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- Sheehan syndrome is a rare disorder of postpartum panhypopituitarism occurring secondary to ischemia and subsequent necrosis of the pituitary gland, classically associated with severe postpartum hemorrhage.
- It is often recognized early postpartum when there is lack of milk production and amenorrhea; however, mean years to diagnosis can be upwards of 20 and symptomatology can be variable depending on hormonal deficiencies.
- Deficiencies in some or all pituitary-regulated hormones may develop and may be complete or partial. The syndrome may be associated with hypocortisolism, hypothyroidism, hypogonadism, and loss of growth hormone (GH) and prolactin (PRL) to or more or lesser extents (1). More rarely, diabetes insipidus may occur (2).
- System(s) affected: endocrine, reproductive
- Synonym(s): postpartum pituitary necrosis; postpartum hypopituitarism; postpartum anterior pituitary necrosis
- There is likely a socioeconomic/sociocultural disparity.
- It is more common in resource-poor countries, particularly because of the prevalence of home births, whereas, it is less common in high resource or developed nations (e.g., United States). However, the diagnosis is more likely to be missed or delayed given its rarity.
- Predominant age: childbearing years
- Predominant sex: female only
One study in Spain found incidence of panhypopituitarism to be 46/100,000/year in general, with only a fraction due to Sheehan syndrome (2), whereas other literature quotes an incidence of 1/10,000/year (3).
Etiology and Pathophysiology
- Postpartum hemorrhage results in decreased intravascular volume and hypotension, leading to ischemia of various organs including the pituitary gland which is enlarged in pregnancy and more reliant on blood flow.
- Ischemia to the pituitary gland results in necrosis and dysfunction.
- Hormones dependent on pituitary synthesis and/or regulation, such as glucocorticoids, thyroid hormone, GH, PRL, and gonadotropins (LH and FSH), become deficient resulting in the clinical syndrome.
Sheehan syndrome is associated with postpartum hemorrhage which may occur in any woman. Factors that increase postpartum hemorrhage risk include but are not limited to:
- Macrosomic neonate
- Multiple gestation (twins, triplets, etc.)
- Prolonged or augmented labor
- Placental disorders: abruption, accreta, previa
- Retained placenta
- Soft tissue lacerations
- Maternal blood disorders
- Hypertensive disorders including preeclampsia
- Lack of access to adequate obstetric care is also a risk factor and thus risk is increased with home deliveries and in resource-poor countries.
- As Sheehan syndrome is associated with postpartum hemorrhage and postpartum hemorrhage is associated with interventions, avoid interventions when possible (e.g., augmented labor, episiotomy, forceps or vacuum delivery, and cesarean section).
- Address or limit modifiable risk factors associated with postpartum hemorrhage, including obesity.
Commonly Associated Conditions