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Agrawal P, Garg R, Agrawal M, Singh MK, Verma U, Chauhan R. Sheehan's Syndrome in India: Clinical Characteristics and Laboratory Evaluation. J Obstet Gynaecol India 2023; 73:51-55. [PMID: 37916020 PMCID: PMC10616000 DOI: 10.1007/s13224-023-01801-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 06/12/2023] [Indexed: 11/03/2023] Open
Abstract
Background Sheehan's Syndrome (SS) is an important cause of hypopituitarism especially in developing countries though it remains underdiagnosed to a great extent. Torrential bleeding after delivery followed by lactation failure and amenorrhoea gives a clue to the diagnosis which is usually made after several years of delivery. Materials and Methods It was a retrospective observational study conducted by reviewing the case records of 38 cases of SS. The age, anthropometric measurements, signs and symptoms, biochemical parameters, hormone levels and imaging reports were examined and analyzed. Results The mean age at presentation was 36.5 years because there was a delay of 8.4 years from last delivery before diagnosis could be made. Ninety percent patients presented with lactation failure. Anaemia, hypotension, hypogonadism, hypothyroidism, and altered lipid profile were the most common findings. The mean systolic blood pressure (BP) was 80.95 mm and diastolic BP was 51.6 mm of Hg at the time of presentation. Hyponatremia was the most common electrolyte abnormality noted and low HDL was the commonest lipid abnormality. Conclusion A large percentage of patients presented with amenorrhea, lactation failure, and decreased or absent axillary/pubic hair. Shock, anemia, and hyponatremia were also common symptoms among the patients studied. The diagnosis of SS rests upon a thorough history taking of the postpartum events in cases presenting with hypopituitarism irrespective of the age at presentation. Proper antenatal care with exclusive institutional deliveries can reduce the prevalence of SS in developing countries.
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Affiliation(s)
| | - Ruchika Garg
- Department of Obs and Gynaecology, SN Medical College, Agra, India
| | - Mohita Agrawal
- Department of Obs and Gynaecology, SN Medical College, Agra, India
| | | | - Urvashi Verma
- Department of Obs and Gynaecology, SN Medical College, Agra, India
| | - Richa Chauhan
- Department of Obs and Gynaecology, SN Medical College, Agra, India
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2
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A Challenging Diagnosis of Sheehan’s Syndrome in Non-obstetric Critical Care and Emergency Settings: A Case Series of Five Patients with Varied Presentations. J Crit Care Med (Targu Mures) 2022; 8:214-222. [PMID: 36062035 PMCID: PMC9396951 DOI: 10.2478/jccm-2022-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 06/14/2022] [Indexed: 11/20/2022] Open
Abstract
Sheehan’s syndrome is a life-threatening endocrine emergency seen in postpartum females secondary to ischemic pituitary necrosis. It is a frequent cause of hypopituitarism in developing countries that occurs secondary to postpartum haemorrhage (PPH). Patients with Sheehan’s syndrome often present with organ dysfunctions in critical care settings, secondary to stressors precipitating the underlying hormonal deficiencies. The initial clinical picture of Sheehan’s syndrome may mimic some other disease, leading to misdiagnosis and diagnostic delay. Strict vigilance, timely diagnosis, and appropriate management are essential to avoid diagnostic delay and to improve the patient outcome. In this case series, we describe 5 cases of previously undiagnosed Sheehan’s syndrome (including young, middle aged and postmenopausal females) that presented to critical care and emergency settings with organ failures.
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3
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Farah E, Barger MK, Klima C, Rossman B, Hershberger P. Impaired Lactation: Review of Delayed Lactogenesis and Insufficient Lactation. J Midwifery Womens Health 2021; 66:631-640. [PMID: 34596953 DOI: 10.1111/jmwh.13274] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 05/08/2021] [Accepted: 06/04/2021] [Indexed: 12/29/2022]
Abstract
It is estimated that as many as 1 in 20 women worldwide are unable to successfully breastfeed or provide adequate nutrition for their infants through their breast milk alone. Compromised nutrition in the early stages of life places the infant at risk for insufficient growth as well as serious and potentially disabling or life-threatening complications. This review summarizes risk factors associated with impaired lactation that may result in either delayed lactogenesis or insufficient lactation. The risk factors for insufficient lactation are categorized into preglandular, glandular, and postglandular causes. Impaired lactation can occur despite maternal motivation, knowledge, support, and appropriate breastfeeding technique. Although there is no clear way to predict who will experience impaired lactation, knowledge about the risk factors can enable health care professionals to better identify at-risk mother-infant dyads. Early intervention may help prevent infant complications associated with inadequate nutritional intake.
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Affiliation(s)
- Erin Farah
- Department of Human Development Nursing Science, University of Illinois at Chicago, Chicago, Illinois
| | - Mary K Barger
- Hahn School of Nursing and Health Sciences, University of San Diego, San Diego, California
| | - Carrie Klima
- Department of Human Development Nursing Science, University of Illinois at Chicago, Chicago, Illinois
| | - Beverly Rossman
- Department of Women, Children, and Family Nursing, Rush University Medical Center, Chicago, Illinois
| | - Patricia Hershberger
- Department of Health Systems Science, University of Illinois at Chicago, Chicago, Illinois
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4
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Genetu A, Anemen Y, Abay S, Bante SA, Mihrete KM. A 45-year-old female patient with Sheehan's syndrome presenting with imminent adrenal crisis: a case report. J Med Case Rep 2021; 15:229. [PMID: 33962642 PMCID: PMC8105925 DOI: 10.1186/s13256-021-02827-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 03/25/2021] [Indexed: 11/25/2022] Open
Abstract
Background Sheehan's syndrome is hypopituitarism due to pituitary gland necrosis resulting from hemorrhagic shock during pregnancy. It is a rare complication with varied manifestations and a considerable delay in diagnosis. Case presentation We describe the case of a 45-year-old Ethiopian woman who presented with generalized fatigue for 18 years which progressed to anorexia, nausea, vomiting, diarrhea, and abdominal pain of 6 years' duration, for which she was treated symptomatically throughout these years. Complete clinical evaluation, endocrine studies, and pituitary magnetic resonance scan revealed hypopituitarism secondary to Sheehan’s syndrome. She had significant improvement noted following the commencement of hormone replacement therapy. Conclusion Previous case reports describe patients being diagnosed after one or more complications from long-term panhypopituitarism. The present case illustrates that undiagnosed Sheehan's syndrome is associated with long-term morbidity, and we want to emphasize that a high index of suspicion is crucial for the early diagnosis of the syndrome in routine clinical visits in order to prevent complications arising with delayed diagnosis. Awareness among clinicians is also essential so that such cases are not overlooked, especially in developing nations, where home delivery is still common and obstetric care is limited.
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Affiliation(s)
- Abere Genetu
- Department of Internal Medicine, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia.
| | - Yibeltal Anemen
- Department of Internal Medicine, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Sinshaw Abay
- Department of Internal Medicine, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Simachew Anemen Bante
- Department of Midwifery, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Kebadnew Mulatu Mihrete
- Department of Epidemiology and Biostatistics, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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5
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Takeda R, Demura M, Sugimura Y, Miyamori I, Konoshita T, Yamamoto H. Pregnancy-associated diabetes insipidus in Japan-a review based on quoting from the literatures reported during the period from 1982 to 2019. Endocr J 2021; 68:375-385. [PMID: 33775975 DOI: 10.1507/endocrj.ej20-0745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
This Review Article overviews the literature on diabetes insipidus (DI) associated with pregnancy and labor in Japan published from 1982 to 2019. The total number of patients collected was 361, however, only one-third of these cases had detailed pathophysiologic information enabling us to identify the respective etiology and subtype. Pregnancy-associated DI can be divided into 3 etiologies, central (neurogenic) DI, nephrogenic DI, and excess vasopressinase-associated DI. Neurogenic DI has various causes: for example, DI associated with tumoral lesions in the pituitary and neighboring area, DI associated with Sheehan's syndrome and/or pituitary apoplexy, and DI associated with lymphocytic infundibuloneurohypophysitis (LINH, stalkitis). Nephrogenic DI results from defective response of the kidney to normal levels of vasopressin. However, the most interesting causal factor of pregnancy-associated DI is excess vasopressinase, caused either by excess production of vasopressinase by the placenta or defective clearance of vasopressinase by the liver. Hepatic complications resulting in pregnancy-associated DI include acute fatty liver of pregnancy (AFLP) and HELLP syndrome (syndrome of hemolysis, elevated liver enzymes, low platelets), as well as pre-existing or co-incidental hepatic diseases. A possible role of glucose uptake in putative stress-induced DI and the importance of correct diagnosis and treatment of pregnancy-associated DI, including use of 1-deamino 8-D arginine vasopressin, are also discussed.
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Affiliation(s)
- Ryoyu Takeda
- Department of Internal Medicine, Kanazawa University*, Kanazawa 920-8640, Japan
- KKR† Kanazawa Hospital, Kanazawa 921-8035, Japan‡
| | - Masashi Demura
- Department of Hygiene, Graduate School of Medical Science, Kanazawa University, Kanazawa 920-8640, Japan
| | - Yoshihisa Sugimura
- Department of Endocrinology and Metabolism, Fujita Health University, Toyoake 470-1192, Japan
| | - Isamu Miyamori
- Department of Internal Medicine, University of Fukui Faculty of Medical Sciences*, Fukui 910-1193, Japan
| | - Tadashi Konoshita
- Third Department of Internal Medicine, University of Fukui Faculty of Medical Sciences, Fukui 910-1193, Japan
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Neuroendocrine manifestations of Erdheim-Chester disease. HANDBOOK OF CLINICAL NEUROLOGY 2021; 181:137-147. [PMID: 34238453 DOI: 10.1016/b978-0-12-820683-6.00010-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Neuroendocrine manifestations are common in Erdheim-Chester disease (ECD) patients. ECD is a rare non-Langerhans form of histiocytosis with multisystemic infiltration. The involvement of the hypothalamo-pituitary axis is common and central diabetes insipidus (CDI) is one of the most common endocrine manifestations in ECD patients. CDI is the first manifestation of ECD in 25%-48% of the cases. Suprasellar region extension, due to the infiltration of ECD lesions, can cause neurologic manifestations by mass effects, such as headache, visual disturbance, and cranial nerve palsies. Recent studies have revealed that disorders affecting anterior pituitary hormones are common in ECD patients. Secondary adrenal insufficiency, secondary hypothyroidism, (adult) growth hormone deficiency, hypogonadotropic hypogonadism, hyperprolactinemia, and hypoprolactinemia can develop as the neuroendocrine manifestations of ECD. Since the symptoms of anterior pituitary hormone deficiencies tend to be nonspecific, the diagnosis of anterior pituitary hormone dysfunctions can be delayed. Some anterior pituitary dysfunctions such as adrenocorticotropic hormone and/or thyroid-stimulating hormone deficiencies can be life-threatening without adequate hormone supplementation therapies. An endocrinological evaluation of the function of the pituitary gland should be performed at the initial diagnosis of ECD. It is important to recognize that endocrine dysfunctions can develop later during the follow-up of ECD.
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Tanitame K, Akagi C, Kamaki N. Disturbance of consciousness after postpartum hemorrhage. Eur J Intern Med 2020; 82:114-115. [PMID: 32980221 DOI: 10.1016/j.ejim.2020.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/20/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Keizo Tanitame
- Department of Diagnostic Radiology, Hiroshima Prefectural Hospital, 1-5-54 Ujinakanda, Minami-ku, Hiroshima, 734-8530, Japan.
| | - Chinatsu Akagi
- Department of Diagnostic Radiology, Hiroshima Prefectural Hospital, 1-5-54 Ujinakanda, Minami-ku, Hiroshima, 734-8530, Japan
| | - Nobuyuki Kamaki
- Department of Diagnostic Radiology, Hiroshima Prefectural Hospital, 1-5-54 Ujinakanda, Minami-ku, Hiroshima, 734-8530, Japan
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8
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Taniguchi J, Sugawara H, Yamada H, Yoshida K, Kurihara I, Yoshida M, Ishii A, Fukuchi T, Fujimoto WY. Adrenal crisis precipitated by influenza A led to the diagnosis of Sheehan's syndrome 18 years after postpartum hemorrhage. Clin Case Rep 2020; 8:3082-3087. [PMID: 33363885 PMCID: PMC7752366 DOI: 10.1002/ccr3.3355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/21/2020] [Accepted: 08/22/2020] [Indexed: 11/25/2022] Open
Abstract
Physicians must recognize and treat adrenal crisis that may occur with acute viral illnesses such as influenza in women with Sheehan's syndrome that has been undiagnosed and hence untreated, sometimes for many years, after postpartum hemorrhage.
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Affiliation(s)
- Jumpei Taniguchi
- Division of General MedicineDepartment of Comprehensive Medicine 1Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Hitoshi Sugawara
- Division of General MedicineDepartment of Comprehensive Medicine 1Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Hodaka Yamada
- Division of Endocrinology and MetabolismDepartment of Comprehensive Medicine 1Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Katsuyuki Yoshida
- Division of General MedicineDepartment of Comprehensive Medicine 1Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Ibuki Kurihara
- Division of General MedicineDepartment of Comprehensive Medicine 1Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Masashi Yoshida
- Division of Endocrinology and MetabolismDepartment of Comprehensive Medicine 1Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Akira Ishii
- Division of General MedicineDepartment of Comprehensive Medicine 1Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Takahiko Fukuchi
- Division of General MedicineDepartment of Comprehensive Medicine 1Saitama Medical CenterJichi Medical UniversitySaitamaJapan
| | - Wilfred Y. Fujimoto
- Division of General MedicineDepartment of Comprehensive Medicine 1Saitama Medical CenterJichi Medical UniversitySaitamaJapan
- Division of Metabolism, Endocrinology and NutritionUniversity of Washington School of MedicineSeattleWAUSA
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9
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Sethuram R, Guilfoil DS, Amori R, Kharlip J, Berkowitz KM. Sheehan Syndrome: An Unusual Presentation Without Inciting Factors. WOMEN'S HEALTH REPORTS 2020; 1:287-292. [PMID: 33786491 PMCID: PMC7784809 DOI: 10.1089/whr.2019.0028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 05/19/2020] [Indexed: 12/03/2022]
Abstract
Background: Sheehan syndrome (SS) is a rare complication of severe postpartum hemorrhage or hypotension during the processes of labor and delivery that results in ischemic pituitary infarction and necrosis. In this case report, we describe an unusual presentation of SS without inciting factors. Case Presentation: A 30-year-old multiparous woman presented 2 hours after a normal spontaneous vaginal delivery with a profound severe headache, and subsequent agalactia, dry skin, and mood changes. She was managed conservatively until 10 months postdelivery when she complained of persistent symptoms including amenorrhea. A brain magnetic resonance (MR) with pituitary imaging revealed findings consistent with SS. The patient's symptoms improved and ultimately resolved after levothyroxine, estrogen replacement therapy, and hydrocortisone were instituted. Conclusions: SS can present without recognized inciting factors. During the initial phase, women may present with profound headache and/or visual disturbances warranting neurological evaluation. A high index of suspicion and a brain MR with pituitary imaging should prompt early consideration of SS to aid in the diagnosis.
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Affiliation(s)
- Ramya Sethuram
- Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.,Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Daniel S Guilfoil
- Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Renee Amori
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Julia Kharlip
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karen M Berkowitz
- Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA.,Department of Biochemistry and Molecular Biology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
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10
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Mandal S, Mukhopadhyay P, Banerjee M, Ghosh S. Clinical, Endocrine, Metabolic Profile, and Bone Health in Sheehan's Syndrome. Indian J Endocrinol Metab 2020; 24:338-342. [PMID: 33088757 PMCID: PMC7540820 DOI: 10.4103/ijem.ijem_345_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/04/2020] [Accepted: 07/11/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Sheehan's syndrome (SS) occurs due to ischemic pituitary necrosis resulting from severe postpartum hemorrhage (PPH). SS is characterized by varying degrees of pituitary insufficiency involving mostly the anterior lobe. Comprehensive data on SS apart from endocrine dysfunction is scarcely available. MATERIALS AND METHODS Thirty-eight subjects previously diagnosed with SS were enrolled in this observational study. Their clinical, biochemical, hormonal, radiological data at presentation were recorded from past records and bone density was measured in all. RESULTS Mean (±SD) age was 39 (±8.7) years and diagnostic delay was 9.3 (±5.5) years. All had history of PPH and lactation failure. About 47% were referred from emergency, and rest 53% were diagnosed from outpatient's department. Mean free T4, TSH, prolactin, morning cortisol, FSH, LH, and IGF-1 were mostly low. Panhypopituitarism was present in 97%. Hyponatremia was most common electrolyte imbalance found in about 53%. More than 40% had elevated transaminases. Dyslipidemia especially low HDL was found in 31 (81.5%) subjects. MRI of hypothalamus-pituitary region showed empty sella in 53% and partial empty sella in 47%. About 13% subjects had diabetes mellitus. Low bone mass (BMD Z-Score ≤-1) was seen in 80% and it was more severe (BMD Z-Score ≤-2) in 44% subjects, affecting predominantly lumbar spine. Bone loss at femoral neck was less prominent. CONCLUSION Apart from variable spectrum of clinical presentation, subjects with SS have significant abnormalities in serum electrolytes, metabolic parameters. Low bone mass is also a frequent accompaniment.
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Affiliation(s)
- Soumita Mandal
- Department of Endocrinology, R. G. Kar Medical College, Kolkata, West Bengal, India
| | - Pradip Mukhopadhyay
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Mainak Banerjee
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
| | - Sujoy Ghosh
- Department of Endocrinology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
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11
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Tanaka S, Abe M, Kohno G, Kushimoto M, Ikeda J, Ogawa K, Suzuki Y, Ishihara H, Fujishiro M. A Single Episode of Hypoglycemia as a Possible Early Warning Sign of Adrenal Insufficiency. Ther Clin Risk Manag 2020; 16:147-153. [PMID: 32161465 PMCID: PMC7051808 DOI: 10.2147/tcrm.s238435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 02/11/2020] [Indexed: 01/08/2023] Open
Abstract
A 65-year-old woman without a history of diabetes mellitus was admitted for elective total knee arthroplasty for osteoarthrosis. There were no specific complaints except for knee flexion contractures, and the results of preoperative tests were unremarkable. On the day of surgery, the patient suffered from a hypoglycemic attack (52 mg/dL) after preoperative overnight fasting. A dextrose infusion immediately corrected the hypoglycemia, and a total knee arthroplasty was then performed. Although a hypoglycemic attack did not recur, further evaluation was required because of nausea that persisted after surgery. The morning serum cortisol level was 0.15 µg/dL with undetectable adrenocorticotropic hormone (ACTH), and the insulin-like growth factor-1 level was 9 ng/mL. An empty sella and bilateral adrenal atrophy were evident in imaging studies. ACTH and growth hormone (GH) did not respond to testing with corticotropin-releasing hormone and GH-releasing peptide-2, respectively. While serum cortisol did not increase on a rapid ACTH stimulation test, urinary free cortisol excretion responded to a prolonged ACTH stimulation test. Finally, the patient was diagnosed as having empty sella syndrome with ACTH and GH deficiencies. After the administration of hydrocortisone as maintenance replacement therapy, the patient's prolonged postoperative nausea disappeared. Adrenal insufficiency is latent in patients with hypoglycemia episodes. Because patients with adrenal insufficiency require appropriate perioperative corticosteroid supplementation, clinicians should give priority to identifying the underlying etiology of hypoglycemia over non-urgent elective surgery when these co-occur.
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Affiliation(s)
- Sho Tanaka
- Division of Nephrology, Hypertension, and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan.,Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan
| | - Masanori Abe
- Division of Nephrology, Hypertension, and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Genta Kohno
- Division of Diabetes and Metabolic Diseases, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masaru Kushimoto
- Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan
| | - Jin Ikeda
- Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan
| | - Katsuhiko Ogawa
- Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan.,Division of Neurology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yutaka Suzuki
- Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan.,Division of Neurology, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hisamitsu Ishihara
- Division of Diabetes and Metabolic Diseases, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Midori Fujishiro
- Department of Internal Medicine, Nihon University Hospital, Tokyo, Japan.,Division of Diabetes and Metabolic Diseases, Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan
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12
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de Sá Cavalcante D, da Silva Castro MG, Quidute ARP, Martins MRA, Cid AMPL, de Barros Silva PG, Cadwell Williams J, Neves FS, Ribeiro TR, Costa FWG. Evaluation of bone texture imaging parameters on panoramic radiographs of patients with Sheehan's syndrome: a STROBE-compliant case-control study. Osteoporos Int 2019; 30:2257-2269. [PMID: 31372710 DOI: 10.1007/s00198-019-05086-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 07/09/2019] [Indexed: 10/26/2022]
Abstract
UNLABELLED Sheehan's syndrome (SHS) is a rare condition related to the risk of osteoporosis and evaluation of bone texture imaging features on panoramic radiographs would be suitable for this condition, which was the aim of the present study. Fractal dimension, lacunarity, and trabecular morphologic aspects were significantly altered in these patients. INTRODUCTION SHS is an important public health problem particularly in developing countries. It is characterized as postpartum hypopituitarism secondary to obstetric complications-related ischemic pituitary necrosis that shows significant systemic metabolic repercussions. Thus, this study aimed to evaluate bone texture parameters in digital panoramic radiographs of patients with SHS. METHODS A case-control study was conducted with 30 SHS patients from an Endocrinology and Diabetology Service of reference in Brazil, and 30 age- and sex-matched healthy controls. A custom computer program measured fractal dimension, lacunarity, and some morphologic features in the following mandibular regions of interest (50 × 50 pixels): below the mental foramen (F1), between the first and second molars (M1), and at the center of the mandibular ramus (R1). RESULTS The fractal analysis showed a statistically significant difference between the studied groups in all regions of interest. The fractal dimension in F1 (p = 0.016), M1 (p = 0.043), and R1 (p = 0.028) was significantly lower in SHS group, as well as lacunarity in R1 (p = 0.008). Additionally, several morphologic features were statistically significant in the SHS group (p < 0.05). CONCLUSION Therefore, individuals with SHS showed altered imaging texture parameters on panoramic radiographs, which reflect a smaller spatial organization of the bone trabeculae and, possibly, a state of reduced mineral bone density.
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Affiliation(s)
- D de Sá Cavalcante
- Department of Clinical Dentistry, Postgraduate Program in Dentistry, Federal University of Ceará, Alexandre Baraúna St 949, Rodolfo Teofilo, Fortaleza, Ceará, 60430-160, Brazil
| | - M G da Silva Castro
- Realistic Simulation Center, Univeristy Center UNICHRISTUS, R. João Adolfo Gurgel St 133, Cocó, Fortaleza, Ceará, 60190-060, Brazil
| | - A R P Quidute
- Division of Endocrinology and Diabetology, Walter Cantídio University Hospital, Alexandre Baraúna St 949, Rodolfo Teofilo, Fortaleza, Ceará, 60430-160, Brazil
| | - M R A Martins
- Division of Endocrinology and Diabetology, Walter Cantídio University Hospital, Alexandre Baraúna St 949, Rodolfo Teofilo, Fortaleza, Ceará, 60430-160, Brazil
| | - A M P L Cid
- Department of Clinical Dentistry, Postgraduate Program in Dentistry, Federal University of Ceará, Alexandre Baraúna St 949, Rodolfo Teofilo, Fortaleza, Ceará, 60430-160, Brazil
| | - P G de Barros Silva
- Department of Clinical Dentistry, Postgraduate Program in Dentistry, Federal University of Ceará, Alexandre Baraúna St 949, Rodolfo Teofilo, Fortaleza, Ceará, 60430-160, Brazil
| | - J Cadwell Williams
- Department of Anatomy and Cell Biology, Indiana School of Medicine, 635 Barnhill Dr, Indianapolis, IN, 46202, USA
| | - F S Neves
- Division of Oral Radiology, School of Dentistry, Federal University of Bahia, Araújo Pinho ave 62, Canela, Salvador, Bahia, 40110-040, Brazil
| | - T R Ribeiro
- Department of Clinical Dentistry, Postgraduate Program in Dentistry, Federal University of Ceará, Alexandre Baraúna St 949, Rodolfo Teofilo, Fortaleza, Ceará, 60430-160, Brazil
| | - F W G Costa
- Department of Clinical Dentistry, Postgraduate Program in Dentistry, Federal University of Ceará, Alexandre Baraúna St 949, Rodolfo Teofilo, Fortaleza, Ceará, 60430-160, Brazil.
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Düğeroğlu H, Karakaş A. MULTIFACETED EVALUATION OF 72 PATIENTS WITH PITUITARY FAILURE. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2018; 14:539-548. [PMID: 31149310 PMCID: PMC6516405 DOI: 10.4183/aeb.2018.539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE We aimed to reach a diagnosis for patients with pituitary failure (PF) with more detailed multifaceted examination, to obtain new gains in this way and to apply this experience to our future patients. PATIENTS AND METHOD The study included 72 patients with pituitary failure diagnosis. Patients were divided into two groups of 32 female patients with Sheehan syndrome (SS) and 40 non-Sheehan syndrome patients (20 female and 20 male). RESULTS The mean age of the 32 patients with Sheehan syndrome was 56.1±11.7 years with mean disease duration 20.3±8.3 years and mean age at disease onset 34.3±7.6 years. For the 40 non-SS pituitary failure patients mean age was 46.5±16.6 years, mean disease duration was 4.7±5.1 years and mean age at disease onset was 41.8±18.2 years. The prolactin response (PRL) on the TRH test was found to be significantly lower in SS patients compared to non-SS patients(p<0.05). Both patient groups had low basal pituitary hormones, with mean PRL level in SS patients 4.9±4.0 ng/mL which was significantly low compared to non-SS patients with 36.8±84.7 ng/mL(p=0.022). CONCLUSION Pituitary failure patients may present with a broad range of clinical symptoms and findings. Early diagnosis and timely replacement treatment have vital importance for SS patients.
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Affiliation(s)
- H. Düğeroğlu
- Ordu University, Faculty of Medicine, Training and Research Hospital, Department of Internal Medicine, Ordu, Turkey
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Cavalcante DDS, Pinto-Quidute AR, Alves-Martins MR, Walter-de-Aguiar AS, Lima-Cid AMP, Silva PGB, Cavalcante RF, Costa FWG. Dental status, salivary flow, and sociodemographic aspects in Sheehan Syndrome patients. Med Oral Patol Oral Cir Bucal 2018; 23:e436-e442. [PMID: 29924763 PMCID: PMC6051684 DOI: 10.4317/medoral.22377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/25/2018] [Indexed: 11/17/2022] Open
Abstract
Background Sheehan’s syndrome (SS) is one of the leading causes of hypopituitarism in developing countries. It occurs after postpartum necrosis of the pituitary gland, and it is considered a significant public health problem. This paper, apparently unpublished, aimed to perform an analysis on oral aspects in patients with SS. Material and Methods A cross-sectional study was performed with 23 women diagnosed with SS at the Division of Endocrinology and Diabetes (Walter Cantídio University Hospital, Fortaleza, Brazil). Results Data on sociodemographic, dental and salivary flow aspects were collected through a clinical approach and a panoramic radiograph request. The mean age was 64 ± 11.5 years old, with the sample consisting mainly of married women (56.5%), socioeconomic class C2 or D / E (78.2%) and years of education up to 8 years (69.5%). The presence of horizontal bone loss (p<0.001) and bilateral pneumatization of the maxillary sinus (p=0.015) were significant data. The mean number of absent teeth considering all subjects was 23.17±9.7, being statistically significant (p<0.001). In relation to age, the mean number of missing teeth was higher in individuals over 65 years old (p=0.048). Reduced salivary flow was observed in 78.3% of the patients. In a bivariate analysis, considering the outcome variables “missing teeth” and “reduced salivary flow”, it was observed that economic class (p<
0.001), family income (0.037) and maxillary sinus pneumatization (0.032) were statistically significant. Conclusions In brief, patients with SS showed severe teeth loss, reduced salivary flow, and low educational status. This study addressed important aspects regarding oral findings in SS and highlighted the importance of researches in oral medicine. Key words:Sheehan’s Syndrome, hypopituitarism, tooth loss, salivary flow.
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Affiliation(s)
- D-D-S Cavalcante
- Alexandre Barauna, 949 Rodolfo Teofilo, 60430-160 Fortaleza, Ceara, Brazil, Federal University of Ceara, Department of Clinical Dentistry, School of Dentistry,
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Shinde SD, Sabnis GR, Lanjewar CP, Kerkar PG. A rare endocrine cause of electrical storm - a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2017; 1:ytx008. [PMID: 31020067 PMCID: PMC6176984 DOI: 10.1093/ehjcr/ytx008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/18/2017] [Accepted: 10/04/2017] [Indexed: 11/30/2022]
Abstract
Sheehan’s syndrome, also called Simmond’s syndrome, postpartum apoplexy, postpartum pituitary necrosis, and postpartum panhypopituitary syndrome, is the name given to postpartum hypopituitarism. The syndrome is caused by an infarction in the adenohypophysis, usually precipitated by massive uterine haemorrhage and hypovolemic shock during or after childbirth. Extensive destruction of pituitary cells results in varying degree of hypopituitarism. Acute loss of adenohypophysis function can be fatal without glucocorticoid and thyroid replacement therapy and survivors will require life time hormonal replacement therapy. Most cases present in the postpartum period with lactation failure or after months to years after the delivery. In many affected women, anterior pituitary dysfunction is not diagnosed for many years. Dyselectrolytemia is one of a common presentation in Sheehan’s syndrome. Herein, we report a case of a 35-year old female with a history of obstetric hysterectomy 2 years ago in view of severe postpartum haemorrhage with history of failure of lactation and three episodes of syncope since last 1½ years and now presented with polymorphic ventricular tachycardia which required DC cardioversion. She was referred as a case of long QT syndrome. On investigating further, she had hypokalaemia secondary to hypopituitarism due to Sheehan’s syndrome.
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Affiliation(s)
- Sunny D Shinde
- Department of Cardiology, Seth G S Medical College and King Edward VII Memorial Medical College, Acharya Donde Marg, Parel, Mumbai 400012, India
| | - Girish R Sabnis
- Department of Cardiology, Seth G S Medical College and King Edward VII Memorial Medical College, Acharya Donde Marg, Parel, Mumbai 400012, India
| | - Charan P Lanjewar
- Department of Cardiology, Seth G S Medical College and King Edward VII Memorial Medical College, Acharya Donde Marg, Parel, Mumbai 400012, India
| | - Prafulla G Kerkar
- Department of Cardiology, Seth G S Medical College and King Edward VII Memorial Medical College, Acharya Donde Marg, Parel, Mumbai 400012, India
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Horie S, Nomura K, Takenoshita S, Nakagawa J, Kido M, Sugimoto M. A relationship between a level of hemoglobin after delivery and exclusive breastfeeding initiation at a baby friendly hospital in Japan. Environ Health Prev Med 2017; 22:40. [PMID: 29165138 PMCID: PMC5664824 DOI: 10.1186/s12199-017-0650-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 04/05/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The recent National Nutrition Survey of 2013 demonstrated that 16.7% of women in childbearing age are underweight, and 5.0-10.0% of these women manifested a Hemoglobin (Hb) level less than 11.0 g/dl. The purpose of this study was to investigate if such maternal nutritional status affects success of exclusive breastfeeding (EBF) practice. METHODS This cross-sectional study investigated 1532 dyads of mothers and infants with full-term singleton pregnancies delivered during 2011 at a perinatal center in Tokyo. Outcome is EBF initiation defined as the successful practice at discharge and 1 month after discharge. A logistic regression model was applied to investigate the impact of Hb levels (<9.0, 9.0-10.9, and ≥11.0 g/dl) measured within 2-3 days after delivery on successful EBF initiation adjusting for covariates including bleeding at delivery. RESULTS Mean age was 34 years, 23.0% were underweight and 63.0% were nulliparous. The success rate for EBF initiation at discharge and at 1 month after discharge was 72.7 and 63.0% for a Hb level <9.0 g/dl, 81.9 and 68.9% for a Hb level of 9.0-10.9 g/dl, and 85.7 and 75.9% for a Hb level ≥11.0 g/dl, respectively. A logistic regression model showed that risk factors of unsuccessful EBF practice at discharge and 1 month after discharge included lower level Hb categories (P < 0.001 and P < 0.001), postpartum hemorrhage > 500 ml (P = 0.089 and P = 0.011), maternal age (P < 0.001 and P < 0.001), nulliparity (P < 0.0001 and P < 0.001), pregnancy-induced hypertension (P = 0.002 and P = 0.012), gestational week (P = 0.006 and P = 0.002), Low Birth Weight (LBW) (P < 0.001 and P < 0.001), and immediate separation (P < 0.001 and P = 0.020). After adjusting for the covariates, compared with a Hb level ≥11.0 g/dl, a Hb level <9.0 g/dl was significantly associated with unsuccessful EBF initiation at discharge [odds ratio (OR): 2.15; 95% confidence interval (CI): 1.37-3.39] and at 1 month after discharge (OR: 1.63; 95% CI: 1.10-2.42), and a Hb level of 9.0-10.9 g/dl also was significant at 1 month after discharge (OR: 1.35; 95% CI: 1.04-1.75). Pre-pregnancy underweight was not associated with success of EBF practice both at hospital discharge and 1 month after discharge. CONCLUSION Maternal severe anemia after delivery was associated with the risk of unsuccessful initiation of EBF even after adjusting for bleeding at delivery, suggesting the importance of dietary management especially in the later trimester.
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Affiliation(s)
- Saki Horie
- Teikyo University Graduate School of Public Health, Tokyo, Japan.,National Institute of Health and Nutrition, Tokyo, Japan
| | - Kyoko Nomura
- Department of Hygiene and Public Health, School of Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Zip 173-8605, Tokyo, Japan.
| | - Shinichi Takenoshita
- Department of Hygiene and Public Health, School of Medicine, Teikyo University, 2-11-1 Kaga, Itabashi-ku, Zip 173-8605, Tokyo, Japan
| | - Junko Nakagawa
- Department of Obstetrics and Gynecology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Michiko Kido
- Department of Obstetrics and Gynecology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Mitsuhiro Sugimoto
- Department of Obstetrics and Gynecology, Tohto Bunkyo Hospital, Tokyo, Japan
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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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Laway B, Misgar R, Mir S, Wani A. Clinical, hormonal and radiological features of partial Sheehan's syndrome: an Indian experience. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2016; 60:125-9. [PMID: 26886088 DOI: 10.1590/2359-3997000000137] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 11/01/2015] [Indexed: 11/22/2022]
Abstract
Objective The objective of this study was to describe clinical presentation, hormonal profile and imaging characteristics of 21 patients with partial Sheehan's syndrome. Subjects and methods This prospective study was carried out over a period of six years (2008-2013). The evaluation of patients included clinical assessment, hormone estimations and contrast enhanced magnetic resonance imaging of pituitary. Results We documented preservation of gonadotroph, corticotroph and lactotroph function in 71.4, 61.9, and 9.5% of patients respectively. Conclusion To conclude some of the pituitary functions can be preserved in Sheehan's syndrome and this has important implications from the treatment and long term morbidity point of view.
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Affiliation(s)
- Bashir Laway
- Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Raiz Misgar
- Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | | | - Arshad Wani
- Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
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Lim CH, Han JH, Jin J, Yu JE, Chung JO, Cho DH, Chung DJ, Chung MY. Electrolyte Imbalance in Patients with Sheehan's Syndrome. Endocrinol Metab (Seoul) 2015; 30:502-8. [PMID: 26485467 PMCID: PMC4722405 DOI: 10.3803/enm.2015.30.4.502] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 07/29/2015] [Accepted: 08/24/2015] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND We investigated the prevalence of electrolyte imbalance and the relationship between serum electrolyte and anterior pituitary hormone levels in patients with Sheehan's syndrome. METHODS In a retrospective study, we investigated 78 patients with Sheehan's syndrome. We also included 95 normal control subjects who underwent a combined anterior pituitary hormone stimulation test and showed normal hormonal responses. RESULTS In patients with Sheehan's syndrome, the serum levels of sodium, potassium, ionized calcium, magnesium, and inorganic phosphate were significantly lower than those in control subjects. The prevalence of hyponatremia, hypokalemia, hypocalcemia, hypomagnesemia, and hypophosphatemia in patients with Sheehan's syndrome was 59.0% (n=46), 26.9% (n=21), 35.9% (n=28), 47.4% (n=37), and 23.1% (n=18), respectively. Levels of sodium and ionized calcium in serum were positively correlated with levels of all anterior pituitary hormones (all P<0.05). Levels of potassium in serum were positively correlated with adrenocorticotrophic hormone (ACTH) and growth hormone (GH) levels (all P<0.05). Levels of inorganic phosphate in serum were positively correlated with levels of thyroid-stimulating hormone, prolactin, and GH (all P<0.05), and levels of magnesium in serum were positively correlated with delta ACTH (P<0.01). CONCLUSION Electrolyte imbalance was common in patients with Sheehan's syndrome. Furthermore, the degree of anterior pituitary hormone deficiency relates to the degree of electrolyte disturbance in patients with this disease.
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Affiliation(s)
- Chur Hoan Lim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Ji Hyun Han
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Joon Jin
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Ji Eun Yu
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jin Ook Chung
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea.
| | - Dong Hyeok Cho
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Dong Jin Chung
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Min Young Chung
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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Abuzaid AS, Birch N. The Controversies of Hyponatraemia in Hypothyroidism: Weighing the evidence. Sultan Qaboos Univ Med J 2015; 15:e207-e212. [PMID: 26052453 PMCID: PMC4450783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 08/13/2014] [Accepted: 10/23/2014] [Indexed: 06/04/2023] Open
Abstract
Hyponatraemia is a common electrolyte disturbance, with moderate (serum sodium: 125-129 mmol/L) to severe (serum sodium: ≤125 mmol/L) forms of the disease occurring in 4-15% of hospitalised patients. While it is relatively common, determining the underlying cause of this condition can be challenging and may require extensive laboratory investigations. To this end, it is important to ascertain the efficacy of laboratory tests in determining the cause of hyponatraemia. Up to 10% of patients with hypothyroidism also have hyponatraemia. Routine evaluation of thyroid function is often advocated in cases of low serum sodium. A review and discussion of the available literature is presented here to examine this recommendation.
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Affiliation(s)
- Ahmed S. Abuzaid
- Department of Internal Medicine, Creighton University, Omaha, Nebraska, USA
| | - Nathan Birch
- Department of Internal Medicine, Nebraska-Western Iowa Health Care System, Omaha, Nebraska, USA
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21
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Ocular findings in Sheehan’s syndrome. Graefes Arch Clin Exp Ophthalmol 2015; 253:759-63. [DOI: 10.1007/s00417-014-2916-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Revised: 12/07/2014] [Accepted: 12/22/2014] [Indexed: 10/24/2022] Open
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Diri H, Tanriverdi F, Karaca Z, Senol S, Unluhizarci K, Durak AC, Atmaca H, Kelestimur F. Extensive investigation of 114 patients with Sheehan's syndrome: a continuing disorder. Eur J Endocrinol 2014; 171:311-8. [PMID: 24917653 DOI: 10.1530/eje-14-0244] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Sheehan's syndrome (SS) is a well-known cause of hypopituitarism resulting from postpartum pituitary necrosis. Because of its rarity in Western society, its diagnosis is often overlooked. We aimed to investigate the clinical, laboratory, and radiological aspects of SS in a large number of patients. STUDY DESIGN A retrospective assessment of the medical records of 114 patients with SS was conducted. In addition, sella turcica volumes of 29 healthy women were compared with those of patients by magnetic resonance imaging examinations. RESULTS The mean period of diagnostic delay was 19.7 years in patients with SS. It was found that 52.6% of patients had nonspecific complaints, 30.7% had complaints related to adrenal insufficiency, and 9.6% had complaints related to hypogonadism when diagnosed. At the time of diagnosis, 55.3% of the patients had panhypopituitarism, while 44.7% had partial hypopituitarism. The number of deficient hormones was found to be increased over the years. None of the patients whose basal prolactin was below 4.0 ng/ml had adequate prolactin responses to TRH test, while all patients whose basal prolactin was above 7.8 ng/ml had adequate responses. Mean sella volume was found to be significantly lower in the SS group (340.5±214 mm(3)) than that in the healthy group (602.5±192 mm(3)). CONCLUSIONS SS is a common cause of hypopituitarism in underdeveloped and developing countries. The main reasons for diagnostic delay seem to be the high frequency of patients with nonspecific complaints and neglect of SS. In addition, the TRH stimulation test was found to have a high sensitivity and specificity to recognize PRL deficiency. Furthermore, small sella size may have an important contributing role in the etiopathogenesis of SS.
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Affiliation(s)
- Halit Diri
- Departments of EndocrinologyRadiologyErciyes University Medical School, 38039 Kayseri, TurkeyDepartment of EndocrinologyOndokuz Mayis University Medical School, Samsun, Turkey
| | - Fatih Tanriverdi
- Departments of EndocrinologyRadiologyErciyes University Medical School, 38039 Kayseri, TurkeyDepartment of EndocrinologyOndokuz Mayis University Medical School, Samsun, Turkey
| | - Zuleyha Karaca
- Departments of EndocrinologyRadiologyErciyes University Medical School, 38039 Kayseri, TurkeyDepartment of EndocrinologyOndokuz Mayis University Medical School, Samsun, Turkey
| | - Serkan Senol
- Departments of EndocrinologyRadiologyErciyes University Medical School, 38039 Kayseri, TurkeyDepartment of EndocrinologyOndokuz Mayis University Medical School, Samsun, Turkey
| | - Kursad Unluhizarci
- Departments of EndocrinologyRadiologyErciyes University Medical School, 38039 Kayseri, TurkeyDepartment of EndocrinologyOndokuz Mayis University Medical School, Samsun, Turkey
| | - Ahmet Candan Durak
- Departments of EndocrinologyRadiologyErciyes University Medical School, 38039 Kayseri, TurkeyDepartment of EndocrinologyOndokuz Mayis University Medical School, Samsun, Turkey
| | - Hulusi Atmaca
- Departments of EndocrinologyRadiologyErciyes University Medical School, 38039 Kayseri, TurkeyDepartment of EndocrinologyOndokuz Mayis University Medical School, Samsun, Turkey
| | - Fahrettin Kelestimur
- Departments of EndocrinologyRadiologyErciyes University Medical School, 38039 Kayseri, TurkeyDepartment of EndocrinologyOndokuz Mayis University Medical School, Samsun, Turkey
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Abstract
INTRODUCTION The number of studies concerning bone mineral density (BMD) in patients with Sheehan's syndrome (SS) are scarce. We aimed to investigate the relationship between BMD and deficient hormones in patients with newly diagnosed SS. MATERIAL AND METHODS Thirty-four patients with SS and age-gender-weight matched 22 controls were included in the study. RESULTS We found osteoporosis in 61.8%, osteopenia in 32.3%, and normal dual energy X-ray absorptiometry (DEXA) findings in 5.9% patients. In the control group, 68.2% of individuals were osteopenic and 31.8% of them were normal. The number of osteoporotic patients was found to be higher and BMD values were lower in the patient group compared with the control group. There was no relation of DEXA measurements with the period between the last delivery and the initial diagnosis and the estradiol levels. While there was no relation between insulin-like growth factor 1 (IGF-1) and T and Z scores of femur head, the relation between the IGF-1 and L1-L4 T scores was statistically significant. There was a significant relation between the IGF-1 and L1-L4 Z scores. CONCLUSIONS SS patients should also be assessed in terms of osteoporosis at the time of diagnosis and then proper treatment should be initiated afterwards.
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Affiliation(s)
- Fettah Acibucu
- Department of Endocrinology, Sivas Numune Hospital , Sivas , Turkey
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Ikeuchi M, Izumi M, Ikemoto T, Tani T. Flexion contractures of the legs as the manifestation of secondary adrenal insufficiency due to Sheehan's syndrome. J Orthop Sci 2014; 19:502-6. [PMID: 22996815 DOI: 10.1007/s00776-012-0310-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 08/24/2012] [Indexed: 11/27/2022]
Affiliation(s)
- Masahiko Ikeuchi
- Department of Orthopaedic Surgery, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan,
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Abstract
Severe postpartum hemorrhage (PPH) can be defined as a blood loss of more than 1500 mL to 2500 mL. While rare, severe PPH is a significant contributor to maternal mortality and morbidity in the United States and throughout the world. Due to the maternal hematologic adaptation to pregnancy, the hypovolemia resulting from hemorrhage can be asymptomatic until a large amount of blood is lost. Rapid replacement of lost fluids can mitigate effects of severe hemorrhage. Current evidence on postpartum volume replacement suggests that crystalloid fluids should be used only until the amount of blood loss becomes severe. Once a woman displays signs of hypovolemia, blood products including packed red blood cells, fresh frozen plasma, platelets, and recombinant factor VIIa should be used for volume replacement. Overuse of crystalloid fluids increases the risk for acute coagulopathy and third spacing of fluids. A massive transfusion protocol is one mechanism to provide a rapid, consistent, and evidence-based team response to this life-threatening condition.
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Mathur D, Lim LFM, Mathur M, Sng BL. Pituitary apoplexy with reversible cerebral vasoconstrictive syndrome after spinal anaesthesia for emergency caesarean section: an uncommon cause for postpartum headache. Anaesth Intensive Care 2014; 42:99-105. [PMID: 24471671 DOI: 10.1177/0310057x1404200118] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pituitary apoplexy is a rare condition involving pituitary necrosis following either pituitary haemorrhage or infarction. Similarly, reversible cerebral vasoconstrictive syndrome is a cerebrovascular disorder characterised by diffuse, multifocal narrowing of cerebral arteries. Both may present with an acute, intense headache and associated neurological deficits. In postpartum women, these conditions should be considered in the differential diagnosis of post-dural puncture headache following regional anaesthesia, as serious morbidity may ensue if they are left untreated. We report the case of a patient who developed pituitary apoplexy during an emergency caesarean section under spinal anaesthesia. It was further complicated by the development of reversible cerebral vasoconstriction syndrome and stroke.
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Affiliation(s)
- D Mathur
- Department of Women's Anaesthesia, KK Women's and Children's Hospital, Singapore
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Manaka K, Makita N, Iiri T. Erdheim-Chester disease and pituitary involvement: a unique case and the literature. Endocr J 2014; 61:185-94. [PMID: 24304810 DOI: 10.1507/endocrj.ej13-0419] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
An early thirties man diagnosed with Erdheim-Chester disease (ECD) was simultaneously disclosed to have hypogonadotropic hypogonadism, central adrenal insufficiency, and GH deficiency in addition to central diabetes insipidus (CDI). Pituitary magnetic resonance imaging (MRI) showed swelling in the stalk, enlargement of the anterior lobe with delayed enhancement, and loss of high intensity of the posterior lobe on T1-weighted images, suggesting of pituitary involvement of ECD. Three months after starting treatment with interferon α and zoledronic acid, polyuria and polydipsia were ameliorated without DDAVP, accompanied with improvement of MRI. Simultaneously technetium-99m bone scintigraphy showed improvement, accompanied with a relief of bone pain and high fever. In contrast, he developed secondary hypothyroidism with slight enlargement of anterior pituitary gland without relapse of CDI, suggesting of different responses to treatment with interferon α between anterior pituitary lobe and posterior one. So far he continues to be replaced with deficient hormone replacement therapy. As for bone pain, it remains to be controlled with the decreased levels of bone resorption marker with decreased abnormal uptake in bone scintigraphy although zoledronic acid was discontinued for osteonecrosis of the jaw. For four years, he has not showed new involvement at other organs besides bones and the pituitary. While CDI is known to be very common in ECD, improvement of CDI has been reported in a few cases. Other endocrine manifestations, especially with detailed endocrine status, have been also reported in limited cases. Thus we report this case and review the literature.
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Affiliation(s)
- Katsunori Manaka
- Department of Endocrinology and Nephrology, The University of Tokyo School of Medicine, Tokyo 113-8655 Japan
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Sasaki S, Fujisawa I, Ishihara T, Tahara Y, Kazuma M, Fujiwara Y, Iwakura T, Hino M, Matsuoka N. A novel hook-shaped enhancement on contrast-enhanced sagittal magnetic resonance image in acute Sheehan's syndrome: a case report. Endocr J 2014; 61:71-6. [PMID: 24162077 DOI: 10.1507/endocrj.ej13-0280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We report characteristic magnetic resonance (MR) image findings in a case of Sheehan's syndrome. A 37-year-old woman experienced complications of retained placenta and massive bleeding (3600 g) during delivery of a full-term baby. A pituitary function test demonstrated panhypopituitarism. MR image of the pituitary gland on postpartum day 10 revealed swelling of the anterior lobe. A hook-shaped enhancement was demonstrated on a sagittal image. The pituitary stalk, majority of the marginal zone of the anterior lobe, the anterior lobe just in front of the posterior lobe, and posterior lobe were well enhanced. In contrast, the central portion and the superior margin, just in front of the stalk insertion of the anterior lobe, were not enhanced. Anatomically, blood supply to these unenhanced portions of the anterior lobe was via the hypophyseal long portal vein and trabecular artery, which are tributaries of the superior hypophyseal artery that originate far from the internal carotid artery. Based on clinical history and MR image findings, the patient was diagnosed with Sheehan's syndrome and treated with hydrocortisone and levothyroxine. Follow-up MR image revealed marked atrophy of the anterior lobe. The characteristic hook-shaped enhancement in Sheehan's syndrome well reflected the vulnerability to massive bleeding based on the complex pituitary vasculature, which has not been reported previously. MR image with contrast enhancement is useful in the diagnosis of the acute phase of Sheehan's syndrome and in evaluating infarction of the anterior lobe.
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Affiliation(s)
- Sho Sasaki
- Department of Endocrinology and Diabetes, Kobe City Medical Center General Hospital, Kobe 650-0047, Japan
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Ramiandrasoa C, Castinetti F, Raingeard I, Fenichel P, Chabre O, Brue T, Courbière B. Delayed diagnosis of Sheehan's syndrome in a developed country: a retrospective cohort study. Eur J Endocrinol 2013; 169:431-8. [PMID: 23864341 DOI: 10.1530/eje-13-0279] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Little is known about Sheehan's syndrome (SS), even though it is believed that its incidence is low. The aims of this study were to determine the clinical features and diagnostic delay of SS and to ascertain whether early signs could have allowed earlier diagnosis. SUBJECTS AND METHODS All patients with SS diagnosed in reference units in the southeast of France between 1980 and 2011 were recruited for this study. Data on obstetrical history, clinical symptoms suggestive of hypopituitarism, early signs, hormone analysis, and magnetic resonance imaging were collected. RESULTS Of the 40 women found to have SS, 39 were studied. Mean delay in the diagnosis of SS was 9 ± 9.7 years. We found that four of the 35 assessable patients were diagnosed with agalactia, 16 of the 29 assessable ones with amenorrhea, 19 of the 39 with hypothyroidism, eight with acute adrenal insufficiency, and 15 with asthenia. Among the patients for whom there was a diagnostic delay of more than 1 year (n=28), seven had headaches during the postpartum period, all assessable patients had agalactia, six of the 22 assessable ones had amenorrhea, seven of 28 had hypothyroidism, and 12 of 28 had asthenia. CONCLUSION Most signs of SS are aspecific and classical signs such as agalactia and amenorrhea are often difficult to detect, which can explain the long diagnostic delay. We suggest that all women failing to lactate after postpartum hemorrhage (PPH) should be evaluated by measuring prolactin levels and women with signs such as amenorrhea and asthenia, even several years after PPH, should undergo a blood test including assessment of thyroxine, TSH, 0800 h ACTH-cortisol, and IGF1 levels.
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Affiliation(s)
- Cynthia Ramiandrasoa
- Department of Gynaecology, Obstetrics and Reproduction, AP-HM La Conception, 147 boulevard Baille, 13005 Marseille, France
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Soresi M, Brunori G, Citarrella R, Banco A, Zasa A, Di Bella G, Giannitrapani L. Late-onset Sheehan's syndrome presenting with rhabdomyolysis and hyponatremia: a case report. J Med Case Rep 2013; 7:227. [PMID: 24083446 PMCID: PMC3843569 DOI: 10.1186/1752-1947-7-227] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 06/20/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Hyponatremia associated with rhabdomyolysis is a rare event and a correct diagnostic approach is required to rule out this or other diseases as a primary cause and to avoid other complications resulting from a lack of appropriate treatment. CASE PRESENTATION A 64-year-old Caucasian woman presented to our facility with worsening fatigue, slurred speech, nausea and vomiting, and high serum levels of creatine kinase and myoglobin together with hyponatremia. Normal arterial blood gas analysis results, normal serum potassium levels, increased urine sodium levels, urine specific gravity of >1003N/m3 and low urine volume suggested an endocrine etiology. Her low cortisol and thyroid hormone serum levels suggested a pituitary disorder. A magnetic resonance imaging study showed atrophy of her pituitary gland. A more detailed study of our patient's obstetric history revealed a post-partum hemorrhage 30 years earlier. She was diagnosed as having late-onset Sheehan's syndrome and treated with hormone replacement therapy, which normalized her clinical picture. CONCLUSIONS This case report shows that, in hyponatremia-associated rhabdomyolysis, an endocrinological origin should always be considered. This should include Sheehan's syndrome as it can occur with late onset.
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Affiliation(s)
- Maurizio Soresi
- Internal Medicine Unit, Biomedical Department of Internal Medicine and Subspecialties (DIBIMIS), University of Palermo, Palermo, Italy.
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Matsuwaki T, Khan KN, Inoue T, Yoshida A, Masuzaki H. Evaluation of obstetrical factors related to Sheehan syndrome. J Obstet Gynaecol Res 2013; 40:46-52. [PMID: 23945005 DOI: 10.1111/jog.12119] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 03/04/2013] [Indexed: 11/28/2022]
Abstract
AIM To evaluate factors related to the occurrence of Sheehan syndrome. METHODS The obstetrical disseminated intravascular coagulation score, total volume of hemorrhage, shock index, level of consciousness at the time of shock occurrence and pituitary magnetic resonance imaging findings were evaluated in nine women who showed massive hemorrhage during delivery. These clinical outcomes were analyzed in all these patients who were prospectively followed-up to identify any possible occurrence of Sheehan syndrome. RESULTS Compared to six women with non-Sheehan syndrome, three women who were diagnosed with Sheehan syndrome showed significant elevation of the obstetrical disseminated intravascular coagulation score, decrease in the level of consciousness during shock and remarkable pituitary gland atrophic change with an empty sella turcica detected by pituitary magnetic resonance imaging. The volume of hemorrhage during delivery and shock index were not significantly different between these two groups of women. CONCLUSION Careful attention and follow-up should be paid to women with post-partum massive hemorrhage for early detection and management of women with Sheehan syndrome.
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Affiliation(s)
- Takahiro Matsuwaki
- Department of Obstetrics and Gynecology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Sanyal D, Raychaudhuri M. Varied presentations of Sheehan's syndrome at diagnosis: A review of 18 patients. Indian J Endocrinol Metab 2012; 16:S300-1. [PMID: 23565406 PMCID: PMC3603054 DOI: 10.4103/2230-8210.104067] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Sheehan's syndrome (SS) occurs due to ischemic pituitary necrosis as a result of severe postpartum hemorrhage (PPH). AIMS AND OBJECTIVES The aim of the present study was to review the presenting features of SS at diagnosis. MATERIALS AND METHODS We retrospectively reviewed 18 cases of SS at diagnosis. Presenting clinical features, laboratory data, pituitary hormone deficiencies, and magnetic resonance imaging (MRI) of the sella were analyzed. RESULTS Age ranged from 28-71 years with a mean age of 47 ± 14.44 years. Time to diagnosis of SS was 6-33 years with a mean of 15.35 ± 6.74 years. Four (22.2%) patients were referred from emergency for hyponatremia, one each (5.6%) for hypotension, hypoglycemia, and vomiting. Three (16.7%) patients presented with asthenia and weight loss, two (11.1%) with slightly raised thyroid stimulating hormone (TSH). Only six (33.3%) presented with classic features of amenorrhea. None presented with isolated lactational failure or apoplexy after PPH. Seventeen (94.4%) patients had lactational failure; thirteen (72.2%) did not menstruate following last delivery. Lactotroph and gonadotroph failure were present in all at diagnosis but corticotrophs preservation was documented in three (16.7%) and thyrotroph in two (11.1%) patients. Twelve (66.7%) patients had empty sella while six (33.3%) had partial empty sella on MRI. CONCLUSION SS has variable features at diagnosis and may present to different specialties. The clinical features of hypopituitarism are often subtle, leading to delay in diagnosis. History of PPH, lactational failure and cessation of menses are important clues. Thyrotroph, corticotroph axis may be preserved in some SS patients.
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Affiliation(s)
- Delmalya Sanyal
- Department of Endocrinology, KPC Medical College and Consultant Endocrinologist, Kolkata, India
| | - Moutusi Raychaudhuri
- Institute of Child Health and Consultant Endocrinologist, Rabindranath Tagore International Institute, Kolkata, India
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Robalo R, Pedroso C, Agapito A, Borges A. Acute Sheehan's syndrome presenting as central diabetes insipidus. BMJ Case Rep 2012; 2012:bcr-2012-007022. [PMID: 23131607 DOI: 10.1136/bcr-2012-007022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Sheehan's syndrome occurs as a result of ischaemic pituitary necrosis due to severe postpartum haemorrhage. Improvements in obstetrical care have significantly reduced its incidence in developed countries, but postpartum pituitary infarction remains a common cause of hypopituitarism in developing countries. We report a case of severe postpartum haemorrhage followed by headache, central diabetes insipidus and failure to lactate, which prompted us to investigate and identify both anterior and posterior pituitary deficiency compatible with Sheehan's syndrome. A timely diagnosis allowed us to implement an adequate treatment and follow-up plan, which are known to improve clinical status and patient outcome.
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Affiliation(s)
- Raquel Robalo
- Department of Maternal and Fetal Medicine, Maternidade Alfredo da Costa, Centro Hospitalar Lisboa Central, Lisboa, Portugal.
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The Symptoms Get Worse after Pregnancy in Sheehan's Syndrome: A Case Report. Case Rep Med 2012; 2012:271345. [PMID: 23049563 PMCID: PMC3461311 DOI: 10.1155/2012/271345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 08/22/2012] [Indexed: 11/17/2022] Open
Abstract
Sheehan's syndrome, which is pituitary necrosis after severe postpartum hemorrhage and hypovolemia, may cause hypopituitarism immediately or several years later, depending on the degree of tissue destruction. We report an unusual case, in which a 55-year-old woman with Sheehan's syndrome got worse symptoms after spontaneous labor. In 1998, she had severe postpartum hemorrhage and pituitary necrosis during the third delivery, thus it was diagnosed as Sheehan's syndrome by clinical manifestations, laboratory tests, and magnetic resonance imaging. She was treated by replacement therapy including hydrocortisone and levothyroxine sodium. However, she had the fourth spontaneous pregnancy in 2000 and got worse symptoms after delivery. We carefully concluded that pregnancy provided no evidence against the diagnosis of Sheehan's syndrome because pregnancy might improve hypopituitarism by stimulating the pituitary remnant to undergo hyperplasia and irritating the placenta to secrete hormone. However, pregnancy might aggravate the symptoms by inducing autoimmunity as well. All in all, early diagnosis and adequate medical treatment are important to provide a good prognosis of Sheehan's syndrome.
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Motivala S, Gologorsky Y, Kostandinov J, Post KD. Pituitary disorders during pregnancy. Endocrinol Metab Clin North Am 2011; 40:827-36. [PMID: 22108282 DOI: 10.1016/j.ecl.2011.08.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The pituitary gland undergoes much anatomic and physiologic variation during pregnancy. Pituitary disease may have a significant impact on a patient prior to conception as well as throughout her pregnancy. It is imperative to provide care to patients affected by pituitary disease with a multidisciplinary approach involving endocrinologists, obstetricians and, when appropriate, neurosurgical care, as this group of disorders can represent a substantial level of morbidity and mortality for both mother and fetus.
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Abstract
Sheehan's syndrome (SS) is postpartum hypopituitarism caused by necrosis of the pituitary gland. It is usually the result of severe hypotension or shock caused by massive hemorrhage during or after delivery. Patients with SS have varying degrees of anterior pituitary hormone deficiency. Its frequency is decreasing worldwide and it is a rare cause of hypopituitarism in developed countries owing to advances in obstetric care. However, it is still frequent in underdeveloped and developing countries. SS often evolves slowly and hence is diagnosed late. History of postpartum hemorrhage, failure to lactate and cessation of menses are important clues to the diagnosis. Early diagnosis and appropriate treatment are important to reduce morbidity and mortality of the patients.
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Affiliation(s)
- C. Shivaprasad
- Department of Endocrinology, M. S. Ramaiah Hospital, Bangalore, India
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37
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Laway BA, Mir SA, Gojwari T, Shah TR, Zargar AH. Selective preservation of anterior pituitary functions in patients with Sheehan's syndrome. Indian J Endocrinol Metab 2011; 15 Suppl 3:S238-41. [PMID: 22029030 PMCID: PMC3183521 DOI: 10.4103/2230-8210.84874] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Sheehan's syndrome manifests as hypopituitarism following a child birth usually preceded by postpartum hemorrhage. The symptoms range from vague feelings of ill health to symptoms of a full blown panhypopituitarism. A large series of such patients is not described in the literature. MATERIALS AND METHODS We present the details of ten women with partial Sheehan's syndrome. They presented with post-partum hemorrhage and lactation failure. RESULTS After delivery, seven out of ten patients had regular menstrual cycles indicating preservation of gonadotroph function. Lactotroph, thyrotroph, and somatotroph failure were present in all and corticotrophs preservation was documented in four out of ten patients. The hypophysial magnetic resonance imaging (MRI) confirmed empty sella in all. CONCLUSION lactotroph, somatotroph and thyrotroph failure are common in patients with Sheehan's syndrome. In addition to known preservation of gonadotroph axis, corticotroph axis may be preserved in some of these patients arguing against the universal treatment of these patients with glucocorticoids.
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Affiliation(s)
- Bashir Ahmad Laway
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Shahnaz Ahmad Mir
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Tariq Gojwari
- Department of Radiodiagnosis, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Tariq Rashid Shah
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Abdul Hamid Zargar
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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38
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Kumar S, Burrows D, Dang S, Simmons D. Sheehan syndrome presenting as central diabetes insipidus: a rare presentation of an uncommon disorder. Endocr Pract 2011; 17:108-14. [PMID: 21041172 DOI: 10.4158/ep10015.cr] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To add to the current scant literature on rare clinical presentations of Sheehan syndrome. METHODS We describe the study patient's clinical, laboratory, and imaging findings and review the literature for publications regarding varied clinical presentations of Sheehan syndrome. RESULTS A 36-year-old multigravida woman developed severe postpartum hemorrhage and disseminated intravascular coagulation followed by Sheehan syndrome, with central diabetes insipidus as the primary presenting feature. This was diagnosed when, postoperatively, she developed polyuria with a urine output of 11 L in 24 hours with an accompanying rise in creatinine. She had laboratory evidence of diabetes insipidus, with serum osmolality greater than urine osmolality. Her clinical status improved significantly with intranasal desmopressin supplementation, thus confirming the diagnosis of Sheehan syndrome. Although Sheehan syndrome is a known complication of postpartum hemorrhage, central diabetes insipidus is seldom considered or suspected. Hypovolemia is usually presumed to be secondary to blood loss and polyuria resulting from a diuretic phase of acute renal failure. CONCLUSIONS It is important to consider posterior pituitary ischemia resulting from Sheehan syndrome presenting as central diabetes insipidus as a cause of polyuria because appropriate hormonal replacement initiated early can possibly improve clinical status and patient outcomes.
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Affiliation(s)
- Saumya Kumar
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA.
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39
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Currás Freixes M, De La Vega IR, de Miguel Novoa MP. [Postpartum hyponatremic coma]. ENDOCRINOLOGIA Y NUTRICION : ORGANO DE LA SOCIEDAD ESPANOLA DE ENDOCRINOLOGIA Y NUTRICION 2011; 58:372-375. [PMID: 21497568 DOI: 10.1016/j.endonu.2011.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2010] [Revised: 02/13/2011] [Accepted: 02/14/2011] [Indexed: 05/30/2023]
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40
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An uncommon cause of anaemia: Sheehan's syndrome. Wien Klin Wochenschr 2010; 122:717-9. [DOI: 10.1007/s00508-010-1480-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Accepted: 09/23/2010] [Indexed: 11/26/2022]
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Touqmatchi D, Chatterjee J, Tayob Y. A rare cause of postpartum headache. J OBSTET GYNAECOL 2010; 30:411-2. [PMID: 20455731 DOI: 10.3109/01443611003706902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- D Touqmatchi
- Department of Obstetrics and Gynaecology, Queen Charlotte and Chelsea Hospital, UK
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43
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Kouatli Y. Is pituitary failure the real therapeutic target in septic shock? Med Hypotheses 2009; 74:574-7. [PMID: 19853383 DOI: 10.1016/j.mehy.2009.09.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2009] [Revised: 09/16/2009] [Accepted: 09/17/2009] [Indexed: 10/20/2022]
Abstract
Severe sepsis and septic shock have been part of intensivists' major challenges since the birth of the specialty. This clinical picture is followed by the development of a multiple organ failure syndrome. Our working hypothesis today is that multiple organ failures develop due to a systemic intravascular malignant inflammatory response. This article proposes an alternative understanding of the problem based on some of the recent data and understandings of non glycemic, non insulinemic endocrine dysfunction in severe sepsis and septic shock. Our presentation of selected literature supports the presence of a decreased production and activity in steroids, thyroid hormones, growth hormone, vasopressin and prolactin in septic shock. These hormones have important and synergistic functions. The disruption of which can lead to multiple organ failure in septic shock. Developing research focusing on the broad hypothalamic and pituitary functions could improve our understanding of metabolic derangements in severe sepsis and septic shock and thus provide new therapeutic options. These new therapies based on hormonal replacement are currently available at low cost and could improve outcomes.
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Affiliation(s)
- Yasser Kouatli
- Division of Critical Care, Department of Anesthesiology, University of Michigan Health System, United States.
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44
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Soares DV, Conceição FL, Vaisman M. [Clinical, laboratory and therapeutics aspects of Sheehan's syndrome]. ACTA ACUST UNITED AC 2009; 52:872-8. [PMID: 18797595 DOI: 10.1590/s0004-27302008000500020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Accepted: 05/22/2008] [Indexed: 11/22/2022]
Abstract
Sheehan's syndrome is characterized by hypopituitarism that occurs as a result of ischemic pituitary necrosis due to severe postpartum hemorrhage. Nowadays it is not usually seen in developed countries because of the improvements in obstetric care. However, in developing countries it is still frequent and probably one of the most common causes of hypopituitarism. Most patients usually present it months to years later, with a history of failure of postpartum lactation, failure to resume menses and other signs of panhypopituitarism. In mild forms of the disease, patients may remain undetected and do not receive treatment for many years. Early diagnosis and appropriate treatment are important to reduce the morbimortality of the patients with Sheehan's syndrome. The aim of this review is to describe clinical, laboratory and therapeutic aspects of Sheehan's syndrome, including our experience in the replacement of recombinant GH in these patients.
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Affiliation(s)
- Débora Vieira Soares
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, RJ, Brazil.
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45
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Gokalp D, Tuzcu A, Bahceci M, Arikan S, Bahceci S, Pasa S. Sheehan’s syndrome as a rare cause of anaemia secondary to hypopituitarism. Ann Hematol 2008; 88:405-10. [DOI: 10.1007/s00277-008-0607-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2008] [Accepted: 08/28/2008] [Indexed: 10/21/2022]
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46
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Datta S, Wykes C. A postpartum bald patch. J OBSTET GYNAECOL 2008; 28:107. [PMID: 18259916 DOI: 10.1080/01443610701846429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- S Datta
- East Surrey Hospital, Redhill, Surrey, UK
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Toledano Y, Lubetsky A, Shimon I. Acquired prolactin deficiency in patients with disorders of the hypothalamic-pituitary axis. J Endocrinol Invest 2007; 30:268-73. [PMID: 17556861 DOI: 10.1007/bf03346292] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
UNLABELLED Acquired PRL deficiency occurs when the anterior pituitary is functionally destroyed, and it usually accompanies other pituitary hormone deficiencies. We retrospectively investigated in an outpatient endocrine clinic of a major tertiary medical center the prevalence and clinical characteristics of acquired PRL deficiency in patients with diseases of the hypothalamic-pituitary axis. The study included 100 consecutive patients, 61 men and 39 women, aged 4-79 yr at diagnosis. Patients were divided by PRL level to normal (>5 ng/ml), mild (3-5 ng/ml), and severe deficiency (<3 ng/ml). Twenty-seven patients (27%) had PRL deficiency, 13 mild deficiency and 14 severe deficiency. Patients with severe PRL deficiency tend to be younger at diagnosis (mean age, 37.5+/-21.8 yr) than patients with normal PRL (46+/-18.5 yr; ns). Underlying diseases including pituitary apoplexy, non-functioning pituitary adenoma, craniopharyngioma, and idiopathic hypogonadotropic hypogonadism were associated with PRL deficiency. The incidence of severe PRL deficiency rose with an increase in the number of other pituitary hormone deficits (ACTH, TSH, gonadotropin, vasopressin), from 0 in patients with no other deficits to 38% in patients with 4 deficits (p=0.006). Patients with severe deficiency had a mean of 3 hormone deficits compared to 1.8 in the other groups (p=0.006). PRL deficiency was significantly associated with TSH, ACTH and GH deficiency. CONCLUSIONS PRL deficiency is common in patients with hypothalamic-pituitary disorders, especially pituitary apoplexy and craniopharyngioma. Acquired severe PRL deficiency can be considered a marker for extensive pituitary damage and a more severe degree of hypopituitarism.
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Affiliation(s)
- Y Toledano
- Unit of Endocrinology and Diabetes, Hillel Yaffe Medical Center, Hadera, Israel
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48
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Weston G, Chaves N, Bowditch J. Sheehan's syndrome presenting post-partum with diabetes insipidus. Aust N Z J Obstet Gynaecol 2006; 45:249-50. [PMID: 15904455 DOI: 10.1111/j.1479-828x.2005.00367.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Gareth Weston
- Department of Obstetrics & Gynaecology, Monash University, Melbourne, Australia.
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Kurtulmus N, Yarman S. Hyponatremia as the presenting manifestation of Sheehan's syndrome in elderly patients. Aging Clin Exp Res 2006; 18:536-9. [PMID: 17255644 DOI: 10.1007/bf03324855] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND AIMS Hyponatremia is not a disease in itself, but a manifestation of a variety of disorders and side-effects of diuretics; alternatively, it may be the only manifestation of hypopituitarism or hypothyroidism. In our experience, diagnosis of hypopituitarism in hyponatremic patients is often overlooked, especially in the elderly. METHODS We report here data from five elderly multiparous women (mean age 69 yr; range 62-78 yr) with a past history of complicated delivery, in whom initial symptoms were due to hyponatremia (serum sodium less than 128 mEq/L) who went undiagnosed and untreated for a long time (up to 42 years) after the initial event. RESULTS Initial hormonal levels indicated hypopituitarism, and magnetic resonance imaging led to diagnosis of empty sella in all patients, so that they were diagnosed as suffering from Sheehan's syndrome (SS). The occurrence of sodium and water disorders associated with SS depends on the degree of pituitary damage, time of onset since the initial pituitary insult, and concurrent medical conditions which also play a role in sodium and water balance. In these patients, clinical condition and hyponatremia improved rapidly after glucocorticoid substitution. L-thyroxine was appropriately substituted subsequently. CONCLUSIONS We suggest that, especially in elderly patients, much more attention should be paid to patients' past history. Early recognition of severe hyponatremia due to hypopituitarism with adrenal insufficiency is critical, and treatment with hydrocortisone results in safe and improved quality of life.
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Dökmetaş HS, Kilicli F, Korkmaz S, Yonem O. Characteristic features of 20 patients with Sheehan's syndrome. Gynecol Endocrinol 2006; 22:279-83. [PMID: 16785150 DOI: 10.1080/09513590600630504] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Sheehan's syndrome occurs as a result of ischemic pituitary necrosis due to severe postpartum hemorrhage. The aim of the present study was to determine the clinical characteristics of Sheehan's syndrome in 20 patients (mean age 60.15 +/- 3.41 years) with typical obstetric history. The mean duration between time of diagnosis and date of the last delivery was 26.82 +/- 2.52 years (range 2-40 years). All patients had a history of massive hemorrhage at delivery and physical signs of Sheehan's syndrome. Fourteen patients (70.0%) lacked postpartum milk production and did not menstruate following delivery. Baseline and stimulated anterior pituitary hormone levels were measured in all patients. According to the hormonal values, 18 (90.0%) patients had secondary hypothyroidism, 11 (55.0%) had adrenal failure and all of them had hypogonadism, prolactin and growth hormone deficiency. Hyponatremia was present in seven patients (35.0%). Total or partially empty sella was revealed in all patients by magnetic resonance imaging. Diabetes insipidus was not found in any patient. We found that lack of lactation in the postpartum period and early menopause seemed the most important clues for diagnosis of Sheehan's syndrome, and inadequate prolactin and gonadotropin responses to stimulation tests were the most sensitive diagnostic signs in patients with severe postpartum hemorrhage.
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