The pituitary is physiologically hypertrophic in pregnancy and, consequently, more susceptible to hypoxic injury Sheehan syndrome
(postpartum hypopituitarism) is a rare but potentially severe complication of massive obstetric hemorrhage and hypovolemic
shock causing ischemic infarction and necrosis of the anterior pituitary
The resulting symptoms of hypopituitarism can occur in the immediate postpartum period or up to several years later. Manifestations
include fatigue, weight loss, hypotension, inability to breastfeed, all of which are seen in this patient. In addition, non-lactating
women typically resume menses within 10 weeks of birth, and this patient's amenorrhea is likely due to hypogonadotropic
hypogonadism. Postpartum hemorrhage can also cause iron-deficiency anemia, which is the likely cause of anemia in this patient.
Management involves evaluation of the pituitary hormones and replacement as needed.
(Choice A) Postpartum thyroiditis is an autoimmune-mediated inflammatory destruction of the thyroid that results in hyper- orhypothyroidism. Symptoms of hypothyroidism can be present in patients with Sheehan syndrome (as pituitary infarction can cause
secondary hypothyroidism), but isolated thyroid dysfunction would not explain this patient's hypotension and lactation failure.
(Choice C) Lymphocytic hypophysitis is caused by lymphocyte-mediated pituitary inflammation and destruction. It is not related to
obstetrical hemorrhage. Patients typically present with headaches, visual disturbances, and hypopituitarism
(Choice D) Anorexia nervosa can lead to deficiencies of folate, iron, and vitamin B12, which in turn can cause anemia and fatigue.
Amenorrhea and bradycardia (pulse <60) may also occur. Although caloric and nutritional needs are greater in lactating women to
maintain milk supply, malnutrition does not typically affect the quantity or quality of breast milk production
(Choice E) This patient's complicated delivery, stress of caring for twins, and history of depression could contribute to fatigue and
weight loss. However, psychosocial impairment alone would not ,explain the patient's persistent hypotension, which is caused by an
underlying medical problem.
Educational objective:
Sheehan syndrome is a complication of massive obstetrical hemorrhage lschemic pituitary necrosis may result in amenorrhea,
lactational failure, and persistent hypotension
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