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Sheehan Syndrome: A Rare Complication of Postpartum Hemorrhage
Sheehan Syndrome: A Rare Complication of Postpartum Hemorrhage
Postpartum Hemorrhage
Sarina Schrager, MD, and Laura Sabo, MD
Life-threatening postpartum hemorrhage is un- gency Department. She started feeling nauseous
common as a result of the advances in obstetric the last 2 days of her initial hospitalization. The
care. As this case illustrates, however, the conse- nausea worsened, and she developed vomiting, di-
quences of postpartum hemorrhage can be severe. arrhea, dizziness, and fatigue.
In the Emergency Department, the patient was
Case Report normovolemic. Her blood pressure, pulse, respira-
A healthy 39-year-old woman, gravida 2 para 1, tory rate, and temperature were normal, and she
came to the Emergency Department with a 2-day did not have orthostatic hypotension. Her sodium
history of nausea, vomiting, diarrhea, dizziness, and was 108 mEq/L. Her hemoglobin was 10.7 mL/dL,
fatigue. Twelve days earlier, she had undergone a hematocrit 29%, white cell count 6,000/L, potas-
primary low transverse cesarean section at term for sium 4.6 mEq/L, chloride 81 mEq/L, carbon diox-
failure to descend after premature rupture of mem- ide content 16 mEq /L, blood urea nitrogen 5.0
branes, oxytocin augmentation, and 21⁄2 hours of mg/L, and creatinine 0.7 mmol/L. She was alert
active pushing. A viable male infant weighing 3,832 and oriented and had normal findings on neuro-
g was delivered with Apgar scores of 9 and 9 at 1 logic examination. She was admitted to the hospital
and 5 minutes, respectively. The patient’s uterus for severe hyponatremia. Initially her hyponatre-
was found to be boggy and patulous after delivery. mia rapidly corrected to 119 mEq/L by active hy-
A lower uterine segment laceration was repaired, dration with normal saline solution and then furo-
and the uterus and skin incisions were closed. She semide diuresis. The patient subsequently had
had considerable postpartum bleeding and received fluids restricted; however, her sodium level was
misoprostol and dinoprostone. slow to correct. At admission, her serum osmolality
The patient continued to hemorrhage despite was 220 mOsm/L, and her urine osmolality was
these interventions and was taken back to the op- 120 mOsm/L. Her cortisol level and thyroid-stim-
erating room for an emergent supracervical hyster- ulating hormone (TSH) level were also measured at
ectomy. Because her right ovary was hemorrhagic, admission and were low at 1.9 g/dL and 0.44
she also had a right oophorectomy. She continued ng/dL, respectively. Later her free thyroxine and
to hemorrhage after the hysterectomy and under- triiodothyronine (T3) levels were found to be ⬍0.4
went an embolization of her right vaginal artery. ng/dL and 44 ng/dL, respectively. These labora-
The embolization finally stopped her bleeding. tory values suggested pituitary failure. To ascertain
During these procedures she was hypotensive and whether this patient did in fact have pituitary fail-
coagulopathic and received numerous units of ure, an insulin tolerance test was conducted on day
blood, platelets, and fresh frozen plasma. After the 4 of her hospitalization; the results are displayed in
embolization, the patient remained in the intensive Table 1.
care unit for 2 days and spent a total of 10 days in Based on these results, pituitary failure caused by
the hospital. A sodium level measured on the 5th Sheehan syndrome was diagnosed. The patient was
day of her hospitalization was normal. She had
started on cortisone acetate while still an inpatient
been home for 2 days when she came to the Emer-
and on levothyroxine and estrogen 1 week after her
discharge. She was advised to wear a Medic Alert
bracelet indicating adrenal insufficiency. The pa-
Submitted, revised, 16 January 2001.
From the Department of Family Medicine (SS, LS), Uni- tient will need to remain on both estrogen and
versity of Wisconsin, Madison. Address reprint requests to levothyroxine therapy for the rest of her life. She
Sarina Schrager, MD, Department of Family Medicine,
University of Wisconsin, 777 S. Mills St, Madison, WI will need adrenocortical steroid replacement when-
53715. ever she has surgery or is severely ill.