Chronic Sheehan’s Syndrome – A Differential to be Considered in Clinical Practice in Women with a History of Postpartum Hemorrhage

Abstract

Sheehan's syndrome is hypopituitarism due to pituitary gland necrosis resulting from hemorrhagic shock during pregnancy. It is a rare complication with varied manifestations and a considerable delay in diagnosis. We describe the case of a 36-year-old female with eight years of non-specific symptoms of generalized myalgias and intense fatigue managed symptomatically all these years. Further clinical assessment revealed amenorrhea and agalactia ongoing for several years without a clinical diagnosis. A good history and physical led to the diagnosis during a routine outpatient visit. She had significant improvement noted following the commencement of treatment. Previous case reports describe cases being diagnosed after one or other complications from long-term panhypopituitarism. Through this case, we want to illustrate that undiagnosed Sheehan's syndrome is associated with long-term morbidity, and there should be a high index of suspicion for it to be diagnosed during a routine clinical visit and thus prevent complications before a diagnosis can be made. It is essential to create awareness, especially in developed countries like the United States, where it has received less attention over the last few years.

Adrenal crisis precipitated by influenza A led to the diagnosis of Sheehan's syndrome 18 years after postpartum hemorrhage

“…Patients with Sheehan's syndrome may present with variable clinical and pathological features at diagnosis. [1][2][3][4][5][6][7][8][9][10][11]24 In a previous study, 55% of patients exhibited panhypopituitarism, whereas 45% exhibited partial hypopituitarism. 2 Depending on the extent of tissue damage, 1 therefore, patients with Sheehan's syndrome may present either an acute or chronic course, and hypopituitarism may be either complete or partial.…”

“…However, our patient was able to live for more than 18 years without any hormone replacement since Sheehan's syndrome had not been suspected even though she had experienced massive hemorrhage during pregnancy at 32 years of age. Patients with Sheehan's syndrome may present with variable clinical and pathological features at diagnosis 1‐11,24 . In a previous study, 55% of patients exhibited panhypopituitarism, whereas 45% exhibited partial hypopituitarism 2 .…”

“…26 The duration between the occurrence of postpartum hemorrhage and diagnosis of Sheehan's syndrome in our patient may seem unusually long, but other cases with equal or even longer delays have been reported, up to 48 years in one report. [2][3][4][5][8][9][10][11] Thus, some patients with Sheehan's syndrome may live for many years without hormone replacement therapy. We believe that the bilaterally atrophic adrenal glands of our patient may still have been partially functioning before hospitalization, and the influenza virus infection then precipitated adrenal crisis.…”

“…12 However, Sheehan's syndrome is often undertreated, possibly owing to the low awareness of this syndrome among physicians. 9 We report a patient with previously undiagnosed and hence untreated Sheehan's syndrome who presented with adrenal crisis following infection with influenza A virus 18 years after severe postpartum hemorrhage.…”

“…6 According to the World Health Organization, approximately 100 000 women worldwide die annually due to Sheehan's syndrome; furthermore, more than three million women worldwide had Sheehan's syndrome in 1996. 7 This syndrome is often overlooked, even in developed countries, 8,9 resulting in lengthy delays [2][3][4][5][8][9][10][11] in the diagnosis of as much as 48 years. 11 Adrenal crisis is a lethal medical emergency in the absence of prompt treatment.…”