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González-González JG, Borjas-Almaguer OD, Salcido-Montenegro A, Rodríguez-Guajardo R, Elizondo-Plazas A, Montes-de-Oca-Luna R, Rodríguez-Gutiérrez R. Sheehan's Syndrome Revisited: Underlying Autoimmunity or Hypoperfusion? Int J Endocrinol 2018; 2018:8415860. [PMID: 29681937 PMCID: PMC5846385 DOI: 10.1155/2018/8415860] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 01/02/2018] [Accepted: 01/08/2018] [Indexed: 12/13/2022] Open
Abstract
Sheehan's syndrome remains a frequent obstetric complication with an uncertain pathophysiology. We aimed to assess the incidence of hypopituitarism (≥2 hormonal axis impairment) within the first six postchildbirth months and to determine the existence of anti-pituitary antibodies. From 2015 to 2017, adult pregnant women, who developed moderate to severe postpartum hemorrhage (PPH), were consecutively included in the study. Pituitary function was assessed 4 and 24 weeks after PPH. At the end of the study, anti-pituitary antibodies were assessed. Twenty women completed the study. Mean age was 26.35 (±5.83) years. The main etiology for severe PPH was uterine atony (65%) which resulted mostly in hypovolemic shock grades III-IV. Within the first four weeks after delivery, 95% of patients had at least one hormonal pituitary affected and 60% of the patients fulfilled diagnostic criteria for hypopituitarism. At the end of the study period, five patients (25%) were diagnosed with hypopituitarism (GH and cortisol axes affected). Anti-pituitary antibodies were negative in all patients. At 6 months follow-up, one in every four women with a history of moderate-to-severe PPH was found with asymptomatic nonautoimmune-mediated hypopituitarism. The role of autoimmunity in Sheehan's syndrome remains uncertain. Further studies are needed to improve the remaining knowledge gaps.
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Affiliation(s)
- José Gerardo González-González
- Endocrinology Division, Department of Internal Medicine, University Hospital “Dr. José E. González”, Universidad Autonoma de Nuevo Leon, 64460 Monterrey, NL, Mexico
- Research Unit, University Hospital “Dr. José E. González”, Universidad Autonoma de Nuevo León, 64460 Monterrey, NL, Mexico
| | - Omar David Borjas-Almaguer
- Gastroenterology Division, University Hospital “Dr. José E. González”, Universidad Autonoma de Nuevo León, 64460 Monterrey, NL, Mexico
| | - Alejandro Salcido-Montenegro
- Endocrinology Division, Department of Internal Medicine, University Hospital “Dr. José E. González”, Universidad Autonoma de Nuevo Leon, 64460 Monterrey, NL, Mexico
| | - René Rodríguez-Guajardo
- Gynecology and Obstetrics Division, University Hospital “Dr. José E. González”, Universidad Autonoma de Nuevo Leon, 64460 Monterrey, NL, Mexico
| | - Anasofia Elizondo-Plazas
- Endocrinology Division, Department of Internal Medicine, University Hospital “Dr. José E. González”, Universidad Autonoma de Nuevo Leon, 64460 Monterrey, NL, Mexico
| | - Roberto Montes-de-Oca-Luna
- Histology Department, Facultad de Medicina, Universidad Autonoma de Nuevo Leon, 64460 Monterrey, NL, Mexico
| | - René Rodríguez-Gutiérrez
- Endocrinology Division, Department of Internal Medicine, University Hospital “Dr. José E. González”, Universidad Autonoma de Nuevo Leon, 64460 Monterrey, NL, Mexico
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, MN 55905, USA
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Abstract
Sheehan syndrome or postpartum hypopituitarism is a condition characterized by hypopituitarism due to necrosis of the pituitary gland. The initial insult is caused by massive postpartum haemorrhage (PPH), leading to impaired blood supply to the pituitary gland, which has become enlarged during pregnancy. Small sella turcica size, vasospasms (caused by PPH) and/or thrombosis (associated with pregnancy or coagulation disorders) are predisposing factors; autoimmunity might be involved in the progressive worsening of pituitary functions. Symptoms are caused by a decrease or absence of one or more of the pituitary hormones, and vary, among others, from failure to lactate and nonspecific symptoms (such as fatigue) to severe adrenal crisis. In accordance with the location of hormone-secreting cells relative to the vasculature, the secretion of growth hormone and prolactin is most commonly affected, followed by follicle-stimulating hormone and luteinizing hormone; severe necrosis of the pituitary gland also affects the secretion of thyroid-stimulating hormone and adrenocorticotropic hormone. Symptoms usually become evident years after delivery, but can, in rare cases, develop acutely. The incidence of Sheehan syndrome depends, to a large extent, on the occurrence and management of PPH. Sheehan syndrome is an important cause of hypopituitarism in developing countries, but has become rare in developed countries. Diagnosis is based on clinical manifestations combined with a history of severe PPH; hormone levels and/or stimulation tests can confirm clinical suspicion. Hormone replacement therapy is the only available management option so far.
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Affiliation(s)
- Züleyha Karaca
- Department of Endocrinology, Erciyes University Medical School, 38039, Kayseri, Turkey
| | - Bashir A Laway
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences (SKIMS), Srinagar, Jammu and Kashmir, India
| | - Hatice S Dokmetas
- Department of Endocrinology, Istanbul Medipol University Medical School, Istanbul, Turkey
| | - Hulusi Atmaca
- Department of Endocrinology, Ondokuz Mayıs University Medical School, Samsun, Turkey
| | - Fahrettin Kelestimur
- Department of Endocrinology, Erciyes University Medical School, 38039, Kayseri, Turkey
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