A case of acute Sheehan’s syndrome and literature review: a rare but life-threatening complication of postpartum hemorrhage

Abstract

BackgroundSheehan’s syndrome occurs because of severe postpartum hemorrhage causing ischemic pituitary necrosis. Sheehan’s syndrome is a well-known condition that is generally diagnosed several years postpartum. However, acute Sheehan’s syndrome is rare, and clinicians have little exposure to it. It can be life-threatening. There have been no reviews of acute Sheehan’s syndrome and no reports of successful pregnancies after acute Sheehan’s syndrome. We present such a case, and to understand this rare condition, we have reviewed and discussed the literature pertaining to it. An electronic search for acute Sheehan’s syndrome in the literature from January 1990 and May 2014 was performed.Case presentationA 27-year-old woman had massive postpartum hemorrhage (approximately 5000 mL) at her first delivery due to atonic bleeding. She was transfused and treated with uterine embolization, which successfully stopped the bleeding. The postpartum period was uncomplicated through day 7 following the hemorrhage. However, on day 8, the patient had sudden onset of seizures and subsequently became comatose. Laboratory results revealed hypothyroidism, hypoglycemia, hypoprolactinemia, and adrenal insufficiency. Thus, the patient was diagnosed with acute Sheehan’s syndrome. Following treatment with thyroxine and hydrocortisone, her condition improved, and she was discharged on day 24.Her next pregnancy was established 2 years after her first delivery. She required induction of ovulation for the next conception. The pregnancy, delivery, and postpartum period were uneventful. An electronic search of the literature yielded 21 cases of acute Sheehan’s syndrome. Presenting signs varied, including adrenal insufficiency (12 cases), diabetes insipidus (4 cases), hypothyroidism (2 cases), and panhypopituitarism (3 cases), with a median time of presentation after delivery for each of those conditions being 7.9, 4, 18, and 9 days, respectively. Serial changes in magnetic resonance imaging were reported in some cases of acute Sheehan’s syndrome.ConclusionClinicians should be aware of the risk of acute Sheehan’s syndrome after a massive postpartum hemorrhage in order to diagnose it accurately and treat it promptly.

<p>Obstetric Outcomes of Pregnancy After Uterine Artery Embolization</p>

“…[1][2][3] Severe PPH is an obstetric emergency that occurs in 1% to 2% of live births and accounts for approximately 140,000 maternal deaths annually worldwide. 4 Treatment strategies include pharmacological measures (eg, oxytocin administration), intrauterine tamponade (eg, Bakri balloon or Sengstaken-Blakemore tube), uterine artery ligation, hysterectomy, uterine compression sutures, and uterine artery embolization (UAE). [5][6][7][8][9][10][11][12] A few publications have shown higher rates of preterm birth, fetal growth restriction (FGR), and placenta accreta spectrum (PAS) among women who became pregnant after UAE for PPH.…”

Sheehan Syndrome: An Unusual Presentation Without Inciting Factors

“…Notably, acute presentation of SS, although rare, can also occur and has been associated with life-threatening complications. 22 Finally, unremitting headache in the early postpartum period can be an initial presentation of SS and should be considered in the differential diagnosis. When the headache workup is negative, serial brain MR may be indicated.…”

MANAGEMENT OF ENDOCRINE DISEASE: Fertility, pregnancy and lactation in women with adrenal insufficiency

“…Matsuzaki and colleagues compiled 21 cases of acute Sheehan's syndrome from the literature (1990-2014) and included his own rare case of a successful second pregnancy after induction of ovulation in a patient with Sheehan's syndrome under replacement treatment with hydrocortisone and thyroxine (Table 1 describes only his case). The authors reported variable onset of symptoms of different pituitary hormonal deficiencies with a median time of presentation of secondary AI being 7.9 days following delivery (29).…”

“…To ensure evaluation of cases in the context of modern treatment, only cases dating 1976 onward were considered for inclusion (8,20,26,27,28,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52). This search identified 28 cases of primary AI, a case series with 17 cases of treated adrenocortical carcinoma patients, out of which 7 were included as they were on hydrocortisone treatment following surgical treatment (51) PAI (5) Y (2/5)…”