TITLE:
Postpartum panhypopituitarism with spontaneous pregnancy
AUTHORS:
Merces Assumpcao-Morales, Maria Milan, Vinuta Mohan, Tasneem Zahra
KEYWORDS:
Sheehan Syndrome; Pregnancy; Panhypopanpituitarism; Pituitary
JOURNAL NAME:
Open Journal of Internal Medicine,
Vol.3 No.2,
May
28,
2013
ABSTRACT: We
are reporting a case of a patient found to be pregnant
in the setting of panhypopituitarism. There are an only
few reports of spontaneous pregnancy in patients with panhypopituitarism.
This is a 26-year-old female who was admitted due to symptomatic hypoglycemia.
Past medical history is significant for uncomplicated pregnancy with C-section
delivery 1 year before admission. She was not able to breastfeed the baby in postpartum
period. Her menses have been irregular since then. She also noticed
increasing fatigue, muscle weakness, episodic diarrhea and 70 pounds weight
loss. Physical exam was remarkable for hypotension. Work up showed elevated
levels of beta-HCG, hyponatremia, normal anion gap metabolic acidosis,
normochromic anemia, and low cortisol levels, appropriate low levels of
insulin and C-peptide. Hypoglycemia panel revealed undetectable levels of sulphonylureas. Serum levels for pituitary hormones showed low levels of ACTH, prolactin and IGF-1, normal levels
of FSH, and inappropriate normal levels of TSH in the setting of decreased T4.
Stress doses of hydrocortisone were initiated along with thyroid hormone replacement. Brain MRI was found to be unremarkable. Sheehan’s syndrome is a very rare
complication of pregnancy when necrosis of the pituitary gland occurs after
severe hemorrhage and hypotension upon delivery. Small sella size, disseminated intravascular coagulopathy, stress of the delivery and autoimmunity are also implicated as
possible causes of Sheehan’s syndrome. We should be very attentive for symptoms
as failure to lactate and failure to resume regular menses after delivery as
they can be the first manifestation of the disease. Infertility is common in these
patients, but in very few of them gonadotropin response will be present due
to residual pituitary function and spontaneous pregnancy can occur. Proper
management of these patients during pregnancy will also be very important
since a high risk of miscarriages can be expected.