Postpartum Hemorrhage Complications Research Articles

Second Stage of Labor Cesarean Section Maternal and Fetal Outcomes

Background: Cesarean section at the second stage of labor occurs when the mother requires delivery with full dilatation of the cervix by cesarean section (CS), which poses a risk to the mother and fetus. Purpose: To study the maternal and fetal outcomes of second-stage cesarean section. Methods: This comparative study was conducted at Alhasahisa Teaching Hospital from August 2021 to January 2022. The study sample comprised 226 women who fulfilled the inclusion criteria, including 113 who delivered by second-stage cesarean section and 113 who delivered by first-stage labor cesarean section as controls. Data were collected using a questionnaire filled out by doctors after informed consent was obtained. Results: The common indications in women who delivered via second-stage cesarean section were fetal distress in 62(51.9%), obstructed labor in 26(23%), and failure to progress in 25(22.1%). In women who underwent first-stage cesarean section, the common indications were failure to progress in 85(75.2%), fetal distress in 16(14.2%), and chorioamnionitis in 12(10.6%) (p < 0.05). The reported maternal complications in women who underwent second-stage cesarean section were postpartum hemorrhage in 34(30.1%), sepsis in 11(9.7%), prolonged labor in eight (7.1%), extended tears in four (3.5%), umbilical cord prolapse in three (2.7%), and episiotomy in three (2.7%). The admission to the neonatal intensive care unit (NICU) and the causes of admission were more common among the babies of the women delivered by second-stage cesarean section than the babies of the women delivered by first-stage cesarean section (p value < 0.05). Maternal complications in women who underwent second-stage cesarean section included postpartum hemorrhage in 34(30.1%), sepsis in 11(9.7%), prolonged labor in 8(7.1%), uterine extension in 4(3.5%), umbilical cord prolapse in 3(2.7%), and episiotomy in 3(2.7%) (p < 0.05). Conclusion: Second-stage labor cesarean section showed more complications of postpartum hemorrhage, sepsis, and extended tears, as well as more fetal complications, such as admission to the neonatal intensive care unit, fresh stillbirths, low Apgar scores, and birth asphyxia.

FRI400 A Rare Case Of Acute Sheehan's Syndrome In An Antepartum Patient

Abstract Disclosure: E. Jalal: None. C. Baldwin: None. Sheehan’s syndrome (SS) is a known complication of postpartum hemorrhage. It is typically diagnosed several years after birth given slow symptom onset related to hypopituitarism. We report a rare case of life-threatening antepartum pituitary ischemia secondary to hypotension, representing an acute presentation of SS. A 19-year-old primigravid woman at 31 weeks of gestation was admitted to the intensive care unit for septic shock secondary to Klebsiella pneumoniae pyelonephritis. Despite appropriate treatment, persistent hypotension prevented weaning of vasopressor support. Due to concurrent mild hyponatremia, the following studies were obtained: morning cortisol (2.46 mcg/dL [4.5-23 mcg/dL]), thyroid stimulating hormone (TSH) (0.379 IU/L [0.47-4.7 IU/L]), free triiodothyronine (2.1 pg/mL [2.8-5.3 pg/mL]), and free thyroxine (0.77 ng/dL [0.7-1.8 ng/dL]). Endocrinology was consulted for evaluation of adrenal insufficiency and abnormal thyroid function tests. Her prolactin was measured at 10.3 ng/mL, far below the expected range in a 3rd trimester pregnancy (35-600 ng/mL). Her remaining anterior pituitary hormone panel was unremarkable. MRI brain without contrast showed no evidence of an acute stroke or hemorrhage and commented that the prominence of the pituitary gland was likely related to current pregnancy. Stress dose hydrocortisone 100mg thrice daily and levothyroxine 50 mcg daily were initiated, allowing for weaning of vasopressor support. By discharge, she was titrated to levothyroxine 75mcg daily and hydrocortisone 20mg in the morning and 5mg in the afternoon. Repeat outpatient pituitary function testing found increase of prolactin to 397 ng/mL (35-600 ng/mL) and of IGF-1 to 486 ng/mL (113-408 ng/mL) as well as normalization of TSH to 3.210 (0.45-4.5IU/L), indicating likely recovery of pituitary axis. When readmitted at 38 weeks gestation for scheduled induction, she was given stress dose hydrocortisone 100mcg for labor. On discharge, she was tapered to prednisone 10mg daily and levothyroxine 50mcg daily. Appropriate hormone replacement and stress dose hydrocortisone resulted in an uncomplicated delivery and signs of clinical pituitary recovery postpartum as she was able to breastfeed without need for supplementation and maintain normotension after self-discontinuing prednisone and levothyroxine. The leading diagnosis to explain this patient’s hypopituitarism is acute SS, which is defined as symptom onset within 6 weeks postpartum. In our case, septic shock caused an abrupt onset of persistent hypotension leading to hormone levels suggestive of panhypopituitarism while the patient was pregnant at 31 weeks of gestation, which has not been reported in prior literature. While known as a chronic diagnosis in the postpartum population, further research should explore possible stunning effect of acute hypotension manifesting as acute SS in peripartum patients. Presentation: Friday, June 16, 2023

P₂A₀ 38-year-old Woman Postpartum Hemorrhage with Hemorrhagic Shock and Severe Anemia Caused by Uterine Atony: A Case Report from Southwest Sumba, East Nusa Tenggara

Postpartum hemorrhage is one of the most common obstetric emergencies and the largest contributor to maternal mortality in the world, with uterine atony being the most common cause. A 38-year-old woman came to Karitas Hospital complaining of vaginal bleeding after giving birth three hours ago. On examination, the patient was somnolent with signs of shock. Anemic conjunctiva, pale lips, weak contractions of the uterus, and active vaginal bleeding. The laboratory results show severe anemia and leukocytosis. The diagnosis was P2A0 38-year-old woman, postpartum spontaneously with hemorrhagic postpartum caused by uterine atony with hemorrhagic shock and severe anemia. The treatment was given according to the algorithm for managing postpartum hemorrhage. Uterine atony is caused by many factors, one of which is precipitous labor as experienced by the patient. Fluid rescucitation, uterotonics, uterine massage, bimanual compression, and the insertion of a condom catheter were given because there was still active bleeding after the 3rd stage of active management. Finally, surgical intervention should’ve been taken as the last step to stop the bleeding. Fast and precise handling can prevent complications of postpartum hemorrhage, namely shock and death.

A RARE CAUSE OF HYPOPITUITARISM - SHEEHAN SYNDROME

Sheehan syndrome is a rare complication of post-partum hemorrhage causing post-partum ischemic necrosis of the pituitary gland. It is a disease with declining incidence, more prevalent in developing countries. The incidence of Sheehan syndrome is 1 in 100,000 births. It was first described by a British pathologist Harold Leeming Sheehan in 1937.We present the case of a 42 year old female who presented with bilateral knee pain for 4 years, on over-the-counter steroids. She gave a history of lactational failure and secondary amenorrhea following childbirth. Her investigations revealed central hypothyroidism and she was diagnosed as Sheehan syndrome.

A Case of Sheehan Syndrome Presenting with Pancytopenia and Dilated Cardiomyopathy: A Rare Combination

Sheehan syndrome is a rare complication of postpartum haemorrhage resulting in pituitary necrosis and panhypopituitarism. We report a case of a 52-year-old female who presented with easy fatigability, asthenia and loss of appetite for 8-10 months. She was found to have alopecia, hypotension, hypoglycaemia, pancytopenia, and a history of failure to lactate after the last childbirth (17 years back) with premature menopause. The hormone profile revealed panhypopituitarism and magnetic resonance imaging of the brain was suggestive of partially empty sella. Her echocardiogram showed dilated cardiomyopathy with an ejection fraction of 35%. A diagnosis of Sheehan syndrome presenting with pancytopenia and dilated cardiomyopathy was made. The patient was started on injectable hydrocortisone and later, on thyroid hormone supplementation after which she improved. Sheehan syndrome is responsive to hormone replacement therapy and therefore should always be ruled out in such patients.

A Rare Case of Post-Partum Hemorrhage with Refractory Thrombotic Microangiopathy, and Hepatic Infarction: A Diagnostic Dilemma with High Mortality

We are presenting a very rare and unique case of postpartum hemorrhage with excessive blood loss requiring 6 units of packed red cells, 2 units of single donor platelet transfusions, 4 fresh frozen plasmas, and 4 cryoprecipitates. The patient developed a life-threatening spectrum of thrombotic microangiopathy which is known to result in pregnancy from eclampsia, pre-eclampsia, thrombotic thrombocytopenic purpura, typical and atypical hemolytic uremic syndrome, and hemolysis, elevated liver enzymes, low platelets syndrome and in non-pregnant patients with a wide differential diagnosis. The patient required 7 sessions of plasma exchange along with systemic steroids. During her illness, she developed rising liver enzymes and bilirubin, diffuse intravascular coagulation, renal failure, alveolar hemorrhage, and acute fulminant hepatic failure. A contrast-enhanced computed tomography scan revealed multiple areas of liver infarction with patent hepato-portal vessels. The patient required continuous renal replacement therapy and high supportive care. She stayed in the intensive care unit for 9 days, developed multi-organ failure, and finally expired. It is highly imperative to be aware of the complications of postpartum hemorrhage, as it should be treated promptly to minimize the possible cascade of multi-organ failure with high maternal and fetal mortality. Liver transplantation is the only possible radical therapy in cases with fulminant hepatic failure, worth considering, if clinically possible and applicable.

Frequency of Gestational Thrombocytopenia in Pregnant OPD Patients: Study in a Tertiary Care Hospital

Objective: Gestational thrombocytopenia can lead to fatal complications. Therefore, the present study aimed to evaluate the frequency of Gestational Thrombocytopenia in pregnant patients attending antenatal outpatients department (OPD) at a tertiary care hospital, Karachi.
 Methodology: This Descriptive observational study was conducted in the department of Obstetrics & Gynecology, Creek general hospital, United Medical & Dental College. All normotensive pregnant patients with no history of Malaria, Systemic Lupus Erythematosus (SLE), Idiopathic Thrombocytopenic Purpura (ITP) were asked to get CBC done which was followed throughout pregnancy. Low platelet counts (<150 x109/L, the patients were followed up with CBC every 10 days to see the decline. Platelet count of 1208 patients was performed using Minray BC 30 automated analyzer.
 Results: Out of 1208 pregnant patients, thrombocytopenia was present in 112 (9.3%); 454 were prim gravida, 269 (22.33%) were second gravida while 485 (40.1%) were multigravida. Out of 112 patients, mild thrombocytopenia was seen in 78 (69.6%), moderate thrombocytopenia was seen in 20 (17.9%) while severe thrombocytopenia was present in 14 (12.5%). Total 996 (82.5%) delivered vaginally; thrombocytopenia was present in 96 (85.7%). Lower segment Cesarian section (LSCS) was done in 212 and 16 (14.3%) had thrombocytopenia. No PPH and safe fetal outcome seen.
 Conclusion: In our study, the majority of the patients had mild gestational thrombocytopenia in pregnancy with no fatal complications. Pregnant females should be routinely screened for thrombocytopenia to avoid the disastrous complication of postpartum hemorrhage.

Anesthetic Management in Parturients With Fontan Physiology

Anesthetic Management in Parturients With Fontan Physiology

Development and Validation of Prognostic Nomogram for Postpartum Hemorrhage After Vaginal Delivery: A Retrospective Cohort Study in China

BackgroundPostpartum hemorrhage (PPH) is a common complication following vaginal delivery and in severe cases can lead to maternal death. A straightforward predictive model is required to enable prenatal evaluations by obstetricians to prevent PPH complications.MethodsData of patients who delivered vaginally after 37 weeks of gestation were retrospectively collected from the medical database at Shengjing Hospital of China Medical University for the period 2016 to 2020. PPH was defined as blood loss of 500 mL or more within 24 h of delivery, and important independent prognostic factors were determined using univariate and multivariate logistic regression analyses to construct nomograms regarding PPH.ResultsA total of 24,833 patients who delivered vaginally were included in this study. The training cohort included 22,302 patients who delivered between 2016 and 2019 and the external validation cohort included 2,531 patients who delivered during 2020. Nomogram was created using data such as age, race, occupation, parity, gestational weeks, labor time, neonatal weight, analgesic delivery, gestational diabetes mellitus, premature rupture of membranes, anemia, hypertension, adenomyosis, and placental adhesion. The nomogram has good predictive power and clinical practicality through the analysis of the area under the curve and decision curve analysis. Internal verification was performed on the nomogram for PPH, demonstrating consistency between the nomogram's predicted probability and actual probability.ConclusionsThe developed and validatable nomogram is a good predictor of PPH in vaginal delivery and can be used in clinical practice to guide obstetricians to administer preventive therapies before delivery.

Utilization of non-pneumatic anti-shock garment and associated factors for postpartum hemorrhage management among obstetric care providers in public health facilities of southern Ethiopia, 2020.

Delays in care have been recognized as a significant contributor to maternal mortality in low-resource settings. The non-pneumatic antishock garment is a low-cost first-aid device that can help women with obstetric haemorrhage survive these delays without long-term adverse effects. Extending professionals skills and the establishment of new technologies in basic healthcare facilities could harvest the enhancements in maternal outcomes necessary to meet the sustainable development goals. Thus, this study aims to assess utilization of non-pneumatic anti-shock garment to control complications of post-partum hemorrhage and associated factors among obstetric care providers in public health institutions of Southern Ethiopia, 2020. A facility-based cross-sectional study was conducted among 412 obstetric health care providers from March 15 -June 30, 2020. A simple random sampling method was used to select the study participants. The data were collected through a pre-tested interviewer-administered questionnaire. A binary logistic regression model was used to identify determinants for the utilization of non-pneumatic antishock garment. STATA version 16 was used for data analysis. A P-value of < 0.05 was used to declare statistical significance. Overall, 48.5% (95%CI: 43.73, 53.48%) of the obstetric care providers had utilized Non pneumatic antishock garment for management of complications from postpartum hemorrhage. Training on Non pneumatic antishock garment (AOR = 2.92; 95% CI: 1.74, 4.92), working at hospital (AOR = 1.81; 95% CI: 1.04, 3.16), good knowledge about NASG (AOR = 1.997; 95%CI: 1.16, 3.42) and disagreed and neutral attitude on Non pneumatic antishock garment (AOR = 0.41; 95%CI: 0.24, 0.68), and (AOR = 0.39; 95% CI: 0.21, 0.73), respectively were significantly associated with obstetric care provider's utilization of Non-pneumatic antishock garment. In the current study, roughly half of the providers are using Non-pneumatic antishock garment for preventing complications from postpartum hemorrhage. Strategies and program initiatives should focus on strengthening in-service and continuous professional development training, thereby filling the knowledge and attitude gap among obstetric care providers. Health centers should be targeted in future programs for accessibility and utilization of non-pneumatic antishock garment.

Comparative Study between Modified Transverse and Hayman Suture Regarding the Efficacy and Purperium Complications in Thi-Qar

Background: Main causes of death post-partum is the uncontrolled hemorrhage, that managed by different modalities, whereuterine compression suture had different efficacies as a main interventional tools of sever postpartum hemorrhage.&#x0D; Aim: comparing different sutures types (modified transverse and Hayman suture) regarding their efficacy through its impact and in determining the final outcome and complications of post-partum hemorrhage.&#x0D; Materials and methods: A prospective comparative analytical study including 122 females , who underwent delivery between march 2017and December 2019, all of them followed for , 1 week, 6,weeks 6 months. Were the samples collected from Bent-Al-Huda teaching hospital and Al-Rehman private hospital-Thi-Qar, 2 groups of study; 1st one (52) underwent modified B-lynch suturing (Hyman suturing) while the 2nd group(70) underwent transverse sutures of modified Ouahba suture, written consent had taken from all patients, SPSS version 24 used for analysis.&#x0D; Results: Among 122 delivered women suffer from primary post-partum hemorrhage, 52 (42.63%) were sutured by Hayman suture, and 70 (57.37%)were sutured by transverse suturing,There was significant statistical difference between the types of intervention and blood loss P value &lt;0.05. There was significant statistical difference between the types of intervention and complication development (p value=0.0001). There was no significant independent predictors or determinant for the complication development except the type of intervention. Only follow-up period and complication were truly to be correlated with type of intervention, the other variable were confounders&#x0D; Conclusion: Even though the hemostasis had been achieved in both maneuver with excellent success rate, the transvers suture carrying high rate of persistent pain but the Hayman suture carry higher rate of serious complication such hysterectomy and intestinal obstruction. several factors determine the choosing of the suture type such as site, severity and cause of bleeding and the surgeon experience.

Measurement of hemorrhage-related severe maternal morbidity with billing versus electronic medical record data

Objective Measurement of obstetric hemorrhage-related morbidity is important for quality assurance purposes but presents logistical challenges in large populations. Billing codes are typically used to track severe maternal morbidity but may be of suboptimal validity. The objective of this study was to evaluate the validity of billing code diagnoses for hemorrhage-related morbidity compared to data obtained from the electronic medical record. Study design Deliveries occurring between July 2014 and July 2017 from three hospitals within a single system were analyzed. Three outcomes related to obstetric hemorrhage that are part of the Centers for Disease Control and Prevention definition of severe maternal morbidity (SMM) were evaluated: (i) transfusion, (ii) disseminated intravascular coagulation (DIC), and (iii) acute renal failure (ARF). ICD-9-CM and ICD-10-CM for these conditions were ascertained and compared to blood bank records and laboratory values. Sensitivity, specificity, positive (PPV) and negative predictive values (NPV) with 95% confidence intervals (CI) were calculated. Ancillary analyses were performed comparing codes and outcomes between hospitals and comparing ICD-9-CM to ICD-10-CM codes. Comparisons of categorical variables were performed with the chi-squared test. T-tests were used to compare continuous outcomes. Results 35,518 deliveries were analyzed. 786 women underwent transfusion, 168 had serum creatinine ≥1.2 mg/dL, and 99, 40, and 16 had fibrinogen ≤200, ≤150, and ≤100 mg/dL, respectively. Transfusion codes were 65% sensitive (95% CI 62–69%) with a 91% PPV (89–94%) for blood bank records of transfusion. DIC codes were 22% sensitive (95% CI 15–32%) for a fibrinogen cutoff of ≤200 mg/dL with 15% PPV (95% CI 10–22%). Sensitivity for ARF was 33% (95% CI 26–41%) for a creatinine of 1.2 mg/dL with a PPV of 63% (95% CI 52–73%). Sensitivity of ICD-9-CM for transfusion was significantly higher than ICD-10-CM (81%, 95% CI 76–86% versus 56%, 95% CI 51–60%, p < .01). Evaluating sensitivity of codes by individual hospitals, sensitivity of diagnosis codes for transfusion varied significantly (Hospital A 47%, 95% CI 36–58% versus Hospital B 63%, 95% CI 58–67% versus Hospital C 80%, 95% CI 74–86%, p < .01). Conclusion Use of administrative billing codes for postpartum hemorrhage complications may be appropriate for measuring trends related to disease burden and resource utilization, particularly in the case of transfusion, but may be suboptimal for measuring clinical outcomes within and between hospitals.

Sheehan's syndrome: A rare cause of delayed recovery after anesthesia

Sheehan's syndrome (SS) or adenohypophyseal insufficiency is a rare but known complication of postpartum hemorrhage (PPH). It develops as result of ischemic pituitary necrosis secondary to a brutal and extended shock due to obstetric hemorrhage. The clinical presentation of this syndrome is variable and marked with abrupt or insidiously developing pituitary insufficiency. We report a case of 35-year-old female scheduled for laparoscopic appendicectomy under general anesthesia who developed delayed recovery. Proper history revealed that patient had history of severe PPH and was amenorrheic after that for last 4 years. Investigation revealed that pan hypopituitarism and neuroimaging (magnetic resonance imaging) showed reduced pituitary size. Replacement of deficient hormone leads to recovery and weaning from mechanical ventilation.

Recurrent episodes of acute psychosis like illness: A very delayed presentation of Sheehan syndrome

Sheehan syndrome, also known as postpartum pituitary gland necrosis, is a very serious complication of postpartum hemorrhage. Although it is a rare disorder in western countries, it is not much uncommon in developing countries like India. We describe 46-year-old female from a rural area of eastern part of India who presented with recurrent episodes of acute psychosis like illness over the last few years. When she came to our medical emergency unit, she was found to have hypoglycemia, hyponatremia, and hypotension. Further evaluation revealed history of postpartum hemorrhage during her last childbirth 17 years back which was followed by amenorrhea, lactation failure, and associated psychiatric illness. Magnetic resonance imaging pituitary showed empty sella and there were decreased levels of all the anterior pituitary hormones. All these parameters led to the final diagnosis of Sheehan syndrome which was diagnosed after a significant delay.

Establishing a Treatment Algorithm for Puerperal Genital Hematoma Based on the Clinical Findings.

Postpartum hemorrhage within 24 hours after delivery remains the leading cause of maternal mortality worldwide. Puerperal genital hematoma (PGHA) is a rare complication of postpartum hemorrhage, and PGHA can be life-threatening if hemostasis is not properly achieved. However, a reliable management algorithm for PGHA based on the clinical findings has not been developed. The objectives were to evaluate the management strategies for PGHA and identify the clinical findings that help select the treatment for PGHA. The medical records of women who were treated for PGHA in our department were reviewed, and data regarding the clinical findings and the treatment strategy for PGHA were analyzed. Thirty-four women who underwent treatment for PGHA were identified and divided into three groups according to the final procedure that achieved hemostasis: conservative management (CM) (n = 9), surgical management (SURG) (n = 15), and arterial embolization management (AEM) (n = 10). Regarding the clinical findings on initial evaluation, the shock index was significantly higher in the AEM group than in the CM or SURG group; and initial platelet count and fibrinogen level were significantly lower in the AEM group than in the CM group. There was no significant difference in any computed tomography (CT) finding among the three groups. In conclusion, this study clearly shows the difference in clinical findings among treatment strategies for PGHA. We suggest that the clinical findings of shock index, platelet count, and fibrinogen level together with CT findings are helpful and valuable for selecting the treatment strategy for PGHA.

Risk factors for peripartum hysterectomy among women with postpartum haemorrhage: analysis of data from the WOMAN trial

BackgroundPeripartum hysterectomy can cause significant morbidity and mortality. Most studies of peripartum hysterectomy are from high income countries. This cohort study examined risk factors for peripartum hysterectomy using data from Africa, Asia, Europe and the Americas.MethodsWe used data from the World Maternal Antifibrinolytic (WOMAN) trial carried out in 193 hospitals in 21 countries. Peripartum hysterectomy was defined as hysterectomy within 6 weeks of delivery as a complication of postpartum haemorrhage. Univariable and multivariable random effects logistic regression models were used to analyse risk factors. A hierarchical conceptual framework guided our multivariable analysis.ResultsFive percent of women had a hysterectomy (1020/20,017). Haemorrhage from placenta praevia/accreta carried a higher risk of hysterectomy (17%) than surgical trauma/tears (5%) and uterine atony (3%). The adjusted odds ratio (AOR) for hysterectomy in women with placenta praevia/accreta was 3.2 (95% CI: 2.7–3.8), compared to uterine atony. The risk of hysterectomy increased with maternal age. Caesarean section was associated with fourfold higher odds of hysterectomy than vaginal delivery (AOR 4.3, 95% CI: 3.6–5.0). Mothers in Asia had a higher hysterectomy incidence (7%) than mothers in Africa (5%) (AOR: 1.2, 95% CI: 0.9–1.7).ConclusionsPlacenta praevia/accreta is associated with a higher risk of peripartum hysterectomy. Other risk factors for hysterectomy are advanced maternal age, caesarean section and giving birth in Asia.

Sheehan’s Syndrome: A Rare but Potentially Life-Threatening Complication of Postpartum Haemorrhage

Sheehan’s syndrome (SS), also known as postpartum pituitary gland necrosis, is a rare but potentially life-threatening complication of postpartum haemorrhage. The diagnosis of Sheehan’s syndrome is based on the features of hormone deficiency, a suggestive obstetric history and decreased levels of basal hormones. Diagnosis of pan-hypopituitarism is straightforward, but partial deficiencies are often difficult to elicit. SS is a frequent cause of hypopituitarism in underdeveloped countries. The clinical features of hypopituitarism are often subtle, and years may pass before the diagnosis is made following the inciting delivery. History of postpartum haemorrhage, failure to lactate and cessation of menses are important clues to the diagnosis.

A case of acute Sheehan\u2019s syndrome and literature review: a rare but life-threatening complication of postpartum hemorrhage

BackgroundSheehan’s syndrome occurs because of severe postpartum hemorrhage causing ischemic pituitary necrosis. Sheehan’s syndrome is a well-known condition that is generally diagnosed several years postpartum. However, acute Sheehan’s syndrome is rare, and clinicians have little exposure to it. It can be life-threatening. There have been no reviews of acute Sheehan’s syndrome and no reports of successful pregnancies after acute Sheehan’s syndrome. We present such a case, and to understand this rare condition, we have reviewed and discussed the literature pertaining to it. An electronic search for acute Sheehan’s syndrome in the literature from January 1990 and May 2014 was performed.Case presentationA 27-year-old woman had massive postpartum hemorrhage (approximately 5000 mL) at her first delivery due to atonic bleeding. She was transfused and treated with uterine embolization, which successfully stopped the bleeding. The postpartum period was uncomplicated through day 7 following the hemorrhage. However, on day 8, the patient had sudden onset of seizures and subsequently became comatose. Laboratory results revealed hypothyroidism, hypoglycemia, hypoprolactinemia, and adrenal insufficiency. Thus, the patient was diagnosed with acute Sheehan’s syndrome. Following treatment with thyroxine and hydrocortisone, her condition improved, and she was discharged on day 24.Her next pregnancy was established 2 years after her first delivery. She required induction of ovulation for the next conception. The pregnancy, delivery, and postpartum period were uneventful. An electronic search of the literature yielded 21 cases of acute Sheehan’s syndrome. Presenting signs varied, including adrenal insufficiency (12 cases), diabetes insipidus (4 cases), hypothyroidism (2 cases), and panhypopituitarism (3 cases), with a median time of presentation after delivery for each of those conditions being 7.9, 4, 18, and 9 days, respectively. Serial changes in magnetic resonance imaging were reported in some cases of acute Sheehan’s syndrome.ConclusionClinicians should be aware of the risk of acute Sheehan’s syndrome after a massive postpartum hemorrhage in order to diagnose it accurately and treat it promptly.

Sheehan's Syndrome Presenting with Hyponatraemia: A Case Report

Sheehan syndrome (SS), or post partum necrosis of the pituitary gland, is a rare complication of post partum haemorrhage usually presenting with failure of lactation and subsequent amenorrhoea. We report a case of a 30-year-old woman with history of secondary amenorrhea and lactational failure following childbirth complicated with severe post partum hemorrhage, who presented to us with anemia, hypotension, acute confusion, neuropsychiatric manifestations, abnormal posturing and severe hyponatraemia. Hormonal assays revealed low pituitary hormones, subnormal levels of cortisol and thyroid hormones, with magnetic resonance imaging of the brain suggestive of SS. Hyponatraemia and late onset neuro-psychiatric manifestations are uncommon presentations of SS. Hence, there should be a high index of clinical suspicion for Sheehan’s syndrome in women with secondary amenorrhea and lactational failure following childbirth, who present with late onset neuro-psychiatric manifestations and hyponatremia.

Diagnosis Delayed but not Denied - Sheehan’s syndrome

Sheehan's syndrome is a rare complication of postpartum hemorrhage. With advancement in obstetric care, Sheehan's syndrome has become uncommon except in developing countries. Here, we report a patient with Sheehan's syndrome who escaped diagnosis for 22 years and presented with life threatening complications. This patient also had certain unusual features of Sheehan's syndrome like pancytopenia and renal failure. A high index of suspicion is necessary in diagnosing such patients.