November 22, 2022
Years published: 1986, 1989, 1998, 2002, 2007, 2009, 2012, 2015, 2018, 2022
NORD gratefully acknowledges Mark E. Molitch, MD, Professor of Medicine, Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, for assistance in the preparation of this report.
Excessive blood loss during or after delivery of a baby may affect the function of the pituitary gland, leading to a form of maternal hypopituitarism known as Sheehan syndrome (SS). Such extensive bleeding may reduce the blood flow to the pituitary gland causing the pituitary cells to be damaged or die (necrosis). Thus, the production of the usual pituitary hormones will be reduced, perhaps by a significant amount. During pregnancy the pituitary gland will enlarge and may double in size. At this time the gland is especially vulnerable to a severe drop in blood pressure (sometimes called “shock”) and excessive maternal bleeding may induce the “shock” and the damage to the cells of the gland. At that time the amount of hormones produced by the pituitary may be decreased giving rise to the symptoms associated with hypopituitarism. There appear to be two forms of the disorder: a chronic form and an acute form, depending on the amount of damage to the gland’s cells. The acute form reflects considerable damage so that symptoms become apparent soon after delivery. In chronic cases, the volume of damage is much less, and symptoms may not appear for months or years after delivery.
The clinical features of Sheehan syndrome are highly variable and depend on the degree of failure of secretion of pituitary hormones including:
• Prolactin, the hormone that stimulates lactation
• Gonadotrophins (luteinizing hormone [LH] and follicle stimulating hormone [FSH]), which regulate the function of the ovaries
• TSH, which stimulates the thyroid gland
• ACTH, adrenocorticotrophin, which stimulates the adrenal cortex
• Growth hormone (GH)
How much pituitary tissue is killed, and by how much the hormone levels in the circulation are decreased, determine what happens to the mother. Patients with the chronic form have a smaller proportion of the pituitary tissue damaged and may not develop symptoms until weeks or even years after the birth.
In its most severe form, the condition is associated with failure of lactation after a woman has a baby. Menstruation does not begin again, sexual interest (libido) is diminished, hair in the armpits (axilla) slowly disappears, breasts diminish in size (atrophy) and the lining of the vagina thins, sometimes causing pain with intercourse. For some women, menstrual periods do recur, and subsequent pregnancies have been reported.
The characteristic symptoms (fatigue, dry skin, constipation, weight gain, sluggishness) of hypothyroidism usually develop gradually. Severe ACTH deficiency is associated with fatigue, chronic hypotension with fainting, and the inability to respond to stress. If these symptoms occur, they usually appear within weeks or months after the baby is born.
Since SS is a disorder affecting adults, the effects of growth hormone deficiency are limited to some loss of muscle strength, increased body fat and increased insulin sensitivity.
The less common acute or more severe form is potentially very dangerous. In these cases, less than 10 percent of the normal volume of pituitary tissue remains. Patients may present with persistent low blood pressure (hypotension), irregular and fast heartbeat (tachycardia), as well as failure to lactate and low blood sugar (hypoglycemia) immediately following delivery.
In both the chronic and acute forms, there may be signs of diabetes insipidus (DI) such as abnormal thirst for and intake of water, as well as high volume of output of urine.
In most instances, a precipitous drop in blood pressure and consequent shock, due to obstetrical bleeding, precede the onset of symptoms. According to many physicians the amount of damage that must be done to the anterior pituitary before Sheehan syndrome occurs varies from 75 to 90 percent. The enlarged pituitary requires more than normal volumes of oxygen, and any disruption of blood flow is a threat to the gland.
A severe spasm of the blood vessels feeding the pituitary (associated with shock) leads to lack of oxygen in the pituitary (pituitary ischemia) and various degrees of cellular damage depending on the severity and duration of arteriolar spasm.
Pituitary necrosis is found in association with other disorders but far less frequently. These disorders include sickle cell anemia, giant cell arteritis and a couple of others including trauma.
Sheehan syndrome affects women with excessive blood loss and circulatory collapse following childbirth. The incidence of Sheehan syndrome is not known.
In patients with severe hemorrhaging on delivery accompanied by long-lasting low blood pressure, treatment is started as soon as possible. Women believed to have the chronic form usually have blood drawn and the levels for several hormones are determined. Often, a head computed tomography (CT) or magnetic resonance imaging (MRI) scan is done; acutely this will usually show hemorrhage in the pituitary but chronically, as the blood resolves, this will show just a diminished size of the pituitary.
Treatment of Sheehan syndrome consists of hormone replacement, i.e., ovarian, thyroid, and adrenocortical hormones (ACTH). Since in most cases ACTH deficiency is only partial, continuing cortisol replacement therapy may not be required. Hydrocortisone or prednisone are generally used to replace ACTH and cortisol; thyroxine replaces thyroid hormone; estrogen/progesterone replacement is usually achieved by administering oral contraceptives, while any indication of diabetes insipidus requires the use of demopressin. Growth hormone (GH) replacement therapy has been approved by the U.S. Food and Drug Administration (FDA) for adults with documented GH deficiency. Its use in cases of Sheehan syndrome should be monitored and managed by a physician experienced in using GH. Benefits include increased muscle mass, reduction in the low-density lipoproteins and an enhanced sense of well-being.
Information on replacement therapy in cases of hypopituitarism is readily available from:
The Pituitary Foundation
The Hormone Foundation
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Corenblum A. Pituitary Disease and Pregnancy. Medscape. Updated: Oct 22, 2021. www.emedicine.com/med/topic3264.htm Accessed Nov 22, 2022.
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