Sheehan Syndrome: Symptoms, Diagnosis, Treatment And Prognosis
Sheehan syndrome is also known as post-partum hypopituitarism , caused by adenohypophysis infarction, which is triggered by excessive blood loss during childbirth. Sheehan syndrome, an endocrine disease, was first reported in 1937 by the English pathologist Harold Leeming. It mostly happens in developing countries where the medical facilities are not upto the mark. It is not very common in developed nations.
Sheehan on the basis of autopsy findings in patients with post-partum pituitary necrosis. Post-partum massive hemorrhage is one of the causes of ischemia-induced pituitary dysfunction secondary to the arrest of blood flow to the adenohypophysis. Necrotized areas of the adenohypophysis undergo organization, form a fibrous scar leading to time-dependent atrophic change of the pituitary gland resulting in empty sella turcica, the lodging bed of pituitary gland, which can be clinically detected by magnetic resonance imaging (MRI).
Clinically, women with Sheehan syndrome exhibited dysfunction of the anterior lobe of the pituitary gland with the manifestation of obstetrical shock accompanied by disseminated intravascular coagulation (DIC) during delivery. When the endicrine functioning is affected , then either one hormone or all hormones can be affected which get secreted by cells of adenohypophysis.
But the clinical features will depend on patient’s age, how was it starts, the aetiology behind the whole pathology, and how many cells of the adenohypophysis are affected.
Functional impairment occasionally extended to the posterior lobe of the pituitary. While the incidence is low, being 1 in 10 000 deliveries, it is a serious disease, and its pathological factors largely remain unclear. It is a hazardous disease that may not only impair the quality of life of women but also may threaten life if left untreated. Mild hypopituitarism can remain undetected for years but complete loss of adenohypophysis function requires immediate treatment. Therefore, careful follow-up intervention for early diagnosis and proper management of patients with Sheehan syndrome is mandatory. However, information on the suitable clinical factors related to the occurrence of Sheehan syndrome is scant.
Sheehan syndrome is a permanent secretion disorder of all pituitary anterior lobe hormones caused by extensive pituitary necrosis secondary to obstetrical shock accompanied by DIC following massive hemorrhage during delivery. No pituitary dysfunction develops if approximately 50% of the normal pituitary gland remains intact, but partial or panhypopituitarism is reported to occur if 70–90% of the pituitary gland is necrosed. Depending on the site and size of the necrosed area of the pituitary gland, the disease varies from panhypopituitarism (Sheehan syndrome), in which the secretion of all gonadal, thyroid and adrenocortical hormones is reduced, to partial hypopituitarism, in which the secretion of two or more hormones is reduced, and to single-hormone hypopituitarism, in which the secretion of only one hormone is reduced.
Sheehan syndrome is a rare but irreversible and serious disorder. When most pregnant women, who suffer massive hemorrhage or shock during delivery, survive and are rehabilitated, some patients are considered to have one-hormone hypopituitarism rather than panhypopituitarism such as typical Sheehan syndrome. However, publications on obstetrical predictive factors targeting early identification or diagnosis of this debilitating disease are still inadequate. With strict prospective follow-up, here we demonstrated for the first time some subjective, hematological, hormonal and MRI imaging parameters which may be suitable in clinical practice to isolate and for early diagnosis of Sheehan syndrome in groups of women with massive post-partum hemorrhage.
In addition to subjective findings of insufficient or no milk secretion and breast atrophy, our current findings of decreased consciousness level and elevated obstetrical DIC score in women with massive post-partum hemorrhage may give us some additional clues in the isolation and early diagnosis of cases with Sheehan syndrome.
Further study on this issue is necessary to strengthen our current findings. Considering future quality of life, early diagnosis of Sheehan syndrome based on our clinical findings is important for proper management of these patients by mutual collaboration and discussion between obstetrical doctors and doctors from internal medicine. Basal cortisol and ACTH level may be an important parameter in decision-making for cortisol treatment in order to normalize ACTH level in cases with Sheehan syndrome. Furthermore, careful attention and strict follow-up are mandatory for any women with massive past-partum hemorrhage in order to identify cases with Sheehan syndrome.
If the ADH or anti-diuretic hormone is suppressed then decrease sodium levels or hyponatremia could occur due to less cortisol production.
A study was done by sert et al, wherein sodium levels, consciousness were gauged and MRI and CT scan of pituitary was done. They reported that a relation between less sodium levels and sells was there and the patients had altered consciousness and confusion.
In a few cases, abnormalities such as an empty sella were noted in all patients in the Sheehan group by pituitary MRI. It has been reported that deficiency of milk secretion is a frequent initial symptom of Sheehan syndrome, and that symptoms such as breast atrophy, sense of fatigue, loss of pubic and axillary hair, continuation of amenorrhea, hypothyroidism and hypoadrenalism are observed for several months to a few years.
Together with insufficient gonadotropin secretion, subsequent onset of breast atrophy and loss of pubic and axillary hair may be considered as an early indication of Sheehan syndrome
Symptoms of Sheehan syndrome
Excessively low pressure of the blood, a lot of blood loss during childbirth could deprive oxygen in the body. The lack of oxygen severely impacts the body and damages the pituitary gland, thus giving rise to Sheehan syndrome. The pituitary gland is the most commonly affected and as a result not enough pituitary hormones are produced in the body leading to what is known as hypopituitarism. If the medical care during pregnancy is good and the conditions are favourable then it can be avoided.
Symptoms of this syndrome don’t appear immediately. They appear slowly over a few years.
These occur due to the presence of few hormones in pituitary gland.
Unable to breast-feed
Problem with periods
Gain of weight
Decreased blood sugar and pressure
Irregularity in heartbeats
These symptoms might seem normal to you, specially for new mothers. Women might not realise they are suffering from it until a thyroid related problem arises. This can also be the case that you don’t have any symptoms at all. Women might not realise this in their entire life. Your pituitary gland is not functioning well, this you may not notice ever. But in cases of extreme stress or surgery where in not enough amounts of cortisol is produced by the adrenal glands.
Causes of Sheehan syndrome
If there is excessive blood loss or the blood pressure of w woman is very low during or after delivery then it might also damage the pituitary gland , so much so that it cannot function well. Pituitary glands regulate the other hormones and the overall endocrinal system of the body. It can alter the hormones which are responsible for blood pressure, milk production and other vital functions.
Various hormones are Growth hormone, Thyroid-stimulating hormone (TSH),
Luteinizing hormone (LH), Follicle-stimulating hormone (FSH).
Adrenocorticotropic hormone (ACTH) which controls cortisol production. Prolactin which produces breast milk.
Blood loss or haemorrhage during pregnancy can be very damaging and can pose a risk for Sheehan syndrome.
If hormones are not produced properly then many functions get impacted.
Very less cortisol is produced
Blood pressure is decreased
Loss of weight
How is it diagnosed?
It is difficult to diagnose it only by symptoms as they might overlap and can be easily confused with other diseases. A detailed history has to be provided by you to the concerned doctor. A few tests can also be done.
Blood test can check the hormonal levels in the body. Pituitary test to check if the pituitary gland is functioning well or not. MRI or CT scan can be done to diagnose any tumor present in any of the glands.
Treatment for Sheehan syndrome
You have to take the hormonal supplements for whichever hormone that is affected. You may see an endocrinologist for this as they specialise in this field. Regular blood tests have to be done to keep a tab on the hormones.
Corticosteroids, estrogen, LH, FSH which are responsible for ovuation and can help you get pregnant.
Growth hormone which helps to helps you grow
Prevention of Sheehan syndrome
Avoidance of blood loss during childbirth and a good medical facility and care is very important to prevent this.