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Sheehan Syndrome: a Rare Complication of Post-Partum Hemorrhage

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Sheehan Syndrome: a Rare Complication of Post-Partum Hemorrhage NJOG 2014 Jul-Dec; 18 (2):61-63 Case Report Sheehan Syndrome: a Rare Complication of Post-partum Hemorrhage Soni M Department of Obstetrics and Gynecology, SPMC and PBMH, Bikaner, Rajasthan, India Received: February 8, 2013; Accepted: August 12, 2014 Incidence of Sheehan syndrome, also known as post-partum hypopituitarism or post-partum pituitary insufficiency or hypopituitarism syndrome has reduced markedly but it does occur in under-developed countries with a reported incidence of 1:10000 deliveries.1-3 We are reporting the case of a 22 year old female with Sheehan syndrome occurring after massive post-partum hemorrhage. Keywords: hypopituitarism syndrome; post-partum hypopituitarism; post-partum pituitary insufficiency; Sheehan syndrome. INTRODUCTION Sheehan Syndrome is a condition that may occur She assumed this to be due to her weakness and did in a woman who bleeds severely during childbirth. not consult any doctor. It implies hypopituitarism caused by necrosis of anterior pituitary gland due to blood loss and On examination, she was a thin, pale lady, weighing hypovolemic shock during and after childbirth. Such 38 Kgs, with breast and genital atrophy and loss life-threatening hemorrhage has become uncommon of axillary and pubic hair. Her pulse rate was 60/ as a result of the advances in obstetric care but it is minute and blood pressure was 90/50 mm Hg. still a major threat for women in developing countries. Urine pregnancy test was negative. On per vaginum Consequences of post-partum hemorrhage can be examination, the uterus felt smaller than normal severe as illustrated in this case report. size. An ultrasound was done, which showed a small uterus with very thin endometrium. CASE The patient was counseled for a hormonal work- A 22-year old female, Mrs. S came with chief up. Her serum FSH, LH and estradiol values were ! "# ! $ -20 complaint of amenorrhea since her last delivery, three 2 years back. She also complained of breast atrophy and %!&'( % %% ( ( ) decreased libido. She was a second para, with history amenorrhea was at probably at pituitary level and [ owing to history of severe post-partum hemorrhage period and breast feeding. During the second and lactation failure, Sheehan syndrome was childbirth, which was conducted by a dai at home, )(*)( low TSH, fT and fT , low morning serum cortisol she had heavy bleeding post-delivery followed by 4 3 unconsciousness. She was taken to a hospital, where and low growth hormone levels. These laboratory four units of blood were transfused. She was unable values suggested pituitary failure. MRI scanning of to breast-feed her baby, as “there was no breast milk.” the pituitary was done and it showed empty sella and (%(() The patient was started on cortisone, thyroxine and CORRESPONDENCE estrogen supplementation. After estrogen priming, Dr Monica Soni progesterone was added. The patient was counseled Department of Obstetrics and Gynecology, SPMC and PBMH, Bikaner, Rajasthan, India. that she may need to remain on hormone replacement Email: [email protected] therapy for rest of her lie with dose adjustments at the Phone: +91-9982350350 time of any surgery or other medical crisis. Initially NJOG / VOL 9 / NO. 2 / ISSUE 18/ Jul-Dec, 2014 61 61 Soni. Sheehan Syndrome the patient had hypomenorrhea but later the menstrual ))((% pattern improved and the general condition of the controls: thyroid, adrenal, breast milk production patient also improved. and menstrual function.4 The presentation is highly variable. It is estimated that 95-99% of the anterior pituitary gland needs to be destroyed before the COMMENT characteristic features appear.3 '( )) 3 Sheehan Syndrome, also known as Post-partum early postpartum sign is failure of lactation. Less ++)) N)Q;QV&) or Hypopituitarism syndrome,1,2 is caused by anterior with an atypical form of the disease with loss of one 3 pituitary necrosis due to blood loss and hypovolemic or more trophic hormones. The signs and symptoms shock during or after childbirth. Such life-threatening of Sheehan Syndrome may include a galactorrhea hemorrhage has become less common as a result of 7) )& ! 7 7 the advances in obstetric care but is still a major threat 7 * O) P& ) to women in developing countries. As such, Sheehan amenorrhea, oligomenorrhea, genital and breast 1-3 Syndrome is rare in industrialized nations but does ((\()7 Secondary occur in under-developed countries. The reported hypothyroidism causes tiredness, intolerance to incidence is around 1:10,000 deliveries.3 '()) cold, constipation, weight gain, hair loss, slow 2,3 association of this syndrome with post-partum shock thinking, slow heart rate and low blood pressure. ((% [ )7 #;<= 7 ( ) )) British pathologist Harold Leeming Sheehan (1900- loss of pubic and axillary hair, fatigue, weight loss, 2,3 #;??&2 Pituitary damage unrelated to pregnancy is hypoglycemia, anemia and hyponatremia. Growth called Simmond’s Disease.2 ( )) ) % including fatigue and decreased muscle mass.2 The Although the exact pathogenesis is still unclear, most serious complication is adrenal crisis, a sudden Sheehan Syndrome is believed to be the result of life-threatening state that can lead to extremely low spasm in the arterial supply to the anterior lobe of blood pressure, shock, coma and death.4 the pituitary gland leading to ischemia and edema and ultimate necrosis and thrombosis in the portal sinuses Diagnosis is based on detailed history and examination and capillaries.2,3 Hypertrophy and hyperplasia of of the patient combined with blood tests to measure 1 lactotrophs during pregnancy results in enlargement the hormone levels. Dynamic provocative testing 3 of the anterior pituitary without a corresponding of the pituitary gland may be required. Low levels increase in blood supply.2 Secondly, the anterior of TSH, ACTH, FSH and LH with low levels of 2 T cortisol and estradiol are reported. Low level of pituitary is supplied by a low pressure portal system. 4, These vulnerabilities, when affected by a major Z# %% Z )) + %% hypotension or hemorrhage during the peri-partum with axial CT or MRI is indicated for diagnosis as period can result in ischemia of the affected pituitary well as to rule out other pituitary problems such as 1 regions leading to necrosis.2 The posterior pituitary is tumors. Treatment for Sheehan Syndrome is life- 4 usually not affected due to its direct arterial supply long hormone replacement therapy. Any stress by the inferior hypophyseal artery and the circle of ) * \[ ) Willis.2,3 A second theory as to the etiology is based cold can cause a crisis and may require adjustment of on the development of Disseminated Intravascular these hormones. Treatment includes replacement of @% ) \ 7 ()[()( $""+&7%2,3 hormone and estrogen with or without progesterone, depending on whether the patient has a uterus or not. Any condition that increases the likelihood of ) ) [ 7) (N severe blood loss during child-birth such as multiple ( ) N)7 %))) )) pregnancies and abnormalities of the placenta and induce adrenal crisis. Replacement of growth increase the risk of Sheehan Syndrome.1,4 In most hormone is controversial. cases, the signs and symptoms appear slowly, after a period of months or years.4 The features are those of 62 NJOG / VOL 9 / NO. 2 / ISSUE 18/ Jul-Dec, 2014 62 Soni. Sheehan Syndrome In summary, the purpose of this case report is to create DISCLOSURE awareness among physicians that Sheehan syndrome '(()\)(* is uncommon as a result of improved obstetric care but it should be a consideration in any woman who No violation of human rights and safety. has a history of post-partum hemorrhage and reports %)) Funding: Nil REFERENCES 1. Sheehan syndrome- PubMed Health. [Cited 2014 November 3. ` {| '( }( $) $%) 1]. Available from http://www.ncbi.nlm.nih.gov In: Foley MR, Strong TH Jr, Garite TJ, editors. Obstetric Intensive Care Manual. 3rd ed. New Delhi, India: Tata McGraw 2. Sheehan’s syndrome- Wikipedia, the free encyclopedia. [Cited Hill; 2011.p.131. 2014 November 12]. Available http://www. en.wikipedia.org/ wiki/Sheehan’s syndrome 4. Sheehan syndrome. [Cited 2014 December 1]. Available from _ (!!))!$|"'!7!((! DS00889 NJOG / VOL 9 / NO. 2 / ISSUE 18/ Jul-Dec, 2014 63 63.
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