Sheehan’s syndrome occurs as a result of ischaemic pituitary necrosis due to severe postpartum haemorrhage. It may rarely be seen without massive bleeding or after normal delivery. Improvements in obstetric care and availability of rapid blood transfusion coincided with a remarkable reduction in the frequency of Sheehan’s syndrome, particularly in developed countries. However, the number of cases from developed countries has recently increased. Due to primitive obstetrics care, it is one of the most common causes of hypopituitarism in underdeveloped and developing countries.1,2
Postpartum haemorrhage leading to pituitary necrosis is one of the explanations for hypopituitarism of Sheehan’s syndrome. Some sources have reported autoimmunity to a partially damaged pituitary gland.3
The clinical presentation can be acute if the pituitary damage is massive and failure of lactation and amenorrhoea are the commonest presentations. Adrenal failure, hypothyroidism and hypogonadism are also well known.4
The diagnosis is easy in adult women of reproductive age because of early presentation, concern about body structure, breast size, hair loss and secondary infertility. Although pregnancy has been reported with Sheehan’s syndrome, these are mostly case reports.5
In older patients presentation is variable as malaise, fatigue, lethargy, loss of bone mass, skin changes, cessation of menses and so on are all attributed to old age.6
However, awareness about the skin changes of growth hormone deficiency such as loss of skin mass, decreased sebum production and increased facial puffiness should always raise the suspicion of Sheehan’s syndrome.7
Our first case had all these features of growth hormone deficiency in addition to hypothyroid features. The presence of recurrent hyponatraemia made our suspicion stronger as did the history of lactational failure. Hyponatraemia and hypoglycaemia have been reported as presentations of hypopitutarism8,9
in older patients that, if ignored or not diagnosed in time, can prove fatal. Hypoglycaemia is another fatal presentation of hypopitutarism and Sheehan’s syndrome and was reported in 44% cases in one study.10
Our second case presented in hypoglycaemic coma and shock, the latter being due to adrenal failure. Absence of a history of diabetes or any hypoglycaemic drug intake made our suspicion stronger, as did the hyponatraemia. This has been the patient’s third episode of hypoglycaemia and coma, which improved with symptomatic treatment. This approach can have disastrous consequences and emphasis must be made on finding the underlying cause irrespective of age. Lethargy, cognitive decline, falls and skin changes are features of old age, but it is worth ruling out hypopitutarism in a suitable clinical setting to provide the appropriate replacement therapy and reverse these pseudoageing symptoms and signs.
- Careful evaluation is needed in older patients presenting with coma, confusion and dyselectrolytaemia.
- Attention must be given to finding the cause of an illness and the practice of symptomatic treatment should be avoided.
- Caution is needed in older patients whose symptoms and signs are attributed to normal ageing, as these could be presentations of a treatable illness.
- Sheehan’s syndrome can have atypical presentation and emphasis must be put on obstetric history to avoid delay in diagnosis.