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