Sheehan’s Syndrome: It Is Time to Become More Proactive in Identifying This Disease

Abstract

Introduction:Pituitary infarction (Sheehan's Syndrome) occurs typically as a result of ischemic pituitary necrosis due to severe postpartum hemorrhage and can present with varying degrees of pituitary insufficiency. It is not common in developed countries and frequently is diagnosed years after delivery due to its nonspecific signs and symptoms. Failure to lactate is a common initial symptom and many women also report amenorrhea or oligomenorrhea. Case: 26-year-old female with history of hypertension, presented to the hospital because of diarrhea and vomiting. She fell prior to admission because of dizziness and severe weakness. In the emergency department she was hypotensive, BP was 80/40 on arrival and despite intensive fluid resuscitation BP remained borderline. Random cortisol level was low 0.6 ug/dL, ACTH stimulation test showed inadequate response 0.7, 3.5, 5.0 and baseline ACTH was very low <1.1 (7.2-63.3 pg/mL). Further investigation showed secondary hypothyroidism, TSH 0.861 (0.400-4.00) and FT4 0.19 (0.80-1.40), prolactin was low <0.2 (1.9 -25). She had no evidence of diabetes insipidus. Her menstrual period could not be assessed because she was on continuous progesterone therapy for contraception after delivery. MRI of the brain showed empty sella. Pt was started on hydrocortisone and levothyroxine. A record review showed she had a complicated child delivery 3 years prior to admission with severe hypertension, reason for which she was admitted for induction. During hospitalization she developed fever and Cesarean section was performed. During the procedure, she developed transient hypotension (70/50) and was resuscitated with intravenous fluids. No prolonged hypotension or postpartum hemorrhage reported. She did not breast feed and never resumed menses. She assumed that this was secondary to treatment with daily progesterone tablets for contraception. She stated that she always felt tired and never felt the same post delivery. Discussion: The frequency of Sheehan's syndrome in developed countries now is rare, largely due to improvement in obstetric care. This could be one of the reasons the diagnosis can be overlooked and diagnosed years later when patient is admitted for an acute problem. Physiological enlargement of the pituitary gland during pregnancy makes it vulnerable to ischemia. The majority of cases reported are due to massive postpartum hemorrhage. We present a unique case where a patient developed Sheehan's syndrome after an episode of severe hypotension induced by medication and sepsis. We think that her very high blood pressure prior to surgery made her more vulnerable to the effect of the transient hypotension. Her diagnosis was delayed because of the nonspecific symptoms. Sheehan's syndrome should be considered in any woman with symptoms of pituitary deficiency who had a complicated delivery even when postpartum hemorrhage was not present.