Category: Pituitary Disorders/Neuroendocrinology
Objective : Sheehan’s Syndrome, or postpartum hypopituitarism, is a rare condition which develops from postpartum pituitary gland necrosis due to massive intrapartum hemorrhage leading to partial or complete loss of pituitary function. We present an atypical case of this rare condition of an older woman presenting with myxedema and profound hypoglycemia 40 years after childbirth.
Case Presentation: A 64-year-old G1P1 woman with no significant past medical history presented with altered mental status. Clinically the patient had been having memory loss, cold intolerance and constipation. The patient had not had a menstrual period since age 23 after she gave birth to her only child with significant intrapartum hemorrhage. Physical exam revealed puffiness of the hands and face, missing outer eyebrows, a hoarse voice as well as an atrophic thyroid, delayed reflexes and slow mentation.
Laboratory results were significant for hypoglycemia (POC Glucose 17 mg/dL, Serum Glucose 53 mg/dL), central hypothyroidism (TSH 1.17 mIU/L, Free T4 0.14 pmol/L, Total T3 39 ng/dL) with hypoosmolar hyponatremia (Na 129 mmol/L, serum osmolarity 273 mosm/kg), central hypogonadism (FSH 2.2 IU/L, LH 0.6 IU/L, estradiol 21 ng/dL, prolactin 1.3 ng/mL), growth hormone deficiency (IGF-1 level < 10 ng/ml) and normal adrenocortical function. MRI revealed pituitary hypoplasia without mass effect.
The patient was diagnosed with myxedema without coma and hypoglycemia secondary to central hypothyroidism, hypogonadism and growth hormone deficiency from likely Sheehan’s syndrome. Patient was initially treated with stress-dose steroids (hydrocortisone 100 mg IV q8h) and weight-based levothyroxine without loading dose (70 mcg levothyroxine IV daily). Patient responded well to levothyroxine and became euglycemic despite growth hormone deficiency so patient was ultimately discharged with levothyroxine 112 mcg PO daily and outpatient follow up.
Methods : n/a
Discussion : Sheehan’s Syndrome has an incredibly variable presentation. Prolactin and GH are most commonly affected but severe cases can include hypogonadism, hypothyroidism or adrenal insufficiency. Lifelong hormone replacement therapy is the mainstay of treatment. The incidence of Sheehan Syndrome has gone down significantly with more aggressive peripartum transfusion protocols, but a detailed pregnancy history is still vital to diagnose this rare disease.
Conclusion : Our patient represents a case of Sheehan’s Syndrome which went undiagnosed for over 40 years demonstrating the catastrophic effects of long-standing pituitary dysfunction. Her case emphasizes the importance of a detailed pregnancy history along with early diagnosis and treatment.
Scripps Mercy Hospital
San Diego, California
I completed medical school at the University of Virginia in 2016. I am currently a third-year internal medicine resident at Scripps Mercy Hospital and I am very excited to be chief resident next year before pursuing a fellowship in endocrinology.
Endocrinology Attending and Associate Program Director, Internal Medicine
Scripps Mercy Hospitals San Diego and Chula Vista
I earned my MD degree at Jefferson Medical College in Philadelphia followed by Internal Medicine residency at Scripps Mercy San Diego. From there, I completed a 2-year Endocrinology fellowship at Scripps Green/Scripps Clinic also in San Diego. I worked in private practice in Phoenix for 2 years before returning to Scripps where I am an Endocrinology teaching attending and Associate Program Director of the Internal Medicine residency program. I have been an AACE member since 2011 and a fellow of AACE since 2016.