The definition of neonatal hypoglycemia has been based on statistical criteria.2 The incidence of this condition in term AGA infants is approximately 2%. Non-specific, including tremulousness, twitching, jitteriness, irritability, exaggerated Moro reflex, high pitched cry, seizures, apnea, limpness, poor feeding, cyanosis, temperature instability, and coma.
Screen by plasma glucose measurements at 1, 2, 4, 8 and 24 hours of age if not receiving glucose containing i.v.
In hypoglycemic infants, plasma glucose values should be repeated 1-2 hours after initiation of treatment if the infant remains asymptomatic, or every 20-30 minutes if symptomatic (see table at end of this section). After the plasma glucose has been normal for 24 hours, and enteral feedings have been started, taper i.v. Plasma glucose measurements should be determined every 1 to 4 hours depending on the degree of hyperglycemia, with therapy adjusted according to plasma plasma glucose results. Monitoring of plasma glucose concentrations in sick and premature infants receiving parenteral fluids is indicated.
In the management of extremely small infants weighing <700 g, it may be advisable to perform less frequent plasma glucose monitoring (once daily), and to rely more on the results of urine glucose testing. Newly admitted infants without risk factors for hypoglycemia should have a plasma glucose value measured between 1 and 4 hours after birth and again between 8-16 hr unless clinical circumstances mandate earlier glucose testing.
An infant whose glucose has been stable on plain IV fluids may show hyperglycemia with the addition of lipids. Anterior pituitary hormones are regulated by hypothalamic releasing and inhibitory hormones and by negative feedback of the target glandular hormones at the pituitary and hypothalamic levels (Table 1). Pituitary adenomas arise from adenohypophyseal cells and are almost always benign (Table 2). Pituitary adenomas are rarely associated with parathyroid and neuroendocrine hyperplasia or neoplasia as part of the multiple endocrine neoplasia type I (MEN I) syndrome. Pituitary tumors can manifest with signs and symptoms of pituitary hypofunction, hormone hypersecretion, or mass effect. The goals for treatment of a pituitary tumor include reduction or complete removal of the tumor, elimination of mass effect, normalization of hormone hypersecretion, and restoration of normal pituitary function.
Pituitary adenomas are the most common cause of hypopituitarism, but other causes include parasellar diseases, pituitary surgery, radiation therapy, inflammatory and granulomatous diseases, and head injury. Random measurements of GH and gender- and age-adjusted insulin-like growth factor-1 (IGF-1) levels are not reliable to diagnose GH deficiency because GH secretion is pulsatile, and up to 65% of patients with GH deficiency have a normal IGF-1 level. In reproductive-aged women, gonadotropin deficiency causes infertility and oligomenorrhea or amenorrhea.
Patients with ACTH deficiency maintain their mineralocorticoid secretion because aldosterone is regulated primarily by the renin-angiotensin system and serum potassium concentration.
An ACTH stimulation test and early morning (8 am) plasma cortisol level measurement are reasonable initial tests for evaluating the corticotropin axis. The symptoms of thyrotropin (TSH) deficiency are similar to those in patients with primary hypothyroidism, including malaise, fatigue, leg cramps, dry skin, and cold intolerance. The diagnosis cannot be established only through measurement of TSH because these patients might have a normal TSH level. Prolactinomas are pituitary adenomas that secret prolactin in varying degrees and account for about 30% of all pituitary adenomas.
Clinical features of prolactinomas may be related to excess prolactin and associated secondary hypogonadism or mass effect. Dopamine agonists are the therapy of choice for most patients, and they are effective in decreasing adenoma size and restoring normal prolactin level in most patients. Acromegaly is a rare disease caused by a GH-secreting pituitary adenoma in more than 99% of patients. Because of the pulsatile nature of GH secretion, random GH levels can overlap in acromegalic patients and normal persons.
Surgery is the treatment of choice for most patients presenting with acromegaly even if a cure cannot be achieved.
Cushing’s syndrome (CS) comprises symptoms and signs associated with prolonged exposure to inappropriately high levels of plasma free glucocorticoids (Box 3). Surgical removal of the ACTH-secreting pituitary tumor is the treatment of choice.10 Availability of an experienced neurosurgeon is crucial, and the long-term remission rate is about 60 to 80% following surgery. Thyrotropin (TSH)-secreting pituitary adenomas account for less than 1% of all pituitary tumors.
Nonfunctional and glycoprotein-secreting pituitary tumors account for about 25% to 30% of all pituitary adenomas.
Patients with small nonfunctional pituitary adenomas are usually observed; however, the standard treatment for those with mass effect is surgery, mainly through the trans-sphenoidal approach.
Lymphocytic hypophysitis is a rare inflammatory lesion of the pituitary gland, commonly affecting young women during late pregnancy or in the postpartum period. The empty sella is defined as a sella that, regardless of its size, is completely or partly filled with cerebrospinal fluid. Pituitary apoplexy is a rare endocrine emergency resulting from hemorrhagic infarction of a preexisting pituitary tumor (Fig. Diabetes insipidus by itself is usually well tolerated and results in few symptoms, including polydipsia and polyuria. Once diabetes mellitus and hypercalcemia have been excluded, patients should have their 24-hour urinary volume measured during ad libitum fluid intake. The therapy of choice for central DI is the administration of the ADH analogue desmopressin (DDAVP). Casanueva FF, Molitch ME, Schlechte JA, et al: Guidelines of the pituitary society for the diagnosis and management of prolactinomas. Ezzat S, Serri O, Chik CL, et al: Canadian consensus guidelines for the diagnosis and management of acromegaly. Krikorian A, Aron D: Evaluation and management of pituitary incidentalomas-revisiting an acquaintance. Schade R, Andersohn F, Suissa S, et al: Dopamine agonists and the risk of cardiac-valve regurgitation. Nachtigall LB, Valassi E, MCarty D, et al: Cardiac valvular function in hyperprolactinemic patients receiving cabergoline. Glucose determinations should be done on capillary blood from an extremity, or from a non-glucose-containing indwelling catheter. Some infants, especially those <1,000g, may not be able to fully utilize high glucose infusion rates, and will spill glucose in their urine.
In these situations, if plasma glucose testing documents the absence of hypoglycemia, urine glucose testing may be substituted for blood glucose testing for the purpose of avoiding hyperglycemia. Chemstrips, is to be discouraged.2 In addition, do not use blood from arterial lines for glucose determination.
Conversely, the addition of protein (NVN) may require an increase in the role of dextrose administration.
Among pituitary hormones, only the secretion of prolactin is increased in the absence of hypothalamic influence, because it is mainly under tonic suppression by dopamine, the main inhibitory factor. Pituitary carcinomas are extremely rare, but metastases from other solid malignancies (mainly breast and lung) can occur. Impingement on the chiasma by a pituitary tumor results in visual field defects, most commonly bitemporal hemianopia (Fig.
Once a pituitary adenoma is found, it is necessary to determine the type of adenoma (secretory vs. Some patients, especially those with large tumors, require several therapeutic modalities, including medical, surgical, and radiation therapies.
The sequential loss of pituitary hormones secondary to a mass effect is in the following order: growth hormone (GH), luteinizing hormone (LH), follicle-stimulating hormone (FSH), thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), and prolactin. Patients with GH deficiency have increased body fat and decreased lean body mass, and they might have decreased bone mineral density.

Measurement of gonadotropin and estradiol levels in reproductive-aged women with irregular menstruation is usually not informative.
Symptoms usually include chronic malaise, fatigue, anorexia, low-grade fever, and hypoglycemia. Patients should be instructed to carry a medical alert, double their replacement dosage for 2 to 3 days in case of an acute disease, and should be covered by stress doses of hydrocortisone if undergoing surgery. For this reason, if secondary hypothyroidism is clinically suspected, TSH and free thyroxine (T4) should be measured together.
The levothyroxine replacement dose should be adjusted according to the patient’s clinical status and free T4 and free triiodothyronine (T3) levels, but not TSH. They are seen in all age groups but are more common in women, with a peak incidence during the childbearing years. Women of reproductive age mainly present with oligomenorrhea, amenorrhea, galactorrhea, or infertility. Dopamine agonists usually restore visual field defects to an extent similar to surgery.4 Therefore, visual field defects associated with prolactinomas are not a neurosurgical emergency. IGF-1 has a longer plasma half-life than GH and is the best single test for the diagnosing acromegaly (Fig. Even a subtotal resection of the tumor will improve the efficacy of subsequent adjuvant therapy. Cyclic CS is characterized by periods of excess alternating with intervals of normal or decreased cortisol production, which occurs in some patients with CS. Radiotherapy is indicated in those with residual pituitary tumor following surgical debulking or in those who are not surgical candidates.
It is important to monitor patients with varying degrees of hypopituitarism, because some have partial or full recovery of their pituitary axes. The true prevalence of DI is unknown, but it is usually underdiagnosed because the symptoms and signs are benign and many patients ignore them or are unaware of them.
Nocturia of a large urine volume is often the primary reason for which patients seek medical attention. Although use of reagent strips is widespread, their use, even for glucose screening purposes, is controversial1. If further hypoglycemia persists, IMMEDIATELY notify staff neonatologist for consideration of further treatment and diagnosis. As noted above, use of either of these high concentration glucose solutions is to be avoided.
Although glucose-induced osmotic diuresis is rare in neonates, it should be looked for once glucosuria is present. Infants whose blood glucose values are within the normal range, and whose urine glucoses are negative, may have their glucose infusion rate increased to increase energy intake if deemed appropriate.
In infants not at high risk, consider monitoring plasma glucose levels once or twice a day in the first week of life.
Cavernous sinuses are located laterally on each side of the sella, inclusive of the internal carotid artery and cranial nerves III, IV, V1, V2 and VI (Fig. Antidiuretic hormone (ADH, vasopressin) is produced by the supraoptic and paraventricular nuclei of the hypothalamus and travels in the axons through the pituitary stalk to the posterior pituitary gland. Autopsy studies suggest that up to 20% of normal persons harbor pituitary microadenomas.1 Pituitary tumors discovered by computed tomography (CT) or magnetic resonance imaging (MRI) examination, in the absence of any symptoms or clinical findings, are referred to as pituitary incidentalomas. The most important factor in pituitary surgery is the availability of an experienced neurosurgeon.
In men, hypogonadism is diagnosed less often, because decreased libido and impotence may be considered functions of aging.
The presence of normal menstruation is the best indicator of the integrity of the gonadotropin axis in women of reproductive age. The serum prostate-specific antigen (PSA) level, hematocrit, and lipid profile should be monitored in men during testosterone replacement therapy. Patients might present with hyponatremia, which is secondary to inappropriate ADH secretion. In general, one should try to keep the free T4 level in the upper normal range while the free T3 level stays in the normal range.
Men and postmenopausal women usually come to medical attention because of mass effect, such as headaches and visual field defects. Biochemical analysis to evaluate renal and hepatic function and the TSH determination should be carried out. Cabergoline and bromocriptine are potent inhibitors of PRL secretion and often cause tumor shrinkage. Medical treatment of acromegaly has gained significance since the limitations of radiation and surgical therapy have become evident.
Symptoms secondary to hyperthyroidism and goiter are the initial complaints in most patients, followed by pituitary mass effect if the disease remains undiagnosed. Somatostatin analogues are effective in most patients for control of excess TSH production leading to improvement in hyperthyroidism and possibly to a decrease in tumor size.11 Beta blockers should be initiated in patients with uncontrolled hyperthyroidism, and antithyroid medications may be used only for a short period before surgery (if somatostatin analogues cannot be used) because long-term use can stimulate tumor growth. The use of high-dose dopamine agonists has been associated with a decrease in tumor size in only about 10% of patients. An empty sella is called secondary when it is seen after surgery, irradiation, or medical treatment for a pituitary pathology.
The clinical manifestations are related to rapid expansion of the tumor secondary to hemorrhage, with compression of the pituitary gland and the perisellar structures leading to headache, hypopituitarism, visual field defect, and cranial nerve palsies.13 Headache is the most prominent symptom in most patients with clinically evident pituitary apoplexy. There are four major types of DI: central (neurogenic) DI, nephrogenic DI, primary polydipsia, and gestational DI.
In most patients, DI is not associated with any abnormality on the physical examination or routine laboratory evaluation, except a low urine osmolality. Patients with DI who are conscious usually have sufficient thirst to maintain a normal serum sodium level in spite of polyuria. The spray or oral form of desmopressin is usually started at bedtime and is gradually titrated for the desired antidiuretic effect. This is because of their inaccuracy and imprecision relative to accepted laboratory determined glucose values. The presence of glucosuria is an indication to perform a chemical determination of plasma glucose for the purpose of defining an individual infant's renal glucose threshold.
Patients with sellar mass pressing on the optic chiasma should have a Humphrey visual field test.
Hypogonadism is often diagnosed retrospectively in men and postmenopausal women when patients present with mass effect. Estrogen replacement is necessary in hypogonadal women of reproductive age to prevent osteoporosis and to treat hot flushes, decreased libido, and vaginal dryness.
It is important to evaluate the corticotropin axis before initiating levothyroxine replacement, because therapy in those with underlying undiagnosed ACTH deficiency can result in an adrenocortical crisis secondary to an increase in metabolic demand.
All patients with macroprolactinomas and most patients with microprolactinomas require treatment. The drug history is an important part of the initial evaluation, because some medications are associated with hyperprolactinemia and their discontinuation for at least 3 days, if possible, will prevent any further and often expensive workup (Fig. Dopamine agonists should be initiated slowly, because side effects often occur at the beginning of treatment.
Clinical features of acromegaly may be related to excess GH or IGF-1 or to associated mass effect including hypopituitarism, because most patients present with pituitary macroadenomas (Box 2 and Fig.
Somatostatin analogues inhibit GH secretion mainly by binding to somatostatin receptors and result in normalization of IGF-1 in up to 65% of patients.
In contrast to pale striae that occur postpartum or with weight gain, the striae in CS are usually red-purple, more than 1 cm wide, and located on the abdomen, upper thighs, breasts, and arms (Fig. The most important biochemical feature is elevation of serum thyroid hormone levels (T4 and T3), with an inappropriately normal or elevated TSH level.

Most patients have no pituitary dysfunction, but partial or complete pituitary insufficiency has been reported. Central DI is secondary to inadequate ADH secretion that is insufficient to concentrate the urine. Overt disturbances in fluid and electrolytes are uncommon unless other factors interfere with the normal compensatory mechanism of polydipsia, such as loss of consciousness.
Treatment decisions in infants without signs ("asymptomatic") of hypoglycemia should not be based on Chemstrip data. Lateral extension of the pituitary mass to the cavernous sinuses can result in diplopia, ptosis, or altered facial sensation.
Diabetes insipidus is almost never seen in patients with pituitary adenomas at presentation. Osteopenia is a consequence of long-standing hypogonadism and responds to hormone replacement therapy. Some indications for treatment of patients with microprolactinomas include bothersome galactorrhea, oligomenorrhea or amenorrhea, infertility, and sexual dysfunction.
The most common side effects include nausea, headache, dizziness, nasal congestion, and constipation. The most common side effects are gastrointestinal, including diarrhea, abdominal pain, and nausea. Medical therapy for Cushing’s syndrome has limited value because of the associated toxicity and gradual decrease in efficacy. The chronologic association with pregnancy or the postpartum period and isolated ACTH deficiency is a diagnostic clue.
The discovery of an empty sella needs to be followed by an endocrine evaluation to determine whether there is any associated pituitary dysfunction.
Patients with mass effect benefit from tumor and blood clot debulking, which leads to resolution of visual field defects and improvement of cranial nerve palsies in most patients. A water deprivation test may need to be performed by an experienced endocrinologist to differentiate among types of partial DI.
There is no specific headache pattern associated with pituitary tumors and, in some patients, the headache is unrelated to pituitary adenoma.
Bromocriptine is the drug of choice in women planning pregnancy because there is considerable worldwide experience with the drug. Excess growth hormone before the fusion of the epiphyseal growth plates results in gigantism. Gallbladder sludge and cholelithiasis have been reported in up to 25% of patients on long-term therapy with somatostatin analogues, but most patients were asymptomatic. Cabergoline is more potent, may be taken only twice a week, and is better tolerated by most patients. Acromegalic patients probably carry an increased risk of malignancy such as premalignant adenomatous colon polyps and colon cancer, although published data vary greatly in their findings.
Dopamine agonists have variable efficacy in patients with acromegaly but may be an attractive first-line therapy, especially in those with cosecretion of prolactin and GH.
Supraclavicular and dorsocervical fat pads (buffalo hump) and moon face are nonspecific and are seen in many patients of obesity clinics.
Pegvisomant has higher affinity to GH receptors than native GH but inhibits its dimerization, which is necessary for the action of GH. Women complain of menstrual irregularity (84%) and hirsutism (especially vellous hypertrichosis of the face), and men and women exhibit loss of libido (≤100%).
Radiation therapy may be considered for patients who poorly tolerate dopamine agonists and cannot be cured by surgery. It is administered once daily and is usually reserved for patients not responding to other medical therapies. Psychiatric abnormalities occur in 50% of patients, with agitated depression and lethargy being the most common manifestations. A high clinical suspicion, attention to suggestive clinical features (see Box 3), and an appropriate screening test are the keys to early diagnosis of CS (Fig.
7).9 Because of the challenging nature of diagnosing CS, it is important to follow a stepwise evaluation, know the limitations of each test, and avoid shortcuts. If output approaches or exceeds input in the 1st hour, repeat NS bolus over the second hour at the appropriate rate. Second Hour: Administer NS + 20mEq potassium acetate per liter + 20mEq potassium phosphate per liter at 2 x maintenance rate.
Radiotherapy is reserved for patients who cannot be cured by surgery and do not respond to or tolerate medical therapy.
It may be necessary to use 10% or even 12.5% dextrose to prevent hypoglycemia while continuing to infuse insulin to correct the metabolic acidosis. Intracellular potassium is depleted because of transcellular shifts of this ion caused by hypertonicity. Increased plasma osmolality results in osmotic water transport from cells to the ECF, thereby concentrating cellular potassium.
Glycogenolysis and proteolysis secondary to insulin deficiency also cause potassium efflux from cells. Potassium is lost from the body as a consequence of vomiting, urinary ketoanion excretion (which requires excretion of cations, particularly sodium and potassium), and osmotic diuresis. Volume depletion causes secondary hyperaldosteronism, which promotes urinary potassium excretion.
Thus, total-body depletion of potassium occurs, but at presentation serum potassium levels may be normal, increased, or decreased. Renal dysfunction, by enhancing hyperglycemia and reducing potassium excretion, contributes to hyperkalemia.
Administration of insulin and the correction of acidosis drive potassium back into the cells, decreasing serum levels.
The serum potassium concentration may decrease abruptly, predisposing the patient to cardiac arrhythmias. Potassium replacement therapy is required regardless of the serum potassium concentration; start replacing potassium after initial volume expansion and concurrent with starting insulin therapy. However, if the patient is hypokalemic, start potassium replacement immediately after initial volume expansion and before starting insulin therapy. If the patient is hyperkalemic, defer potassium replacement therapy until urine output is documented. Potassium administration should continue throughout the period of intravenous fluid therapy. Controlled trials have shown no clinical benefit from bicarbonate administration, and there are well-recognized adverse effects of bicarbonate therapy, including paradoxical CNS acidosis and hypokalemia from rapid correction of acidosis. Failure to account for the sodium being administered and appropriately reducing the NaCl concentration of the fluids can result in increasing osmolality.
This complication has a high mortality rate (21-24%), and a substantial percentage of survivors (15-26%) are left with permanent neurological injury. A lesser rise in the measured serum sodium concentration during treatment (as the serum glucose concentration falls) has also been associated with cerebral edema.
Treatment of cerebral edema Because cerebral edema occurs infrequently, data are limited regarding the effectiveness of pharmacological interventions for treatment of cerebral edema. In intubated patients, therefore, hyperventilation beyond that which would normally occur in response to metabolic acidosis should likely be avoided unless absolutely necessary to treat elevated intracranial pressure.

Blood sugar increases when fasting
Normal glucose after meals


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    Author: Super_Krutoy_iz_BK
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  3. 24.05.2015 at 22:52:33

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  5. 24.05.2015 at 19:26:41

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    Author: KINQ_BOXINQ