Necrosis Of Pituitary Gland Research Articles

8100 Late Onset Sheehan Syndrome 23 Years After Post-Partum Hemorrhage: A Rare Case

Abstract Disclosure: I. Dosunmu: None. A. Alvi: None. S. Kaufman: None. A. Malik: None. Introduction: Sheehan syndrome is defined as ischemic necrosis of pituitary gland following massive postpartum hemorrhage. The majority of cases remain undiagnosed for many years after delivery. We present a unique case of late onset of Sheehan syndrome 23 years after the last childbirth which was complicated by hemorrhage. Although the syndrome can present with panhypopituitarism, most patients have partial hormone deficiency which leads to a delay in the diagnosis. Patients can remain asymptomatic for many years until the body is exposed to stressful situations. This is what we believe caused our patient to develop hyponatremia after staying symptom free for 23 years. Case Description: A 46-year-old female with no medical history presented with abdominal pain and dark colored urine. Her initial vital signs were normal. Labs showed sodium of 132 mmol/L, AST of 552 U/L, ALT of 518 U/L, ALP of 196 U/L, GGT of 166 U/L. CT scan of abdomen, liver ultrasound, and liver biopsy were unremarkable. AMA was positive with value of 1.98, consistent with diagnosis of primary biliary cholangitis. On day 2 her blood pressure decreased to 76/42 mmHg and her sodium decreased to 129mmol/L and on day 5 her blood pressure was 88/43mmHg and her sodium decreased to 122mmol/L. TSH was found to be 2.54 uIu/ml. Upon further evaluation by endocrinology, patient appeared to have sluggish speech and appeared edematous particularly in her face. A free T4 was found to be less than 0.07 ng/dl and cortisol 0.5 mcg/dl, and ACTH 22.4 pg/ml, FSH of 4.2 mIU/ml, LH 1.3 mIU/ml. On further questioning, patient confirmed history of complicated childbirth 23 years ago requiring multiple transfusions and a hysterectomy and she reported agalactorrhea after delivery. Brain MRI confirmed empty sella and she was diagnosed with Sheehan syndrome. She was started on levothyroxine and hydrocortisone and ursodiol for PBC. Discussion: Delayed onset Sheehan's syndrome stems from inadequate blood supply or ischemia to the pituitary gland during childbirth. Diagnosis can be challenging due to its gradual onset and vague presenting symptoms. In our patient, the possibility of Sheehan syndrome was suspected after evaluation for hyponatremia revealed central hypothyroidism and secondary adrenal insufficiency. 
The immediate initiation of hydrocortisone followed by levothyroxine, resulted in the normalization of blood pressure and sodium and an increase in free T4 levels from <0.07 to 0.26 four days after hormone initiation. Early diagnosis and prompt treatment are crucial for the best outcomes. Our patient reported feeling much better and denied any symptoms 6 months after discharge. Conclusion: Delayed onset Sheehan's syndrome is a rare but important condition that can occur months or years after childbirth. Early diagnosis, proper medical management, and hormone replacement therapy are essential for improving the quality of life for affected women. Presentation: 6/2/2024

Cardiovascular Risk Factors in Sheehan's Syndrome: A Case-Control Study.

Obesity, dyslipidaemia and insulin resistance are associated with hypopituitarism. The association between these conditions and Sheehan's syndrome (SS) caused by post-partum pituitary gland necrosis is poorly understood. This study aimed to assess cardiovascular risk surrogate markers in SS patients, and we compared clinical, biochemical and radiological testing with healthy controls. In this cross-sectional study, we studied 45 patients with SS on standard replacement therapy and compared them with healthy controls. All subjects underwent anthropometric, inflammatory marker and hormonal measurement (adrenocorticotropic hormone (ACTH), stimulated cortisol, insulin-like growth factor-1 (IGF-1), thyroxine (T4), follicle-stimulating hormone (FSH), luteinising hormone (LH), oestradiol (E2), prolactin (Prl), insulin, interleukin-6 (IL-6) and high-sensitivity C-reactive protein (hs-CRP)). Carotid intima-media thickness (CIMT), flow-mediated dilation (FMD) and echocardiography were also performed. The mean age and body mass index (BMI) of SS patients were 48.1 ± 10.0 years and 24.3 ± 4.3 kg/m2, respectively, while those of controls were 44.6 ± 12.0 years and 24.6 ± 3.2 kg/m2, respectively. Systolic blood pressure was significantly higher in SS (124.6 ± 20.8 vs. 117.0 ± 18.6 mm of Hg, P < 0.05). All SS patients were hypothyroid, and all except one were hypocortisolaemic. Triglyceride (TG) levels were significantly higher in SS patients (165.6 ± 83.3 vs. 117.2 ± 56.1, P < 0.01), but no difference in the prevalence of metabolic syndrome (MetS) was found. hs-CRP (9.1 (5.2-18.5) vs. 1.5 (0.6-2.8), P < 0.001) and IL-6 (4.9 (3.7-7.3) vs. 3.1 (2.0-4.2), P < 0.001) were significantly higher in SS patients. CIMT was significantly increased in SS patients, but no difference in FMD was found. Echocardiography revealed no significant difference in left ventricular (LV) dimensions, interventricular thickness, posterior wall thickness, ejection fraction, LV mass and diastolic function. SS patients show increased cardiovascular risk with hypertension, dyslipidaemia and increased atherosclerotic and inflammatory markers.

ODP332 Maternal Central Diabetes Insipidus Immediately after Delivery, Owing to Vasospasm of the Internal Carotid Artery

Abstract Background Sheehan's syndrome is a cause of hypopituitarism during the postpartum period, but it rarely manifests immediately after birth. Clinical Case We report the case of a 30-year-old woman who delivered her second child, lost 1,050 mL of blood in the process, but did not receive a blood transfusion. A few hours after delivery, the patient complained of headache, nausea, and thirst, and her urine production increased to 9 L/day. No menstrual irregularities or abnormalities during pregnancy or childbirth had been reported. None of hypotension, external eye muscle paralysis, or visual impairment were identified on physical examination. The laboratory findings were low urine osmolality and high serum osmolality and sodium concentration. The concentrations of thyroid hormones, growth hormone (GH), and anti-diuretic hormone (ADH) were found to be low. The IgG4 concentration was not high (4.7 mg/dL; normal &amp;lt;105 mg/dL) and the patient was negative for anti rabphilin-3A antibody. Pituitary magnetic resonance imaging (MRI) on the day of admission showed enlargement of the pituitary gland and stalk, and magnetic resonance angiography showed stenosis of the left internal carotid artery. The patient showed a poor response to GH-releasing peptide 2 and thyroid releasing hormone stimulation. Hypertonic saline administration did not cause an increase in ADH concentration. We diagnosed adult growth hormone deficiency (aGHD), central hypothyroidism, and central diabetes insipidus (DI). The enlargement of the pituitary gland was slightly less marked and the stenosis of the left internal carotid artery improved 7 days after admission. After 6 months, the pituitary gland was almost normal in size, although the aGHD, central hypothyroidism, and central DI remained. Sheehan's syndrome or lymphocytic hypophysitis could have been responsible for the postpartum hypopituitarism. This case was not typical of lymphocytic hypophysitis with respect to the hormone deficiency pattern, the MRI findings, and the lack of anti rabphilin-3A antibody. Sheehan's syndrome is caused by ischemic necrosis of the anterior pituitary gland after severe postpartum hemorrhage. The prevalence of central DI is estimated to be 2%–3%. Typically, pituitary dysfunction progresses slowly and develops several years after childbirth. In contrast, in the present patient, stenosis of the left internal carotid artery developed and improved during short periods of time. The vasospasm of the internal carotid artery caused reductions in flow through the superior and inferior hypophysial arteries, which resulted in ischemia and necrosis of the pituitary gland, similar to Sheehan's syndrome. Clinical Lesson: Although rare, maternal central DI can be caused by ischemia and vasospasm immediately after the delivery of a child. The possibility of a pituitary stroke in the presence of neoplastic disease should not be ruled out, and imaging and pituitary gland function should be followed over the long term. Presentation: No date and time listed

Effectiveness of video assisted teaching on knowledge regarding Sheehan’s Syndrome among staff nurses working at selected hospital, Kolar.

Background: Sheehan’s syndrome is caused because of huge blood loss during or after childbirth which decreases blood pressure leading to reduced oxygen level in the body causing hypovolemic shock. The lack of oxygen in the pituitary gland will decrease its function leading to postpartum pituitary gland necrosis. This is known as Sheehan’s syndrome. In view of assessing the knowledge of this rare condition among Staff Nurses, this study was conducted. Objectives: The aim of the study was: 1. to assess the knowledge level on Sheehan’s syndrome among staff nurses working at selected hospital using structural knowledge questionnaire. 2. To estimate the effectiveness of video assisted teaching on Sheehan’s syndrome among Staff nurses. 3. To Find the association between post-test knowledge scores with selected demographic variable. Methods: Quantitative approach, one group pre- test, post-test design was adopted in the study. Using non probability, purposive sampling technique 200 staff nurses were selected who were working in selected hospitals at Kolar city and who fulfilled inclusion criteria. Pre-test data was collected by self reporting technique using structured knowledge questionnaire. Video- Assisted Teaching on Sheehan’s syndrome was given after pre-test and after 7 days post test was conducted using same structured knowledge questionnaire. Analysis of data was done using descriptive and inferential statistics. Result: Study findings showed that, in pre-test showed that 20 (10%) staff nurses had Good knowledge, 32 (16%) nurses had average knowledge and 148 (74%) staff nurses had poor knowledge. In post-test, study findings showed that 24 (12%) staff nurses had Good knowledge, 42 (21%) staff nurses had average knowledge and 134 (67%) staff nurses had poor knowledge. findings related to administration of video assisted teaching using paired‘t’ test showed that t(tab199) was1.646 was greater than’ t’(cal199)-0.636 value at 0.05 level of significance. This findings showed that video assisted teaching was not much effective method in improving the knowledge on Sheehan’s syndrome among staff nurses. Conclusion: Overall findings showed that there is knowledge deficit among staff nurses regarding Sheehan’s syndrome. And different methods of teaching can be adopted to improve the level of knowledge along with video assisted teaching among staff nurses. Keywords: knowledge, Video assisted teaching (VAT), Sheehan’s syndrome, staff nurses, pituitary necrosis, hypopitutarism, hypovolemic shock.

Sheehan’s syndrome with hypothyroidism: a rare case report

Sheehan's syndrome is a form of hypopituitarism caused by pituitary gland necrosis caused by hemorrhagic shock during pregnancy. It's a rare issue with a wide range of symptoms and a long time to diagnose. A 40-year-old female presented with a giddiness which was rotatory type followed by headache, vomiting associated with nausea, decreased appetite for one week. She has experienced excessive vaginal bleeding and secondary amenorrhea exists for 20 years. Patients diagnosed to have acute liver injury, hyponatremia, and acute gastritis. The thyroid profile showed hypothyroidism and the patient started on appropriate medication. Hypopituitarism due to Sheehan's disease was discovered after a thorough clinical examination, endocrine investigations, and a pituitary magnetic resonance scan. Following the start of hormone replacement therapy, she showed significant improvement. The current case demonstrates that undiagnosed Sheehan's syndrome is linked to long-term morbidity, and we want to emphasize the importance of a high index of suspicion for early diagnosis of the syndrome during routine clinical visits to avoid complications that can arise from delayed diagnosis.

Co-presentation of Acute Sheehan Syndrome with Raised Intracranial Pressure in a Post-partum Lady

Sheehan’s syndrome (SS) or necrosis of pituitary gland is a rare complication of severe postpartum hemorrhage. It may cause hypopituitarism immediately or several years later, depending on the degree of tissue destruction. Sheehan’s syndrome though rare is still one of the commonest causes of hypopituitarism in developing countries like ours. The presence of an intercurrent infection and administration of thyroxine exacerbated her corticosteroid insufficiency. Intracranial hypertension (IH) manifested as bilateral optic disc swelling with reduced visual acuity, bilateral sixth nerve palsies, and impaired consciousness. Intracranial hypertension (IH) has been associated with hypocortisolism caused by either primary adrenocortical insufficiency or corticosteroid withdrawal. The author describes a case of a young lady with IH with acute SS who presented on 3rd day postpartum after lower uterine cesarean section with acute severe symptomatic hyponatremia which was complicated by postpartum hemorrhage. The clinical manifestations of IH resolved with corticosteroid replacement

A 45-year-old female patient with Sheehan\u2019s syndrome presenting with imminent adrenal crisis: a case report

BackgroundSheehan'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 presentationWe 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.ConclusionPrevious 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.

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.

Precipitation of Sheehan's syndrome following severe dengue infection

Sheehan's syndrome as described by Sheehan refers to necrosis of pituitary gland due to severe postpartum hemorrhage. Although its incidence is decreasing in developed countries, it still continues to be one of the most common causes of hypopituitarism in the underdeveloped and developing countries. The clinical presentation can be variable, and emphasis must be on adequate obstetric history to avoid undue delay in diagnosis. We report a 42-year-old female with the unmasking of Sheehan's syndrome who had lactation failure and amenorrhea for 9 years, developing panhypopituitarism following an episode of severe dengue infection.

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.

Antepartum Pituitary Necrosis Occurring In Pregnancy with Uncontrolled Gestational Diabetes Mellitus: A Case Report

Antepartum pituitary necrosis is a rare medical condition that has only been reported in pregnant women with type I diabetes attributable to diabetes-related vasculopathy and hypercoagulability. We present for the first time a case of antepartum pituitary necrosis occurring in an uncontrolled gestational diabetes mellitus (GDM) patient. The patient was a 32-yr-old woman at 33 weeks and 2 days of gestation. She suffered from severe headache, blurred vision, dizziness, and vomiting. Her baby was delivered by Cesarean section. The brain magnetic resonance images revealed pituitary necrosis. This suggests that pituitary gland necrosis may also complicate GDM pregnancy when glucose levels are uncontrolled.

ADRENAL HEMORRHAGE IN THE ADULT

Bilateral adrenal gland hemorrhage was found in 22 of 2,000 (1.1%) consecutive general hospital autopsies. Clinical features of these 22 patients with diffuse or focal bilateral adrenal hemorrhage have been analyzed and compared with previous series. In our experience, patients with this postmortem finding rarely manifest features of adrenocortical insufficiency and appear instead to die as a consequence of concomitant overwhelming illness, such as septicemia, body surface burns or cardiovascular catastrophe. Two-thirds of the current series had impaired renal function at the time of adrenal hemorrhage and three patients had pituitary gland necrosis. Experimental and clinical observations indicate that the "stressed" adrenal gland--under substantive endogenous or exogenous ACTH stimulation--is unusually susceptible to hemorrhage. While our own experience indicates that bilateral adrenal hemorrhage can infrequently be implicated as a factor contributing to patients' death, the possibility of adrenocortical insufficiency must be considered in patients at risk for adrenal hemorrhage. Such patients are those who are azotemic and have bacteremia, burns, or recent cardiovascular catastrophe, particularly when the latter is managed with anticoagulant administration. In these patients, unexplained clinical deterioration or the appearance of findings consistent with adrenocortical insufficiency mandate measurement of serum cortisol concentration and institution of stress-level corticosteroid replacement therapy until a diagnosis of acute adrenocortical insufficiency can be established or refuted.