A Case of Pulmonary Thromboendarterectomy

Yıl 2009, Cilt: 14 Sayı: 1, 93 - 96, 01.02.2009

Aydın Köşüş Nermin Köşüş Metin Çapar

Öz

Fourtyfive years old patient with parity 1 was admitted hospital due to amenorrhea. She had given birth at home 20 years ago and had severe bleeding due to retained placenta. Her hormonal examination showed panhypopitiutarism. Empty sella was diagnosed by MRI examination. Glucocorticoid, thyroxin and estrogen-progesteron treatment were given. Sheehan's Syndrome is insufficiency of pituitary and adrenal gland due to postpartum hemorrhage and hypovolemia. Symptoms may develop immediately or after years depending on severity of pituitary destruction. Most prominant symptoms are secondary amenorrhea, loss of lactation, loss of libido and other symptoms due to loss of pituitary reserves. Empty sella is complete or incomplete insufficiancy of hypophysis due to intracellar herniation of subarachnoid structures. One cause of empty sella is pituitary necrosis developing after severe postpartum hemorrhage (Sheehan's Syndrome). CT and MRI are best methods for diagnosis of empty sella. Hormon replacement treatment (glucocorticoid, thyroxin and estrogen-progesteron) is given to patients with Sheehan's Syndrome.

Anahtar Kelimeler

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Yavaş Gelişen Sheehan Sendromu ve Empty Sella: Postpartum Kanamanın Nadir Bir Komplikasyonu

Öz

45 yaşındaki 1 çocuklu hasta adet görememe şikayetiyle kliniğimize başvurdu. Hastanın özgeçmişinde 20 yıl önce evde doğum yaptığı, doğum sonrası plasentanın düşmemesi nedeniyle aşırı kanamasının olduğu öğrenildi. Hastanın yapılan hormon tahlillerinde panhipopituitarizm bulguları görüldü. MRI incelemesinde hastada empty sella tesbit edildi. Glukokortikoid, tiroksin ve estrojen - progesteron tedavisi başlandı. Sheehan Sendromu postpartum kanama ve hipovolemiye bağlı olarak gelişen hipofiz ve adrenal yetmezliğidir. Hipofizin hasar derecesine göre belirtiler hemen ya da yıllar sonra ortaya çıkabilir. En belirgin özellikler laktasyonun kesilmesi, sekonder amenore, libido kaybı ve hipofiz rezervlerinin kaybına bağlı gelişecek semptomlardır. Empty sella, suprasellar subaraknoid yapıların intrasellar herniasyonu sonucu meydana gelen komplet ya da inkomplet hipofiz yetmezliğidir. Empty sella sendromunun nedenlerinden biri aşırı postpartum kanama sonucu gelişen hipofiz nekrozudur (Sheehan Sendromu). CT ve MRI empty sellanın tanısında en önemli teşhis metodlarıdır. Sheehan Sendromu gelişen hastalarda hormon replasman (glukokortikoid, tiroksin ve östrojen/progesteron) tedavisi uygulanır.

Anahtar Kelimeler

Sheehan Sendromu, Hipopituitarizm, Empty Sella Sendromu

Kaynakça

• Sheehan HL. Postpartum necrosis of the anterior pituitary. J Pathol bacteriol 1937; 5:189-214.
• Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap LC. Williams Obstetrics 20th Edition, New-York: Appleton and Lange, 1997: 763
• Kovacs K. Sheehan syndrome. Lancet 2003; 361 (8):520–522.
• Muller B, Trepp R, Diem P, Christ E. das Paradoxon der TSH- Erho¨hung bei Sheehan-Syndrom. Dtsch MedWochenschr 2002; 127:2610-2612.
• Kaufman B. The “empty” sella turcica, a manifestation of the intrasellar subarachnoid space. Radiology 1968; 90: 931-946.
• DiZerega G, Kletzky OA, Mishell DR. Diagnosis of Sheehan's syndrome using sequential pituitary stimulation tests. Am J Obstet Gynecol 1978; 132:348-353.
• Ozbey N, Inanc S, Aral F, et al. Clinical and laboratory evaluation of 40 patients with Sheehan's syndrome. Isr J Med Sci 1994; 30:826-829.
• Lakhdar AA, McLaren EH, Davda NS, McKay EJ, Rubin PC. Pituitary failure from Sheehan's syndrome in the puerperium. Two case reports. Br J Obstet Gynaecol 1987; 94: 998-9.
• Aron DC, Findling JW, Tyrel JB. Hypothalamus and pituitary. In: Greenspan FS, Strewler DJ (Editors). Basic & Clinical Endocrinolgy. 5 th ed, New Jersey: Appleton&Lange, 1997: 95– 156.
• Barkan AL. Pituitary atrophy in patients with Sheehan’s syndrome. Am J Med Sci 1989; 298:38-40.
• Ishikawa K, Sohmiya M, Furuya H, Kato Y. A case of Sheehan’s syndrome associated with severe anemia and empty sella proved 48 years after postpartum hemorrhage. Endocr J 1995; 42:803-809.
• Goswami R, Kochupillai N, Crock PA, Jaleel A, Gupta N. Pituitary autoimmunity in patients with Sheehan’s syndrome. J Clin Endocrinol Metab 2002; 87: 4137-4141.
• Abucham J, Castro V, Maccagnan P, Vieira JGH. Increased thyrotropin levels and loss of nocturnal thyrotropin surge in Sheehan’s syndrome. Clin Endocrinol(Oxf) 1997; 47:515-522.
• Maccagnan P, Oliveira MA, Castro V, Abucham J. Abnormal circadian rhythm and increased non-pulsatile secretion in Sheehan’s syndrome. Clin Endocrinol (Oxf) 1999; 5: 439-448.
• Oliveira JHA, Persani L, Beck-Peccoz P, Abucham J. Investigating the paradox of hypothyroidism and increased serum thyrotropin (TSH) levels in Sheehan’s syndrome: characterization of TSH carbohydrate content and bioactivity. J Clin Endocrinol Metab 2001; 86:1694-1699.
• Boulanger E, Pagniez D, Roueff S, et al. Sheehan syndrome presenting as early post-partum hyponatremia. Nephrol Dial Transplant 1999; 14:2714-2715.
• Neelon FA, Goree JA, Lebovitz HE. The primary empty sella: clinical and radiographic characteristics and endocrine functions. Medicine 1973; 52: 73-92.
• Meador CK, Worrell JL. The sella turcica in post-partum pituitary necrosis (Sheehan’s syndrome). Ann Intern Med 1966; 65:259- 264
• Sherif IH, Vanderley CM, Beshyah S, Bosairi S. Sella size and contents in Sheehan’s syndrome. Clin Endocrinol (Oxf) 1989; 30:613-618.
• Bakiri F, Bendib SE, Maoui R, Bendib A, Benmiloud M. The sella turcica in Sheehan’s syndrome: computerized tomographic study in 54 patients. J Endocrinol Invest 1991; 14:193-196.
• Chong BW, Newton TH. Hypothalamic and pituitary pathology. Radiol Clin North Am 1993; 31:1147-1153
• Dejager S, Gerber S, Foubert L, Turpin G. Sheehan's syndrome: differential diagnosis in the acute phase. J Intern Med 1998; 244:261-266.
• Banzal S, Ayoola EA, Banzal S. Sheehan's syndrome in Saudi Arabia. Int J Gynaecol Obstet 1999; 66:181-182.
• Otsuka F, Kageyama J, Ogura T, Hattori T, Makino H. Sheehan's syndrome of more than 30 years' duration: an endocrine and MRI study of 6 cases. Endocr J 1998; 45:451-458.
• Dash RJ, Gupta V, Suri S. Sheehan's syndrome: clinical profile, pituitary hormone responses and computed sellar tomography. Aust NZ J Med 1993; 23:26-31.
• Orrego JJ, Barkan AL. Pituitary disorders. Drug treatment options. Drugs 2000; 59:93-106.
• Guiot G. Transsphenoidal approach in surgical treatment of pituitary adenoma: general principles and indicationsin non- functioning pituitary adenomas. In: Diagnosis and Treatment of pituitary tumors. Kohler PO, Ross GT. (Editors) Amsterdam: Excerpta Medica, 1973: 176-206.
• Olson DR, Guiot G, Derome P. The symptomatic empty sella: Prevention and correction via transphenoidal approach. J Neurosurg 1972; 37: 533-546.
• Kabul Tarihi: 09.05.2008