Review Question - QID 106965

Action	Numeric Key	Letter Key	Function Key
Choose 1	1
Choose 2	2
Choose 3	3
Choose 4	4
Choose 5	5
Submit Response			Enter
Previous Question			Left Arrow
Next Question		N	Right Arrow
Open/Close Bookmode		C
Open Image			Spacebar

Hypopituitarism Sheehan Syndrome Imaging QID: 106965 (M2.EC.15.4404)

QID 106965 (Type "106965" in App Search)

A 28-year-old G2P1 female with a history of hypertension presents to the emergency room at 33 weeks with headache and blurry vision. On exam, her vitals include BP 186/102 mmHg, HR 102 beats per minute, RR 15 breaths per minute, and T 98.9 degrees Fahrenheit. She undergoes an immediate Caesarian section, and although she is noted to have large-volume blood loss during the procedure, the remainder of her hospital course is without complications. Four weeks later, the patient returns to her physician and notes that she has had blurry vision and has not been able to lactate. A prolactin level is found to be 10 ng/mL (normal: 100 ng/mL). Which of the following is the most appropriate next step?

Type & Select Correct Answer

Type in at least one full word to see suggestions list

Galactogram

0/21

Observation of maternal-child interactions

0/21

Brain MRI

67%

14/21

Head CT

29%

6/21

Breast ultrasound

0/21

Select Answer to see Preferred Response

Review TC In New Tab

This patient's clinical condition is consistent with Sheehan's syndrome, which is best diagnosed with a brain MRI.

Sheehan's syndrome is characterized by peripartum pituitary necrosis due to hypotension during or immediately after childbirth. During pregnancy, increased lactotrophs cause enlargement of the pituitary gland without a corresponding increase in blood supply. This makes the pituitary gland particularly vulnerable to infarction due to hypotension. The major characteristics of Sheehan's syndrome are explained by the loss of pituitary hormone products, including thyroid stimulating hormone (symptoms of hypothyroidism), prolactin (inability to lactate), and gonadotrophs (loss of pubic hair). Treatment of the condition includes life-long hormone replacement.

Samra discusses the ocular complications of Sheehan's syndrome. She notes that pituitary hemorrhage and swelling from infarction can impact the neighboring ocular structures. Overall, 78% of patients with Sheehan's syndrome have opthalmoplegia and 64% have decreased visual acuity.

Soares et al. performed a case-control study to evaluate the effects of long-term growth hormone replacement in patients with Sheehan's syndrome. They find that hormone treatment is associated with a decreased high-density lipoprotein and visceral fat and increased rates of glucose intolerance.

Illustration A shows a T1-weighted head MRI with gadolinium showing an enlarged, rim-enhancing pituitary gland, suggesting Sheehan's syndrome with non-hemorrhagic pituitary ischemia.

Incorrect Answers:
Answer 1: Galactogram should be considered if the cause of this patient's inability to lactate is thought to be structural.
Answer 2: There is no indication that this patient has poor maternal-child interactions.
Answer 4: Although pituitary infarct is visible on head CT, the more sensitive imaging test is a head MRI.
Answer 5: Breast ultrasound is useful for diagnosing a breast abscess, which can cause a plugged duct. Abscesses are usually unilateral, and may be associated with breast tenderness and fever.

ILLUSTRATIONS: