Endocrine Abstracts

Introduction: Sheehan Syndrome (SS) is a cause of hypopituitarism resulting from postpartum pituitary infarction. Its frequency is decreasing worldwide, particularly in developed countries due to advances in obstetric care.

Case report: A 50-year-old female patient was admitted to the emergency department with complains of progressive pain in the lower hemithorax and abdomen. She also referred constipation, weight gain and asthenia. The initial laboratory tests showed raised creatinine kinase (4661 U/l [<145]) and aminotransferases (AST 86 U/l [<31]; ALT 36 U/l [<36]). Thyroid function was assessed revealing thyroid stimulating hormone (TSH) of 0.27 uIU/ml [0.4-4.0] and free thyroxine <0.40 ng/dl [0.7-1.5]). Assessment of anterior pituitary function was carried out indicating pan-hypopituitarism: FSH 3.8 mIU/ml; LH 0.6 mIU/ml; Prolactin <0.8 ng/ml [5.2-26.5]; ACTH 16 pg/ml [9-52]; Cortisol 2.1 mg/dl [5-25]; GH <0.1 µg/l [<1]. A brain magnetic resonance imaging (MRI) was performed, revealing the presence of an intrasellar arachnoidocele. She was started on replacement therapy with hydrocortisone and later levothyroxine with symptomatic improvement. The patient had a past medical history of a stillbirth at 28 years old, in Guinea-Bissau, due to postpartum haemorrhage requiring transfusion support. Afterwards a combined oral contraceptive was started, which she maintained for 11 years. After discontinuing the drug at the age of 39, she remained amenorrhoeic.

Discussion: This case fulfils the classic criteria of Sheehan’s syndrome with severe postpartum haemorrhage requiring transfusion; postpartum oligomenorrhea; hypopituitarism and the presence of arachnoidocele at brain MRI. Stillbirth in an underdeveloped country is also frequently described and related to a diagnostic latency. The diagnosis was obtained 26 years after the incident, with unspecific symptomatology. The fact that the corticotropic axis tends to be affected later in these cases, may explain the absence of significant consequences. This illustrates a difficulty in diagnosing Sheehan’s syndrome outside the acute context and highlights the need to be alert for this entity.