hospital so can’t understand why she feels so tired. Her periods have not returned after delivery. She has struggled to breastfeed and has ended up giving her baby formula milk, which she has also found very disappointing. She bursts into tears during the consultation.
Summary of issues:
* Tired
* No periods
* Difficulty breastfeeding
* Tearful
The baby had no difficulty latching on to the breast to feed, but she couldn’t produce much milk.
She has returned to 3kg below her pre-pregnancy weight without any effort at all.
Her mood is ok and she doesn’t seem particularly stressed about new motherhood. She feels really tired, all day every day, even if she has a good night’s sleep. The baby is sleeping through the night. She feels guilty about not breastfeeding her baby.
She has a good support network at home. Her husband is back at work (so no financial worries) but helps a lot in the evenings and her mum lives nearby and pops in every day to help. In fact, her mum encouraged her to speak to the doctor about how tired she was feeling.
No family history of autoimmune disease eg coeliac, thyroid disease, type 1 diabetes. On examination, she has a BMI of 22kg/m2.
You receive the patient’s blood results:
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)
How do the clinical examination findings and blood results change your differential diagnosis? Why might this have happened?
- Anterior pituitary enlarges in pregnancy (lactotroph hyperplasia)
- Post-partum haemorrhage leads to hypotension
- Pituitary infarction (obstruction to blood supply to pituitary tissue)
- Primary hypopituitarism
A 34 year old woman sees her GP. She is three months post-partum after delivery of her first baby and is exhausted. This is particularly frustrating for her as before she was pregnant, she was very active and enjoyed going for a run a few times per week. She describes a difficult labour requiring forceps delivery and lost a lot of blood during delivery. She had a blood transfusion before discharge from the hospital so can’t understand why she feels so tired. Her periods have not returned after delivery. She has struggled to breastfeed and has ended up giving her baby formula milk, which she has also found very disappointing. She bursts into tears during the consultation.
Summary of issues:
* Tired
* No periods
* Difficulty breastfeeding
* Tearful
The baby had no difficulty latching on to the breast to feed, but she couldn’t produce much milk.
She has returned to 3kg below her pre-pregnancy weight without any effort at all.
Her mood is ok and she doesn’t seem particularly stressed about new motherhood. She feels really tired, all day every day, even if she has a good night’s sleep. The baby is sleeping through the night. She feels guilty about not breastfeeding her baby.
She has a good support network at home. Her husband is back at work (so no financial worries) but helps a lot in the evenings and her mum lives nearby and pops in every day to help. In fact, her mum encouraged her to speak to the doctor about how tired she was feeling.
No family history of autoimmune disease eg coeliac, thyroid disease, type 1 diabetes. On examination, she has a BMI of 22kg/m2.
You receive the patient’s blood results:
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)
What treatment does she need (5)?
- GH injection
- Levothyroxine
- Hydrocortisone / Prednisolone (Double dose of steroid during sickness)
- Oestrogen / Progesterone
- Gonadotrophin in case of fertility prospects
