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Table 2 A summary of the literature review findings for acute Sheehan syndrome

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

First author Year (Reference number) Age (years) Day cause of hemorrhage   Blood loss Hb level Shock DIC Symptom Headache Etiology Treatment
Putterman C 1991 [9] 27 7 days uterine atony vaginal delivery estimated blood loss was 2 L not described presented not described paresthesia not described hyponatremia, adrenal insufficiency hydrocortisone, levothyroxine, estrogen and progesterone
The patient was resuscitated with blood and colloids; hemorrhage was controlled with uterine massage, oxytocin, and ergotamine.
Syndrome of inappropriate secretion of antidiuretic hormone caused by Sheehan’s syndrome should be considered in the differential diagnosis of postpartum hyponatremia.
Zuker N 1995 [10] 20 14 h uterine atony vaginal delivery 1200 mL Decreased to 5.1 g/dl presented presented hypoglycemia not described adrenal insufficiency hydrocortisone.
An urgent subtotal hysterectomy was performed due to life threatening hemorrhage.
Acute hypoglycemic coma as the initial manifestation of Sheehan’s syndrome in the first few hours postpartum is extremely rare.
Lavallee G 1995 [11] 30 6 h uterine inversion vaginal delivery not described Decreased to 7.6 g/dl not presented not described generalized tonic-clonic convulsions presented adrenal insufficiency hydrocortisone and levothyroxine
She underwent a uterine revision under 5 mg intravenous midazolam hydrochloride.
MR was performed 6 days after delivery; a large intrasellar mass with superior extension was confirmed on T1-weighted. The mass effect has disappeared, and the pituitary gland is somewhat atrophic (postpartum day 48)
It is therefore important to be alert to the possibility that an enlarged nonhemorrhagic pituitary gland may be present in the post-infarction phase of Sheehan’s syndrome, as shown in the present case report
Kan AK 1998 [12] 32 24 h unclear cesarean section 500 mL Decreased to 5.7 g/dl not presented not described excessive urination not described diabetes insipidus desmopressin
She was transfused 4 units of blood and additional treatment was not performed.
This is a report of a case of diabetes insipidus developing within 24 h postpartum in a grand multipara who had an elective lower segment Cesarean section for twins.
Dejager S 1998 [13] 32 3 days * not described little not described presented not described Severe headache excessive urination presented diabetes insipidus hydrocortisone and desmopressin
The delivery was complicated by a occurrence of a severe hypotention episode at the beginning of the epidural anesthesia.
MRI was performed 6 days after delivery. MRI revealed the presence of a holosellar 11-mm diameter mass.
Follow-up MRI showed a spontaneous and rapid shrinkage of the pituitary, within 20 days, which appeared as an empty sella 3 months later.
Sheehan’s syndrome may initially closely mimic hypophysitis, or the necrosis of an adenoma.
Boulanger E 1999 [14] 30 10 days uterine scar disjunction VBAC not described not described not described presented asthenia not described hyponatremia, adrenal insufficiency glucocorticoids.
Hysterectomy was performed to control blood loss and transient disseminated intravascular coagulation occurred.
MRI was not performed.
The report of early and acute hyponatremia with inappropriate secretion of antidiuretic hormone occurring 10 days after vaginal delivery with severe blood loss.
Kale K 1999 [15] 23 20 days not described not described not described not described not described not described psychosis not described maybe hypothyroidism predonisolone and thyroxine sodium
The treatment to control the bleeding was not described.         
MRI was not performed.             
It was interesting to note that all the clinical features of Sheehan’s syndrome and psychosis improved with hormone replacement therapy and she did not require treatment with antipsychotic medications.   
Schrager S 2001 [16] 39 12 days atonic bleeding cesarean delivery severe not described presented feeling nausea general fatigue not described hyponatremia, adrenal insufficiency cortisone acetate
Hysterectomy was performed to control blood loss and underwent an embolization of her right vaginal artery.
A sodium level measured on the 5th day of her hospitalization was normal.
Although Sheehan’s syndrome is uncommon as a result of improved obstetric care, it should be a consideration in any woman who has a history of a postpartum hemorrhage and who reports signs or symptoms of pituitary deficiency.
Lust K 2001 [17] 32 3 days atonic bleeding vaginal delivery 3200 ml not described presented presented headache presented hyponatremia thyroxine and cortisone acetate
Uterotonic agents successfully controled the bleeding.
MRI scan of pituitary day five after delivery showed the enlarged pituitary gland with its superior margin reaching the undersurface of the optic chiasm.
MRI scan of pituitary 4 months after delivery showed atrophic pituitary gland and empty sella.
Wang HY 2002 [18] 32 7 days persistent bleeding from uterus cesarean delivery severe 3.5 g/dL presented presented excessive urination not described diabetes insipidus desmopressin
Angiography with bilateral uterine artery embolization was performed.
MRI was not performed.
There are very few existing literature discussing concomitant Sheehan’s syndrome and acute renal failure.
Bunch TJ 2002 [19] 23 6 days atonic bleeding cesarean delivery massive hemorrhage not described presented presented general fatigue not described hyponatremia, adrenal insufficiency predonisolone and levothyroxine
She received large volumes of fluid and blood products for resuscitation. Additional treatment was not performed.
MRI demonstrates an enlarged pituitary gland with abnormal signal on the T1 weighted precontrast images (postpartum approximately day 10).
There are many studies describing complications of late Sheehan’s syndrome; however, relatively few contain descriptions of the acute phase.
Munz W 2004 [20] 33 6 days    Hb level decreased to 3.0 g/dL     headache, vomitting   hyponatremia, adrenal insufficiency hydrocortisone and levothyroxine
Hysterectomy was performed to control blood loss. The patient received a transfusion of 12 units of blood and six units of fresh frozen plasma.
MRI of the pituitary was normal on postpartum day 6.
Sheehan’s syndrome can be associated with hyponatremia, illustrating the need to include hyponatremia as an initial symptom in the differential diagnosis of Sheehan’s syndrome.
Wang S 2005 [21] 33 19 days postpartum hemorrhage cesarean delivery Massive bleeding 6.6 g/dL presented presented hemodynamic instability not described adrenal insufficiency hydrocortisone and thyroxine sodium
Hysterectomy was performed to control blood loss.
MRI showed no notable abnormality (postpartum day 19).
MRI showed a flattened pituitary gland and loculation of cerebrospinal fluid (postpartum day 32).
Although the occurrence of Sheehan’s syndrome is now rare, it should still be considered in any woman with a history of peripartum hemorrhage who develops manifestations of pituitary hormone deficiency.
Kaplun J 2008 [22] 29 17 days retained placenta unknown massive 3.8 g/dL not described not described general fatigue presented panhypopituitarism not described
   21 3 days perineal laceration vaginal delivery massive 5.5 g/dL presented not described fever and a severe headache not presented hyponatremia, adrenal insufficiency prednisone and levothyroxine
The treatment used to control the bleeding was not described for either case 1 or 2.
MRI on postpartum day 26 revealed a nonenhancing, minimally hypointense lesion in the pituitary gland (case 1).
MRI obtained on postpartum day 6 showed an enlarged pituitary gland with suprasellar extension to the optic chiasm (case 2).
Anfuso S 2009 [23] 35 8 days none vaginal delivery 500 mL 8.8 g/dL not presented not presented asthenia, persistent headache not presented hyponatremia, adrenal insufficiency hydrocortisone and levothyroxine
The treatment to control the bleeding was not described.
MRI on postpartum day 8 revealed an abnormal lack of enhancement of pituitary grand.
MRI 3 months postpartum confirmed previous vascular necrosis.
Early diagnosis of early-onset Sheehan’s syndrome associated with severe hyponatremia, following dystocic childbirth complicated by postpartum hemorrhage.
Kumar S 2011 [24] 36 4 days atonic bleeding vaginal delivery massive 6.1 g/dL presented presented excessive urination not presented diabetes insipidus desmopressin
Hysterectomy was performed to control the blood loss. The patient received the massive transfusion.
MRI showed a normal pituitary gland (postpartum day 6).
It is important to consider posterior pituitary ischemia resulting from Sheehan’s syndrome, presenting as central diabetes insipidus, as a cause of polyuria. Appropriate hormonal replacement that is initiated early can improve the clinical status and outcomes of patients.
Shoib S 2013 [25] 31 16–18 days unknown unknown not described not described not described not described psychosis not described possibly hypothyroidism prednisolone and thyroxine sodium
The treatment to control the bleeding was not described.
CT and MRI scans were not performed.
Psychosis in patients with Sheehan’s syndrome is uncommon. Clinicians should have a high index of suspicion when postpartum-psychosis presents with a significant obstetric history.
Sasaki S 2014 [26] 37 4–6 days retained placenta vaginal delivery massive 4.0 g/dL presented presented failure to lactate not described panhypopituitarism hydrocortisone.
Emergency uterine embolization was performed.
Sagittal T1-weighted image showing slight swelling of the anterior lobe and the pituitary stalk (postpartum day 10).
At 1 month after delivery, swelling of the anterior lobe was reversed.
At 5 months after delivery, marked atrophy of the anterior lobe was observed
Hale B 2014 [27] 31 6 days retained placenta vaginal delivery 1500 ml 6.2 g/dL presented presented headache, failure to lactate, fatigue presented partial hypopituitarism prednisone, levothyroxine, desmopressin and somatropin
Retained placenta required manual extraction.
Cranial magnetic resonance imaging scan performed on postpartum day six. The pituitary gland appears enlarged with peripheral enhancement and an isodense central area.
Postpartum headache is a common occurrence with a broad differential diagnosis. Combined pathophysiological features of Sheehan’s syndrome and postpartum headache is an atypical acute presentation.
Present case 2015 27 8 days atonic bleeding vaginal delivery at least 5000 mL 4.1 g/dl presented presented grand mal convulsion not presented hyponatremia, adrenal insufficiency hydrocortisone and thyroxine sodium
Emergency uterine embolization was performed to control the blood loss.
A sagittal T1-weighted image of the pituitary gland was normal on postpartum day 15.
At 6 months after delivery, marked atrophy of the anterior lobe was observed.
Early onset of Sheehan’s syndrome is rare. Acute Sheehan’s syndrome presenting with a sudden onset of postpartum seizures is rarer still.
VBAC: Vaginal birth after cesarean section
  1. *Severe hypotension episode at the beginning of the epidural anesthesia with loss of consciousness was observed
  2. Abbreviations: CT computed tomography, Hb hemoglobin, MRI magnetic resonance imaging