The following results are from a 29-year-old post-partum female, day 6 following elective Caesarean section at 37 weeks gestation for placenta accreta, complicated by massive intra-operative haemorrhage.
She made a good recovery but has had a persisting dull headache, dizziness, lethargy, polyuria and failure of lactation.
|
Parameter |
Patient Value |
Normal Adult Range |
|
Sodium |
114 mmol/L* |
135 - 145 |
|
Potassium |
4.6 mmol/L |
3.5 - 5.0 |
|
Bicarbonate |
26 mmol/L |
22 - 32 |
|
Urea |
2.2 mmol/L* |
3.0 - 8.0 |
|
Creatinine |
46 mmol/L |
45 - 90 |
|
Serum osmolalitv |
232 mOsm/L* |
275 - 295 |
|
Urine osmolality |
493 mOsm/L |
|
a) Give the diagnosis for this clinical picture. (20% marks)
b) How will you confirm the diagnosis? (20% marks)
c) Outline the underlying pathophysiology of this condition. (20% marks)
d) What is your immediate treatment? (10% marks)
a) Sheehan's syndrome.
b) MRI brain showing empty pituitary fossa
Hormone profile – cortisol, TFTs, prolactin
c) Ischaemic pituitary necrosis due to severe post-partum haemorrhage. Vasospasm, thrombosis and vascular compression of hypophyseal arteries with an enlarged pituitary gland and DIC are possible factors.
d) Hydrocortisone.
a) This is a hypoosmolar hyponatremia with history of polyuria, failure of lactation, and lethargy. All sounds very endocrine. Given the history of pospartum haemorrhage, one must consider post-partum hypopituitarism, or Sheehan' syndrome.
b) Endocrine-sounding tests are in order.
c) The pituitary gland in pregnancy is enlarged, and in context of haemorrhagic shock it can become infarcted. As a result of this:
d) Supplement the following:
Cukierman, Ronit L., et al. "Post-Partum Hyponatraemia in the Setting of Massive Haemorrhage: An Unusual Presentation of Sheehan? s Syndrome." Critical Care Obstetrics and Gynecology (2016).