The management of type 2 diabetes has become increasingly controversial. Tight control has been advocated for years; however, there was a recent revision published by the American College of Physicians in which limitations were made to liberalize glycaemic goals for most diabetics, targeting a level between 7% and 8%. In recent years, the evolution of diabetes care has been such that more potent drugs, with low risk of hypoglycaemia when used in the absence of insulin or secretagogues, have made their way into the market place. Use of such agents has made it easier to achieve greater glycaemic control reasonably safely. Unfortunately, it appears that there has been a significant amount of inertia over the past decade, which continues to persist. Relaxing the glycaemic control targets, as recommended by the American College of Physicians, may only help to propagate this inertia.

Type 2 diabetes is a disorder of progressive beta cell failure. Additional therapeutic interventions will likely need to be added during the lifetime of the diabetic. Factors that can contribute toward the progressive nature of loss of glycemic control include genetics, the contribution of weight towards insulin resistance, hypertension, dyslipidemia, all of which can contribute to impaired glucose tolerance and subsequent development of overt diabetes. 1

We are reporting a case of a patient found to be pregnant in the setting of panhypopituitarism. There are an only few reports of spontaneous pregnancy in patients with panhypopituitarism. This is a 26-year-old female who was admitted due to symptomatic hypoglycemia. Past medical history is significant for uncomplicated pregnancy with C-section delivery 1 year before admission. She was not able to breastfeed the baby in postpartum period. Her menses have been irregular since then. She also noticed increasing fatigue, muscle weakness, episodic diarrhea and 70 pounds weight loss. Physical exam was remarkable for hypotension. Work up showed elevated levels of beta-HCG, hyponatremia, normal anion gap metabolic acidosis, normochromic anemia, and low cortisol levels, appropriate low levels of insulin and C-peptide. Hypoglycemia panel revealed undetectable levels of sulphonylureas. Serum levels for pituitary hormones showed low levels of ACTH, prolactin and IGF-1, normal levels of FSH, and inappropriate normal levels of TSH in the setting of decreased T4. Stress doses of hydrocortisone were initiated along with thyroid hormone replacement. Brain MRI was found to be unremarkable. Sheehan’s syndrome is a very rare complication of pregnancy when necrosis of the pituitary gland occurs after severe hemorrhage and hypotension upon delivery. Small sella size, disseminated intravascular coagulopathy, stress of the delivery and autoimmunity are also implicated as possible causes of Sheehan’s syndrome. We should be very attentive for symptoms as failure to lactate and failure to resume regular menses after delivery as they can be the first manifestation of the disease. Infertility is common in these patients, but in very few of them gonadotropin response will be present due to residual pituitary function and spontaneous pregnancy can occur. Proper management of these patients during pregnancy will also be very important since a high risk of miscarriages can be expected.

Introduction: We are reporting a case of an incidental mass later diagnosed as an extradural pheochromocytoma at t2-t4 level during a presurgical work up for a gynecological procedure. Only a few cases of extradural paravertebral tumors are described in literature. case report: this is a clinical case of an asymptomatic 26-year-old female with an incidental finding of thoracic mass in chest X-ray during preoperative screening for myomectomy. Work up for this mass showed elevated plasma and urinary metanephrine levels which was consistent to pheochromocytoma. computed tomography, magnetic resonance imaging and metaiodobenzylguanidine scans demonstrate a mass originating from thoracic spine with cord compression, no adrenal mass, multifocal disease or metastasis. Prior to surgery, the patient was treated with phenoxybenzamine and metoprolol to decrease hemodynamic instability during surgical procedure and also embolization to the arteries supplying the mass to decrease intraoperative bleeding. Patient

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