SHEEHAN'S SYNDROME

Sheehan's Syndrome, also known as Postpartum Hypopituitarism or Postpartum Pituitary Necrosis, is a condition in which hypopituitarism develops after severe bleeding ('Postpartum hemorrhage') during or immediately after childbirth .

The incidence of Sheehan's syndrome has decreased with better health care during childbirth and delivery but is still about 0.5% of all cases of hypopituitarism in women.

Blood loss generally has to be more than 800ml for Sheehan's Syndrome to develop. But in certain women, even minimal bleeding seems to cause this condition.

Cause of Sheehan's Syndrome

Sheehan's syndrome occurs due to necrosis of the anterior lobe of the pituitary gland.

This part of the gland secretes important hormones like the ACTH, TSH, FSH, LH, growth hormones, endorphins and prolactin.

During pregnancy, the anterior pituitary lobe increases greatly in size since it is required to secrete larger amounts of these hormones, especially FSH, LH and prolactin.

Pituitary Gland

Prolactin is required to help the breasts grow and secrete breastmilk during breastfeeding the baby. The level of prolactin reaches a peak about 1 -3 weeks after childbirth.

The blood supply of the gland does not increase simultaneously with the enlarging size of the gland. Due to this irregularity, the blood supply to this part of the pituitary gland is in a compromised state during pregnancy. If heavy bleeding occurs at any time during or after pregnancy or childbirth, the blood supply becomes inadequate and the cells undergo necrosis.

It is also believed that the acute loss of blood causes spasm in the arteries supplying the anterior pituitary leading to further necrosis.

The secretion of all the hormones produced by the anterior pituitary ( ACTH, TSH, FSH, LH, growth hormones, endorphins and prolactin) is affected to a greater or lesser extent.

Symptoms of Sheehan's Syndrome

The symptoms depend on the degree of necrosis of the cells.

• No Symptoms: In very mild Sheehan's syndrome, there may be no symptoms at all. The woman may complain of vague feelings of illhealth or fatigue which are often passed off as the after effects of childbirth, or being due to anemia, or poor nutrition.

• First Symptoms after childbirth: In a moderate degree of Sheehan's syndrome, the first signs usually appear within the first few months after childbirth. The woman fails to initiate breastfeeding and secrete breastmilk even after putting in her best efforts. The breasts and genital organs show signs of atrophy.

• Later Symptoms after childbirth: There is failure of menstruation and the condition is often discovered when there is no menstruation ('amenorrhea') even after a considerable length of time after childbirth . There is also loss of pubic and axillary hair.

• Symptoms of a fullblown Sheehan's syndrome: In a fully developed Sheehan's syndrome, the main symptoms are due to suppression of the thyroid gland (hypothyroidism) and the adrenal glands (Cushing's disease and Addison's disease).

  The woman typically has a pale, puffy face, coarse scanty hair, cold sensitivity, weight gain, low blood pressure, slow mental functions and delayed response to stimuli. Sometimes, there may be overt psychological disturbances. The breasts and genital organs are atrophied with absent pubic and axillary hair. Insulin tolerance may be reduced and Type I diabetes may occur.

Diagnosis of Sheehan's Syndrome

Sheehan's Syndrome is mainly diagnosed by low levels of TSH, ACTH, FSH, and LH with low levels of T4, cortisol, and estradiol in the blood. Low levels of IGF-I suggests GH deficiency.

MRI and CT scans should be carried out to evaluate the pituitary gland for other causes of hypopituitarism like pituitary tumors.

Treatment of Sheehan's Syndrome

Treatment is essentially by replacing the hormones that the pituitary gland fails to produce. Hormones like corticosteroids, thyroid hormones and estrogens and medicines to control diabetes become necessary to maintain normal functioning of the body. Any minor illnesses like influenza or even a common cold can cause a crisis and may require adjustment of these hormones.

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