Sheehan's Syndrome Presenting as Postpartum Psychosis

Abstract

Sheehan's syndrome is characterized by hypopituitarism following ischemic necrosis of the pituitary gland caused by postpartum hemorrhage and impaired blood supply to the enlarged pituitary gland during pregnancy. The worldwide prevalence has since decreased due to improvements in obstetric care. Behavioral change is a rare presentation and is often misdiagnosed and managed as psychosis. We report a 42-year-old woman presenting with behavioral changes associated with postpartum failure of lactation and amenorrhea. Hormonal work-up revealed panhypopituitarism; serum cortisol, 98.93 (NV: 138-690 nmol/L); free T4, less than 5.15 (NV: 11.5-23.00 pmol/L); free T3, less than 2.30 (NV: 2.89-4.88 pmol/L); FSH, 3.63 (NV: 30-135 mIU/mL); LH, 3.88 (NV: 13-80 mIU/mL); serum estradiol, 3.89 (NV: 10.41-35.0 pg/mL); IGF-1, 13.13 (NV: 56-194 ng/mL); and serum prolactin, 1.8 (NV: 2.6-24.8 ng/mL). Cranial MRI with contrast revealed an atrophic pituitary gland consistent with Sheehan's syndrome. The symptoms improved substantially upon replacement with steroids and thyroid hormones and she was able to resume her routine activities. The psychiatric features of hypopituitarism can be attributed to a combination of hypothyroidism, hypoglycemia, and hypocortisolism and have been shown to reverse with adequate hormone replacement.