Síndrome de Sheehan Fabrício Junqueira Acadêmico do 5º ano de Medicina da FCMMG, Monitor da Disciplina de Patologia

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SÍNDROME DE SHEEHAN “Insuficiência hipofisária, iniciada no puerpério, acompanhada de necrose da glândula.” Llusiá JB, ENDOCRINOLOGÍA DE LA MUJER. Editorial Científico – Médica. 5ª ed. 1976. Pg 628

70%: necrose s/ manifestação clínica EPIDEMIOLOGIA 1932: 30% dos casos de choque 70%: necrose s/ manifestação clínica Llusiá JB, ENDOCRINOLOGÍA DE LA MUJER. Editorial Científico – Médica. 5ª ed. 1976. Pg 628

FISIOLOGIA DA HIPÓFISE NA GRAVIDEZ Hiperplasia fisiológica da hipófise Aumento da vascularização Diminuição do aporte sanguíneo Regressão fisiológica Vilar L., ENDOCRINOLOGÍA CLÍNICA. Medsi – Guanabara Koogan. 3ª ed. 2006. Capítulo 2 1. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2003;26(suppl 1):S33-S50. 2. American Association of Clinical Endocrinologists/American College of Endocrinology. American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. Endocr Pract. 2002;8(suppl 1):40-82. 3. International Diabetes Federation (European Region). European Diabetes Policy Group 1998-1999. Guidelines for diabetes care. A desktop guide to type 2 diabetes mellitus. Diabetic Medicine. 1999;16:1-35.

Diminuição do aporte sangüíneo Vasoespasmo das arteríolas FISIOPATOLOGIA Diminuição do aporte sangüíneo Vasoespasmo das arteríolas Isquemia prolongada da hipófise Necrose hipofisária Pan-hipopituitarismo Vilar L., ENDOCRINOLOGÍA CLÍNICA. Medsi – Guanabara Koogan. 3ª ed. 2006. Capítulo 2 1. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2003;26(suppl 1):S33-S50. 2. American Association of Clinical Endocrinologists/American College of Endocrinology. American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. Endocr Pract. 2002;8(suppl 1):40-82. 3. International Diabetes Federation (European Region). European Diabetes Policy Group 1998-1999. Guidelines for diabetes care. A desktop guide to type 2 diabetes mellitus. Diabetic Medicine. 1999;16:1-35.

Desenvolvimento lento Lesão tissular: Ac (PitAb) 2/3 dos pacientes FISIOPATOLOGIA Auto-imune ??? Desenvolvimento lento Lesão tissular: Ac (PitAb) 2/3 dos pacientes Vilar L., ENDOCRINOLOGÍA CLÍNICA. Medsi – Guanabara Koogan. 3ª ed. 2006. Capítulo 2 1. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2003;26(suppl 1):S33-S50. 2. American Association of Clinical Endocrinologists/American College of Endocrinology. American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. Endocr Pract. 2002;8(suppl 1):40-82. 3. International Diabetes Federation (European Region). European Diabetes Policy Group 1998-1999. Guidelines for diabetes care. A desktop guide to type 2 diabetes mellitus. Diabetic Medicine. 1999;16:1-35.

MANIFESTAÇÕES CLÍNICAS Síndrome de hipertensão intra-craniana Alterações do campo visual Paralisia nervos periféricos Deficiência hormonal Vilar L., ENDOCRINOLOGÍA CLÍNICA. Medsi – Guanabara Koogan. 3ª ed. 2006. Capítulo 2 1. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2003;26(suppl 1):S33-S50. 2. American Association of Clinical Endocrinologists/American College of Endocrinology. American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. Endocr Pract. 2002;8(suppl 1):40-82. 3. International Diabetes Federation (European Region). European Diabetes Policy Group 1998-1999. Guidelines for diabetes care. A desktop guide to type 2 diabetes mellitus. Diabetic Medicine. 1999;16:1-35.

MANIFESTAÇÕES CLÍNICAS 1. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2003;26(suppl 1):S33-S50. 2. American Association of Clinical Endocrinologists/American College of Endocrinology. American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. Endocr Pract. 2002;8(suppl 1):40-82. 3. International Diabetes Federation (European Region). European Diabetes Policy Group 1998-1999. Guidelines for diabetes care. A desktop guide to type 2 diabetes mellitus. Diabetic Medicine. 1999;16:1-35.

DEFICIÊNCIA DE GH Fraqueza Depressão Osteoporose Labilidade emocional Redução da massa magra Aumento da massa gorda (tronco) Aumento LDL Aumento do RCV Hipoglicemia Vilar L., ENDOCRINOLOGÍA CLÍNICA. Medsi – Guanabara Koogan. 3ª ed. 2006. Capítulo 2 1. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2003;26(suppl 1):S33-S50. 2. American Association of Clinical Endocrinologists/American College of Endocrinology. American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. Endocr Pract. 2002;8(suppl 1):40-82. 3. International Diabetes Federation (European Region). European Diabetes Policy Group 1998-1999. Guidelines for diabetes care. A desktop guide to type 2 diabetes mellitus. Diabetic Medicine. 1999;16:1-35.

DEFICIÊNCIA DE GONADOTROFINAS Amenorréia secundária Perda da libido Atrofia mamária Dispareunia Infertilidade Vilar L., ENDOCRINOLOGÍA CLÍNICA. Medsi – Guanabara Koogan. 3ª ed. 2006. Capítulo 2 1. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2003;26(suppl 1):S33-S50. 2. American Association of Clinical Endocrinologists/American College of Endocrinology. American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. Endocr Pract. 2002;8(suppl 1):40-82. 3. International Diabetes Federation (European Region). European Diabetes Policy Group 1998-1999. Guidelines for diabetes care. A desktop guide to type 2 diabetes mellitus. Diabetic Medicine. 1999;16:1-35.

DEFICIÊNCIA DE TIREOTROFINA Amenorréia secundária Astenia Sonolência Intolerância ao frio Pele seca e descamativa Voz arrastada Edema facial Anemia Bradicardia Assintomáticos Vilar L., ENDOCRINOLOGÍA CLÍNICA. Medsi – Guanabara Koogan. 3ª ed. 2006. Capítulo 2 1. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2003;26(suppl 1):S33-S50. 2. American Association of Clinical Endocrinologists/American College of Endocrinology. American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. Endocr Pract. 2002;8(suppl 1):40-82. 3. International Diabetes Federation (European Region). European Diabetes Policy Group 1998-1999. Guidelines for diabetes care. A desktop guide to type 2 diabetes mellitus. Diabetic Medicine. 1999;16:1-35.

DEFICIÊNCIA DE CORTICOTROFINA Fraqueza Astenia Sonolência Anorexia Perda de peso Hipotensão postural leve Hipoglicemia Hiponatremia (Casos graves) Vilar L., ENDOCRINOLOGÍA CLÍNICA. Medsi – Guanabara Koogan. 3ª ed. 2006. Capítulo 2 1. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2003;26(suppl 1):S33-S50. 2. American Association of Clinical Endocrinologists/American College of Endocrinology. American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. Endocr Pract. 2002;8(suppl 1):40-82. 3. International Diabetes Federation (European Region). European Diabetes Policy Group 1998-1999. Guidelines for diabetes care. A desktop guide to type 2 diabetes mellitus. Diabetic Medicine. 1999;16:1-35.

DEFICIÊNCIA DE PROLACTINA Impedimento da lactação Vilar L., ENDOCRINOLOGÍA CLÍNICA. Medsi – Guanabara Koogan. 3ª ed. 2006. Capítulo 2 1. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2003;26(suppl 1):S33-S50. 2. American Association of Clinical Endocrinologists/American College of Endocrinology. American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. Endocr Pract. 2002;8(suppl 1):40-82. 3. International Diabetes Federation (European Region). European Diabetes Policy Group 1998-1999. Guidelines for diabetes care. A desktop guide to type 2 diabetes mellitus. Diabetic Medicine. 1999;16:1-35.

DIAGNÓSTICO Síndrome de Sheehan Dosagens Basais T4 Livre TSH Cortisol 8:00 ACTH Estradiol, FSH, LH Testosterona GH IGF-I Prolactina Normal Baixo TESTES PROVOCATIVOS GnRH TRH ITT Vilar L., ENDOCRINOLOGÍA CLÍNICA. Medsi – Guanabara Koogan. 3ª ed. 2006. Capítulo 2 1. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2003;26(suppl 1):S33-S50. 2. American Association of Clinical Endocrinologists/American College of Endocrinology. American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. Endocr Pract. 2002;8(suppl 1):40-82. 3. International Diabetes Federation (European Region). European Diabetes Policy Group 1998-1999. Guidelines for diabetes care. A desktop guide to type 2 diabetes mellitus. Diabetic Medicine. 1999;16:1-35.

DIAGNÓSTICO Teste Procedimento Interpretação TRH GnRH ITT Infundir 200 mcg de TRH TV e dosar TSH e prolactina nos tempos 0’, 30’, 60’, 90’, 120’ O TSH deve aumentar pelo menos 10 mcU/mL A PRL deve aumentar cerca de 3 vezes GnRH Infundir 100 mcg de GnRH EV e dosar LH e FSH nos tempos 0’, 30’, 60’, 90’, 120’ A resposta do LH deve preceder a do FSH, sendo normal o aumento de 3 vezes ou 15 UI/L ITT Indundir 0,10 U/Kg de peso de insulina R EV e dosar glicose, GH e cortisol nos tempos 0’, 30’, 60’, 90’, 120’ A glicemia deve ser menor que 40 mg/dL para induzir resposta do GH (> 5 ng/mL) e do cortisol (> 20 mcg/mL) Vilar L., ENDOCRINOLOGÍA CLÍNICA. Medsi – Guanabara Koogan. 3ª ed. 2006. Capítulo 2 1. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2003;26(suppl 1):S33-S50. 2. American Association of Clinical Endocrinologists/American College of Endocrinology. American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. Endocr Pract. 2002;8(suppl 1):40-82. 3. International Diabetes Federation (European Region). European Diabetes Policy Group 1998-1999. Guidelines for diabetes care. A desktop guide to type 2 diabetes mellitus. Diabetic Medicine. 1999;16:1-35.

TRATAMENTO Dificiência de ACTH Hidrocortisona – 20 a 30 mg/dia Prednisona – 5 a 7,5 mg/dia Obs: 2/3 da dose pela manhã e 1/3 à tarde Deficiência de TSH Levotiroxina sódica – 1,0 a 1,5 mcg/Kg/dia Obs: tomar em jejum Deficiência de GH GH recombinante humano – 0,1U/Kg/dia Obs: Injeções subcutâneas à noite Vilar L., ENDOCRINOLOGÍA CLÍNICA. Medsi – Guanabara Koogan. 3ª ed. 2006. Capítulo 2

TRATAMENTO Dificiência de FSH/LH Estradiol – 1 a 2 mg/dia Estrogênios conjugados – 0,3 a 1,25 mg/dia Estrogênios transdérmicos – 0,05 a 0,1 mg/dia Estrogênios em gel Deficiência de Progesterona Medroxiprogesterona – 5 a 10 mg/dia Noretisterona – 0,7 a 1 mg/dia Deficiência de Testosterona Ésteres de testosterona – 250 mg Testosterona em gel Vilar L., ENDOCRINOLOGÍA CLÍNICA. Medsi – Guanabara Koogan. 3ª ed. 2006. Capítulo 2

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