Demonstration of reserved anterior pituitary function among patients with amenorrhea after postpartum hemorrhage

Abstract

To demonstrate the residual pituitary function of patients with Sheehan's syndrome years after the obstetric complication, 14 patients with postpartum hemorrhage followed by secondary amenorrhea and agalactia were included in this review. Due to their unfamiliarity with the clinical symptoms, these patients did not receive pretreatment hormonal therapy. The mean age at their last delivery was 29 years (range 21-38 years). The mean duration between postpartum hemorrhage and the subsequent clinical manifestations leading to the endocrine investigation was 18 years (range 1-33 years). Eight patients presented with symptoms of severe hyponatremia (serum sodium less than 125 mmol/l) more than 16 years (mean 23 +/- 10) after the occurrence of postpartum hemorrhage. The electrolyte abnormality was primarily due to adrenal dysfunction. Seven out of 14 patients had normal basal luteinizing hormone (LH) levels and adequate LH responses to gonadotropin releasing hormone stimulation. Administration of thyrotropin releasing hormone provoked thyrotropin release and/or prolactin secretion in four cases. The manifestation of clinical hypopituitarism and the degree of empty sella on computed tomography scanning did not accurately indicate the secreting ability of the pituitary in patients with Sheehan's syndrome. Although all the patients had amenorrhea, the gonadotropic functions of the pituitary still remain in some patients. Various degrees of other pituitary functions can also been demonstrated even several decades after the occurrence of obstetric complications. Our data suggest that the amenorrhea of Sheehan's patients is not simply due to a dysfunction of the pituitary gonadotrophs.

Posterior pituitary function in Sheehan’s syndrome

“…Little attention has been given to the posterior pituitary function (9)(10)(11)(12). Clinical diabetes insipidus is apparently an uncommon complication of postpartum pituitary necrosis.…”

Aspectos diagnósticos e terapêuticos da síndrome de Sheehan

“…O que vemos são sintomas compatíveis com diferentes graus de hipofunção hipofisária diagnosticados dias ou anos após o parto. Há relatos de pacientes que evoluíram com hiponatremia aguda e sín-drome de secreção inapropriada de hormônio antidiurético (ADH) 10 dias após o parto (16) e outras que tiveram seu diagnóstico somente 33 anos após o nascimento do último filho (17). Em nossa série, as pacientes apresentavam sintomas crônicos de hipopituitarismo, algumas com diagnóstico no primeiro ano após o parto e outras mais de 20 anos após o parto (10).…”

“…A extensão da disfunção hipofisária varia nas diversas séries (10,(17)(18)(19)(20)(21)(22), visto que na maioria dos estudos o principal acometimento foi o da secreção de prolactina e GH (90% a 100%), enquanto as deficiências na secreção de cortisol, TSH e gonadotrofinas variaram de 50% a 100%. A deficiência de GH é muito comum na síndrome de Sheehan, desde que os somatotrófos estejam localizados nas regiões inferiores e laterais da hipó-fise, sendo bastante suscetíveis à isquemia (23).…”

Pregnancy and pituitary disorders

“…Subsequent pregnancies are reported following SS (195,(214)(215)(216)(217)(218)(219)(220). Pregnancy might improve hypopituitarism by stimulating the pituitary remnant (221).…”

“…Postpartum pituitary apoplexy should be kept in mind in patients with hypotension and shock who have a bleeding history during the peripartum period. The mean duration between postpartum hemorrhage and clinical manifestations varies from 1 to 33 or 2 to 40 years without a correlation between severity of hypopituitarism and degree of empty sella (195,196). SS detected in the acute phase is rare (197)(198)(199), but most of the SS cases are diagnosed during the early postpartum period in the western countries.…”