A case of Sheehan syndrome in early pregnancy

INTRODUCTION

Sheehan syndrome is postpartum anterior hypopituitarism caused by necrosis of the pituitary gland. It results from severe hypotension or shock secondary to bleeding postpartum.¹ It is not so common in developed countries but it’s still frequent in underdeveloped and developing countries. In most cases, it is diagnosed late as clinical features like failure to lactate, cessation of menses, loss of axillary and pubic hair, breast atrophy and loss of libido are seen late.² Prompt suspicion of Sheehan syndrome based on the patient’s presentation either with hypotension or hypoglycaemia or shock secondary to postpartum bleeding.3 Also MRI findings suggestive of an empty Sella sign or partially empty Sella sign help to diagnose Sheehan syndrome as early as possible.⁴

CASE REPORT

A 35-year-old G5P4L4, married for 10 years with 1 month 15 days amenorrhea came to our hospital with complaints of bleeding per vagina for 2 to 3 hours, dizziness, and weakness. The urine pregnancy test was weakly positive. The patient was conscious and oriented to time Place and person but’ had pallor with hypotension with systolic blood pressure of 50 mmHg pulse rate of 126 bpm and saturation was 98% on room air. The patient was given a packed cell transfusion and intravascular fluid and put on ionotropic support to raise blood pressure.

Simultaneously, the patient was taken for check curettage after which she was shifted to ICU. Blood reports were Hb. 5.2 gm%, TLC.13800, Platelets.³ lacs, BUN.16.90, Creatinine.0.85, RBS.59, T3. 0.36, T4. 5.79, TSH.2.22, serum cortisol level.17.50, LH. 0.16. After stabilization, an MRI of the brain showed a partially empty Sella (fig 1 & fig 2).5 She was treated for hypoglycaemia and hypotension with dextrose saline and hydrocortisone. Injection of hydrocortisone 200mg given loading dose followed by infusion of 200 mg over 24 hours. The patient responded well to hydrocortisone. On discharge patient was prescribed tab prednisolone 5 mg.

DISCUSSION

Sheehan’s syndrome is panning hypopituitarism characterized by anterior pituitary necrosis after postpartum bleeding which leads to hypotension, hypoglycaemia, and shock. Hypertension, vasospasm, and compression of pituitary arteries can cause Sheehan’s syndrome. The anterior pituitary is more commonly affected in Sheehan’s syndrome as it has a low-pressure venous system. Also, the size of the pituitary gland increases during pregnancy to meet the normal physiological demands of pregnancy. Enlargement of the pituitary gland is mainly due to hyperplasia of lactotrophs. Sheehan’s syndrome may present as panhypopituitarism or selective loss of pituitary function. Growth hormone and prolactin are most commonly affected in selective hypopituitarism. Rarely diabetes insipidus can be seen in Sheehan’s syndrome. It can be present in acute or chronic form but chronic presentation is more common. Sheehan’s syndrome mainly presents with symptoms of hypothyroidism like generalized weakness, asthenia easy fatiguability, weight gain, and hair loss. On examination hypotension and low heart rate can be found. The secondary form of adrenal insufficiency caused by ACTH deficiency leads to hypercortisolism which can be manifested as weight loss and fatigue.⁶

Acute forms mainly present as lactation failure. Some women may present with irregularity in menses after childbirth. Acute presentation can be dangerous if it is not diagnosed early and treated accordingly. Persistent hypotension and tachycardia with hypoglycaemia can help to reach the diagnosis.

Biochemical diagnosis of pituitary insufficiency is made by demonstrating low hormone levels which are secreted from the pituitary gland. Thyroid function test shows low thyroxine with normal or low TSH level. Also, LH and FSH show decreased blood levels.

Growth hormone deficiency can be tested with an insulin tolerance test, growth hormone releasing hormone (GHRH) test, L-arginine test, and L dopa test. Prolactin levels can be tested with the TRH hormone test.⁷ Serum ACTH hormone level is tested by insulin tolerance test.⁸ And Corticotropin-releasing hormone test. Management of hypopituitarism is nothing but the lifelong replacement of deficient hormones.

Gonadotrophin deficiency can be replaced with estrogen and progesterone and if the uterus has been removed it can be treated with only estrogen. Growth hormone deficiency is treated with regular injections of synthetic human growth hormone. Hypothyroidism is treated with thyroxine. Cortisol deficiency is treated with prednisolone or hydrocortisone.

CONCLUSION

Sheehan syndrome often presents with delayed onset of clinical features, which can result in late diagnosis. This delay in recognition can expose patients to severe complications, such as myxoedema coma due to thyroid dysfunction, hypoglycaemic episodes that may lead to loss of consciousness, and an increased risk of mortality from cardiovascular and cerebrovascular complications. The risk of these serious outcomes underscores the importance of early identification and intervention.

To facilitate early diagnosis, clinicians should obtain a comprehensive medical history focused on identifying potential causes of hypotension or shock, especially in the postpartum period. Rigorous monitoring of vital signs is essential to detect signs of endocrine dysfunction early. Additionally, the MRI brain plays a crucial role in confirming the diagnosis by identifying characteristic pituitary gland abnormalities associated with Sheehan syndrome. Early diagnosis and prompt management can prevent serious complications and improve long-term outcomes for patients with Sheehan syndrome.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

1. 1. Laway BA, Baba MS. Sheehan syndrome. JPMA. The Journal of the Pakistan Medical Association. 2021;71(4):1282-568.
2. 2. Ratarasarn C, Rajatanavin R, Himathongkam T. Salient clinical features of Sheehan's syndrome. J Med Assoc of Thailand Chotmaihet thangphaet. 1989;72(1):41-7.
3. 3. Matsuzaki S, Endo M, Ueda Y, Mimura K, Kakigano A, Egawa-Takata T, et al. A case of acute Sheehan’s syndrome and literature review: a rare but life-threatening complication of postpartum hemorrhage. BMC Pregnancy and Childbirth. 2017;17:1-10.
4. 4. Lundholm MD, Yogi-Morren D. A Comprehensive Review of Empty Sella and Empty Sella Syndrome. Endocr Pract. 2024;30:497–502.
5. 5. Chiloiro S, Giampietro A, Bianchi A, De Marinis L. Empty sella syndrome: multiple endocrine disorders. Handbook of Clinical Neurology. 2021;181:29-40.
6. 6. Karaca Z, Tanriverdi F, Unluhizarci K, Kelestimur F. Pregnancy and pituitary disorders. European J Endocrinol. 2010;162(3):453-75.
7. 7. Snyder PJ, Utiger RD. Inhibition of thyrotropin response to thyrotropin-releasing hormone by small quantities of thyroid hormones. The J Clin Invest. 1972;51(8):2077-84.
8. 8. Poon P, Smith JF. The short Synacthen and insulin stress tests in the assessment of the hypothalamic-pituitary-adrenal axis. Clin Endocrinol. 1996;45(2):245-9.