Review Question - QID 218498

This patient who has history of postpartum hemorrhage presenting with lactation failure, lethargy, amenorrhea, and weight loss most likely has Sheehan syndrome.

Sheehan syndrome is a form of hypopituitarism secondary to infarction of the pituitary gland in the setting of postpartum hemorrhage. The pituitary gland is enlarged in pregnancy and is thus more prone to infarction from hypovolemic shock. Damage to the pituitary gland can range from mild to severe, affecting the secretion of one or several of its hormones and primarily affecting the anterior pituitary gland. Common clinical features include a combination of failure to lactate postpartum, amenorrhea or oligomenorrhea, and the manifestations of hypopituitarism, e.g. hyponatremia, hypotension, hypothyroidism, loss of pubic hair, lethargy, anorexia, weight loss. The treatment is the same as for other causes of hypopituitarism and involves replacing each of the individual pituitary hormonal deficiencies.

Kilicli et al. discuss the characteristics of Sheehan syndrome. The authors note that deficiencies of growth hormone and prolactin are the most commonly seen. The authors recommend treatment of Sheehan syndrome based on the appropriate replacement of deficient hormones.

Incorrect Answers:
Answer 1: Pituitary apoplexy describes sudden hemorrhage into the pituitary gland, often with bleeding into a pituitary adenoma. Clinical presentation can include sudden onset severe headache, diplopia (due to pressure on the oculomotor nerves), and altered mental status. This can cause deficiencies of all pituitary hormones.

Answer 2: Postpartum blues manifests with several mild depressive symptoms that typically develop within days of delivery, peak over the course of the next few days, and resolve within two weeks of onset. Symptoms can include crying, irritability, anxiety, insomnia, exhaustion, decreased concentration, and mood lability. Although this patient describes fatigue, she does not have other symptoms associated with postpartum blues and she is now 5 weeks postpartum.

Answer 3: Postpartum depression describes depression that begins within 12 months of childbirth and diagnostic criteria are the same as those used for diagnosis of major depression. Symptoms can include depressed mood, anhedonia, change in appetite or weight, sleep disturbance, fatigue, neurocognitive dysfunction, psychomotor agitation or retardation, and suicidal ideation or behavior.

Answer 4: Postpartum thyroiditis is considered a form of autoimmune thyroiditis in which patients have elevated serum antithyroid peroxidase antibodies leading to inflammatory injury to thyroid follicles, activating the release of thyroglobulin stored within. Patients typically experience an initial hyperthyroid state, subsequent hypothyroid state, and then recovery. Hypothyroidism shares signs and symptoms with hypopituitarism given the hormones affected, but this patient's history of postpartum hemorrhage makes diagnosis of Sheehan syndrome more likely.

Bullet Summary:
Sheehan syndrome describes pituitary infarction in the setting of postpartum hemorrhage and typically presents with lactation failure, amenorrhea or oligomenorrhea, along with other manifestations of hypopituitarism.