Two days after vaginal delivery of a healthy newborn at term, a 32-year-old woman, gravida 2, para 2, is unable to breastfeed.

Her
labor was complicated by antepartum hemorrhage and she received two units of packed red blood cells. Her pulse is 99/min and
blood pressure is 90/55 mm Hg. Further evaluation of this patient is most likely to show which of the following sets of serum findings?

ACTH Aldosterone Cortisol

A ↑ ↓ ↓
B Normal ↑ normal
C↓ normal ↑
D↑ normal ↑
E ↓ ↑ ↓
F ↓ normal ↓

Show Hint

A. A

B. D

C. E

D. C

E. F

F. B

Incorrect. Correct answer is C

31% answered correctly

Explanation:

Correct Answer Is C [ 31% ]

A pituitary infarction causes a decreased production of anterior pituitary hormones, including ACTH. A decrease in ACTH causes
secondary adrenal insufficiency with decreased cortisol production, which leads to decreased vascular tone. In response, the RAAS
increases aldosterone production in an attempt to maintain stable blood pressure values.

[ A ] [ 11% ]

Decreased cortisol and aldosterone with increased ACTH levels can occur in primary adrenal insufficiency (Addison disease).
Although this patient's hypotension is a main feature of primary adrenal insufficiency, lactation failure is not. Additionally, increased
ACTH levels are not caused by pituitary infarction.

[ B ] [ 8% ]

An increase in both ACTH and cortisol levels indicates secondary hypercortisolism. Cushing disease is the most common cause of
secondary hypercortisolism and is characterized by excessive endogenous ACTH production. This patient does not have any typical
symptoms of Cushing disease (e.g., buffalo hump, truncal obesity, striae, hyperpigmentation, moon facies).

[ D ] [ 7% ]

An increased cortisol level with decreased ACTH raises suspicion for primary hypercortisolism, also called Cushing syndrome. The
most common cause is iatrogenic hypercortisolism due to chronic exogenous cortisol intake. Aldosterone is not affected by the
ACTH–cortisol axis. Also, this patient has no history of corticosteroid use and does not express the typical symptoms of
hypercortisolism (e.g., moon facies, buffalo hump, petechiae, truncal obesity).

[ E ] [ 36% ]

A decrease in both ACTH and cortisol levels raises suspicion for secondary adrenal insufficiency, which can be caused by Sheehan
syndrome. ACTH does not directly affect aldosterone secretion, which is primarily regulated by the RAAS. This patient is hypotensive
(blood pressure is 90/55 mm Hg), however, which activates the RAAS. Therefore, a normal aldosterone concentration would not be
expected.