Pituitary And Adrenal Disease

Question 1

What are causes of hyperprolactinaemia?

Answer 1

Normal pregnancy
Pituitary adenomas i.e. Prolactinomas 
Hypothalamic and pituitary stalk lesions
Empty sella syndrome
Hypothyroidism
CKD
Seizures
Drugs e.g. Metoclopramide

Question 2

What is the difference in definition between macro and micro prolactinomas?

Answer 2

Macro >1cm

Micro <1cm

Question 3

What are the three discriminatory clinical features of hyperprolactinaemia in pregnancy?

Answer 3

Frontal headache
Visual field defects (bitemporal hemianopia due to compression of optic nerve)
Diabetes insipidus

Question 4

What is the effect of pregnancy on prolactinomas?

Answer 4

They may enlarge, most likely to in the third trimester

Question 5

What is the treatment for prolactinomas?

Answer 5

Dopamine agonists
Bromocriptine / cabergoline

These are usually discontinued once pregnancy is confirmed
But are safe to be reintroduced if there is concern regarding tumour expansion

Question 6

What are the clinical and biochemical features of diabetes insipidus?

Answer 6

Excessive thirst and polyuria
Increased plasma osmolality
Decreased urine osmolality (failure to concentrate the urine)

Question 7

What is the cause of diabetes insipidus?

Answer 7

Relative deficiency of vasopressin (ADH)

Question 8

What are the four types of diabetes insipidus?

Answer 8

1. Central - deficienct production of ADH from posterior pituitary
2. Nephrogenic - ADH resistance, associated with CKD
3. Transient - increased vasopressinase production by the placenta OR decreased vasopressinase breakdown by the liver (associated with PET / HELLP and AFLP)
4. Psychogenic - compulsive water drinking

Question 9

What is the treatment of Diabetes insipidus?

Answer 9

DDAVP

Good water intake

Question 10

What are the clinical features of acromegaly / GH excess?

Answer 10

Altered facial appearance
Macro glossia
Large hands and feet
Headaches and sweating
HTN, CAD, Cardiomyopathy, IGT / DM
Hyperprolactinaemia

Question 11

Does GH cross the placenta?

Answer 11

No

Question 12

What is the effect of acromegaly on pregnancy?

Answer 12

Increased risk of GDM and macrosomia

Question 13

What is the treatment of acromegaly in pregnancy?

Answer 13

Dopamine agonists
Bromocriptine and cabergoline

Not as effective as they are in hyperprolactinaemia, but are still effective in approx 50% cases

Question 14

What are causes of hypopituitarism?

Answer 14

Pituitary surgery
Radiotherapy
Pituitary or hypothalamic tumours
Postpartum pituitary infarction (Sheehan’s syndrome)
Pituitary haemorrhage
Lymphocytic hypophisitis

Question 15

What is the pathophysiology of Sheehan’s syndrome?

Answer 15

Usually presents following PPH with hypotension
Anterior pituitary is particularly vulnerable to hypotension in pregnancy
Infarction

Question 16

What are the clinical features of Sheehan’s syndrome?

Answer 16

Most commonly presents with hypoprolactinemia, but can present with acute pituitary failure.

Failure of lactation
Persistent amenorrhoea, infertility
Loss of auxiliary and pubic hair
Hypothyroidism
Adrenocortical insufficiency

Question 17

What is the management of acute pituitary insufficiency?

Answer 17

IV fluids
Dextrose
Corticosteroids - IV hydrocortisone
Levothyroxine

Question 18

What are the clinical features of Cushing’s syndrome?

Answer 18

Excessive weight gain
Extensive purple striae
DM
HTN
Easy bruising
Headache
Hirsutism
Acne
Proximal myopathy (discriminating feature in pregnancy)

Question 19

What is the cause of Cushing’s syndrome?

Answer 19

Most common cause is exogenous steroids.

Outside pregnancy: 80% due to pituitary adenomas

In pregnancy: <50% due to pituitary adenomas. Most caused by adrenal adenomas or adrenal carcinoma

Question 20

What are the clinical features of Conn’s Syndrome?

Answer 20

Conn’s = hyperaldosteronism

HTN and hypokalaemia

Question 21

What are the causes of Conn’s?

Answer 21

1. Adrenal aldosterone-secreting adenoma
2. Adrenal carcinoma
3. Bilateral adrenal hyperplasia

Question 22

What are Phaeochromocytomas?

Answer 22

Tumours of the adrenal medulla

Secreting excess catecholamines

Question 23

What is the effect of pregnancy on phaeochromocytomas?

Answer 23

Potentially fatal hypertensive crises may be precipitated by
- labour, delivery, GA or opiates

Question 24

What is the effect of phaeochromocytomas on pregnancy?

Answer 24

Increased maternal and fetal mortality rate

Maternal death

• arrhythmia
• cerebrovascular accidents
• pulmonary oedema

Question 25

What is the treatment of Phaeochromocytoma?

Answer 25

Alpha-blockade to control HTN
Followed by beta-blockade
Surgical removal is the only cure

Question 26

What are the clinical features of Addison’s disease?

Answer 26

Adrenocortical failure: causing glucocorticoid and mineralocorticoid deficiency

Weight loss
Nausea, vomiting
Postural hypotension
Weakness, lethargy
Hyperpigmentation

Question 27

What is the pathogenesis of Addison’s disease?

Answer 27

Autoimmune destruction of the adrenal glands by adrenal antibodies
TB is another main cause

Primary adrenocortical failure resulting in deficiency of

• glucocorticoids
• mineralocorticoids
• androgens

Question 28

What is the management of Addison’s disease in pregnancy?

Answer 28

Maintenance hydrocortisone and fludrocortisone
Maintenance steroids

Labour: parenteral hydrocortisone as women are unable to mount an increased output of endogenous steroids that normally accompanies labour and delivery

During delivery, 100 mg hydrocortisone should be injected at the onset of active labour (contractions every 5 min for the last hour, or cervical dilation > 4 cm), followed by either continuous infusion of hydrocortisone 200 mg.24 h−1, or hydrocortisone 50 mg intramuscularly every 6 h, with rapid tapering (over 1–3 days) to the regular replacement dose after an uncomplicated delivery.

Question 29

What is the most serious risk in congenital adrenal hyperplasia?

Answer 29

Salt losing crisis

Question 30

What is an important (but rare) side effect of cabergoline?

Answer 30

Valvulopathy

Question 31

In Addison’s disease i.e. adrenal insufficiency, what are indication to increase the dose of corticosteroids or parenteral hydrocortisone?

Answer 31

Surgery
Labour
Infection
Other significant stress
Unwell - double the dose