Post-partum complications

Question 1

What is the name of the syndrome due to pituitary infarction post labour ( due to excessive post-partum blood loss +/- hypovolemic shock)?

Answer 1

Sheehan’s syndrome = pituitary infarction due to excessive post-partum blood loss and hypovolemic shock
~pituitary is enlarged in pregnancy “juicy” with hormones, so prone to infarction
~ can affect secretion of some or all hormones of pituitary (TSH, LH, FSH, prolactin, ACTH, GH)

Question 2

How does Sheehan’s present?

Answer 2

~ prolactin gone = failure to lactate post-delivery
~ amenorrhea (no period) or oligomenorrhea (> 35 days, oligo = long) due to loss of FSH/LH
~ can have hypothyroidism, hypotension, etc

Question 3

How do you treat hypopituitarism (Sheehan’s in GYNE specifically)?

Answer 3

~ prolactin deficiency - currently no treatment, recombinant human prolactin used in pilots (lack of milk)
~ LH/FSH deficiency (amenorrhea/oligomenorrhea >35 d) if not interested in pregnancy, treat with estrogen-protestin therapy (oral contraceptives), with just progestin occasionally to rid of endometrial hyperplasia and carcinoma; if interested in pregnancy can gonadadotropin therapy to change pulsatility of GnRH
~ lack of ACTH primarily causes cortisol deficiency. Treatment consists of the administration of hydrocortisone or other glucocorticoid in an amount and timing to mimic the normal pattern of cortisol secretion
~ TSH - results in T4 deficiency (thyroxine), treated with levothyroxine. T4 should not be administered until adrenal function, including ACTH evaluated and author normal or treated.