Sheehan’s Syndrome:

A case report
 GOOD AFTERNOON! 

DEPARTMENT OF FAMILY AND COMMUNITY MEDICINE

PGI Ramos, Jo Anne N.
General data
 R.C.
 49 years of age
 Female
 Married
 Filipino
 Born Again Christian
 6157 Feliciano St., Mapulang Lupa, Valenzuela City
 Admitted for the 7th time on February 19, 2010 around
11:45AM
CHIEF COMPLAINT

 BODY WEAKNESS
HISTORY OF PRESENT ILLNESS
 3 days PTA muscle pain on both upper
and lower extremities described as
cramping for about minutes in duration
every 1-2 hours, usually
occurring during the night and relieved by
rest or sleep
 Consult Meloxicam 15mg/tab once
a day which would afford temporary relief
 Few ours PTA condition worsened now
with associated generalized body
weakness

 Admitted
PAST MEDICAL HISTORY
 (+) 2008, CKD @ MCUH- Folic Acid+Vit. B complex, 1
tab once daily and EDA/DHA 1tab thrice daily
 (+) AUG 2009, Metabolic encephalopathy, Hyponatremia
probably secondary to salt wasting nephropathy @
MCUH
 (+) HPN Olmesartan 10mg, 1 tab once daily
 (+) DM Sitagliptin 25mg, 1 tab once daily
 (+) Dyslipidemia Fenofibrate 160mg, 1 tab once daily
 (-) Allergy
 (-) Asthma
FAMILY HISTORY
 (+) Hypertension- paternal
 (+) CVA- paternal
 (- ) Diabetes
 (- ) Cancer
 (- ) Kidney disease
 (- ) Asthma
 (- ) PTB in the household
PERSONAL AND SOCIAL HISTORY
 Housewife
 Daily chores serves as her exercise
 Diet: Low salt low fat diet
 Nonsmoker
 Alcohol beverage drinker (occasional), twice a year,
consuming 2-3 bottles of beer (San Mig Light)
 Nuclear type of family, neolocal
 No prevalent disease in the community such as dengue
fever
OB-Gyne history
 G3P3 (3003)
 All pregnancies are delivered at home by a midwife
 (+) surgical menopause, TAHBSO @ MCUH (G3) 1981,
secondary to postpartum hemorrhage secondary to uterine
atony, home delivery assisted by a midwife
Physical examination
 General Survey- Patient is conscious, coherent,
not in cardiorespiratory distress

 Vital Signs: BP 150/90 mmHg CAR 75 bpm

RR 18 cpm T 36.5°C BMI 20 kg/m2
Wt 53kg Ht 150cm
 Skin- hair distribution on the facial area is diminished,
dry, pale with fair turgor
 HEENT- No nasoaural discharge, no
tonsillopharyngeal congestion, no cervical
lymphadenopathy
 Chest/Lungs-Symmetrical chest expansion, no
retractions, clear breath sounds
 Heart- Adynamic precordium, normal rate and
regular rhythm , no murmur
 Abdomen- Flabby, normoactive bowel sounds, soft,
non-tender
 Extremities- Grossly normal, diminished axillary hair,
full and equal peripheral pulses
Neurological Exam
 Cerebral- oriented 3 spheres
 Cerebellar- no ataxia, no dyskinesia
 Cranial Nerves
 1 can smell
 II (+) pupillary light reflex
 III, IV, VI intact extraocular muscles
 V (+) bicorneal blink reflex
 VII no facial asymmetry
 VIIIcan hear
 IX, X (+) gag reflex
 XI able to shrug shoulders
 XII no tongue deviation
 SENSORY MOTOR

100% 100% 3/5 3/5

100% 100% 3/5 2/5

++ ++

++ ++
++ ++

++ ++

Deep Tendon Reflex

 Genogram
Ramos-Tadeo Family
6157 S. Feliciano St., Mapulang Lupa, Valenzuela City
2-19-10, 9:30 AM

I.
Jose, 79 Eliza, 73 Crrisanto Adoracion
? 76

II
.
Marcelina Eduardo Manuel Federico Celia Renato ConsolacionLeoplodo Corazon Romulo Aurora Cristina Crisanto Nestor Tomas Gabriel Jun Noel
62 61 60 59 58 57 49 48 39 38
60 57 55 52 47 45 44 40

III
. Nephtalie Nerissa Naneth
32 31 28

DIABETES DECEASED
FEMAL
E
HYPERTENSION
MALE

LIVING TOGETHER STROK

E
INDEX PATIENT BREAST CANCER
Diagnostics (at the ER)
CBC RESULT Normal value
Hemoglobin 10.6 g/dL 13.5-18
Hematocrit 0.32 0.42-0.50
Leukocytes 3.5 4.5-11
Segmenters 0.61 0.56
Stabs 0.02 0.03
Eosinophils 0.07 0.027
Lymphocytes 0.25 0.34
Monocytes 0.05 0.04
Platelets 91 150-400
MCV 89.3 80-96
MCH 29.7 27-31
MCHC 0.33 0.32-0.36
Clinical Chemistry Result Reference Value

Creatinine 112.7 umol/L 53-106

Sodium 114.0 mmol/L 135-148

Potassium 3.52 mmol/L 3.5-4.3

Admitting impression:

 Hyponatremia
 HASCVD, NIF
 DM type 2
Differential Diagnosis:

 Cerebrovascular Accident
 Hypokalemic Periodic
Paralysis/Electrolyte
Imbalance
 Cerebrovascular Accident HPP/Electrolyte Imbalance

• rapidly developing loss •rare channelopathy characterized by

of brain function(s) due to disturbance in muscle weakness or paralysis with a
the blood supply to the brain, caused by a matching fall in potassium levels in
blocked or burst blood vessel. the blood. 
•leading to inability to move one or more
limbs on one side of the body, inability
to understand or formulate speech, or
inability to see one side of the visual
field.
Plan

 To correct electrolyte imbalance

 To determine the etiology of
hyponatremia
 To establish the diagnosis
Problem List

 Body weakness
 Leg cramping
 Hyponatremia
 Anemia
 Dizziness
Admitting Orders
 Diet: LSLF diet, DM diet
 CHO- 200 kcal/day
 CHON- 67 kcal/day
 Fats- 29 kcal/day
 IVF: PNSS 1L FOR 8 HOURS
 Diagnostics:
 CBC w/ APC, Na, K, Creatinine, CBG tid premeals
 12-lead ECG
 Therapeutics:
 Olmesartan 10mg/tab OD C/O patient’s
 Sitagliptin 25mg/tab OD medications
 Fenofibrate 160mg/tab OD @ HS
Course in the Ward
 1st day of hospitalization
 S> (+) leg pain, (+) body weakness, occasional dizziness
 O> BP 120-130/70-80 CAR 72 RR 20 T 36°

 A> Hyponatremia
 Anemia secondary Chronic Kidney Disease secondary to
DM Nephropathy
 Hypertensive Atherosclerotic Cardiovascular Disease
 DM type II
 P> Na Cl tablet , 1 tab, 2x daily
 for Urinalysis
 for Lipid profile, FBS, and SGPT
SGPT 105.9 U/L (4-24)

FBS 4.02 mmol/L (3.85-6.05)

Cholesterol 5.76 (3.9-6.5)

Triglycerides 1.81 (.11-2.09)

HDL 0.99 (1.15-1.68)

LDL 3.94 (3.37-4.12)

VLDL 0.82 (0-1.04)

urinalysis
Color Yellow
Specific Gravity 1.010
Character Clear
Reaction Alakali
Sugar Negative
RBC 0-1/hpf
PMN 0-1/hpf
Amorphous urates Rare
Bacteria Rare
Epithelial cells Rare
 12-lead ECG
 Sinus rhythm
 1st degree AV block
 Non-specific ST-T wave changes
 2nd day of hospitalization
 S> Decreased body weakness, (-) Dizziness, (+) Headache,
6/10 squeezing bitemporal, (+) cramping leg pain, 7/10 (+)
epigastric pain, (+) 1 episode of vomiting, previously ingested,
 O> Comfortable
 BP 120/80 CAR 54-66 RR 18
 (+) signs of hypothyroidism
 (+) epigastric tenderness, direct
 A> Patient is still manifesting signs of hyponatremia as well as
hypothyroidism. Fasting blood sugar is normal, which is
assessed as DM controlled. Blood pressure is within normal
limits.
Cont..
 A> Hyponatremia
 Anemia secondary Chronic Kidney Disease secondary to
DM Nephropathy
 Hypertensive Atherosclerotic Cardiovascular Disease
 P> Omeprazole 40mg/tab OD
 Folic Acid tab OD
 Paracetamol 500mg/tab 1 tab statP> For repeat CBC w/
APC, Na, Creatinine
 For serum Calcium
 Discontinue Fenofibrate 160mg/tab OD
 P> for thyroid function test (FT3, FT4, TSH)
 for UTZ of the whole abdomen
 for repeat serum Na, creatinine
 For GI referral to consider GI pathology
 Omeprazole 40mg/tab OD for epigastric pain
 D/C Fenofibrate 160mg/tab OD
 Paracetamol 500mg/tab stat for headache
 3rd day of hospitalization
 S> (-) Calf pain, (-) headache, fair appetite, (+) epigastric pain
 (+) vomiting, post-meal
 O> Stable vital signs
 (-) epigastric tenderness
 (+) still with signs of hypothyroidism
 Na 109.2 mmol/L
 Ft3 1.21 pmol/l (3.1-6.8)
 Ft4 1.68 pmol/l (12-22)
 Tsh 1.37 uIU/ml (0.27-4.2)
 A> Hyponatremia
 Hypothyroidism
 DM type 2 controlled
 HASCVD, not in failure
 P> NaCl tab 1 tab BID
 Levothyroxine 100mg/tab OD, monitor heart rate
 For repeat serum Na, K, Creatinine, Cl
 For HBA1C
Result: Whole abdomen UTZ
 Early signs of liver cirrhosis
 Mild vs acute cholecystitis
 Splenomegaly
 Chronic medical renal disease, bilateral
 Small lefty kidney
 Urinary retention
 Normal sonogram of the pancreas
 4th day of hospitalization (AM)
 S> Still with calf pain, (+) epigastric pain, (+) difficulty of
sleeping, (+) vomiting, 1 episode post-meal
 O> Stable vital signs
 (+) signs of irritability
 Na- 117.2 mmol/L in comparison with previous result
 HBA1C- 7.59 % (4.8-5.9)
 K- 3.24 mmol/L slightly decereased
 Cl- 87.80 mmol/L (96-106)
 A> Patient is still experiencing signs of electrolytes imbalance
as well as hypothyroidism. HBA1C revealed to be elevated
which depicts an uncontrolled blood sugar for the past 3 weeks.
 P>Diphenhydramine tab OD
 KCl tab, BID
 Na tab 2 tab bid
 repeat Na, K
 Regular diet
 4th day of hospitalization (PM)
 S> (+) mental disturbance, combative
 O> awake, incoherent
 A> Metabolic encephalopathy is highly considered
 P> 4 point restraint was contemplated
 5th day of hospitalization
 S> (+) shouting spells, (+) blank stares, not conversant
 O> Awake, incoherent, delirium
 Still in 4 point restraint
 Na- 122.8 mmol/L
 A> Hyponatremia, still correcting salt loss
 Metabolic encephalopathy secondary to hyponatremia
 P> Hydration is continued
 Diazepam 25mg/IV PRN
 Repeat Na, K
 6th day of hospitalization (AM)
 S> Still unable to sleep, combative, with episodes of shouting
spells
 O> BP 170/100
 Awake, delirium
 Na- 125 mmol/L
 K- 3.37 mmol/L
 A> Correcting salt loss, elevated BP may be secondary to
inability to sleep
 P> Diphenhydramine 50mg/IV
 Clonidine 75 mcg/tab SL

 6th day of hospitalization (PM)
 S> Patient is able to sleep
 O> BP 140/80
 Asleep, comfortable
 A> Metabolic encephalopathy
 Patient was able to sleep and calm down after administration
of Diphenhydramine
 P> still correcting electrolyte imbalance
 for serum cortisol, repeat Na, K
 remove patient from restraint
 7th day of hospitalization
 S> (-) BM for 3 days, difficulty to move bowel, no headache,
no leg cramps, no epigastric pain, able to sleep
 O> Stable VS
 Coherent, comfortable, not in distress
 Na- 129 mmol/L
 K- 4.33 mmol/L
 A> Patient had manifested hypotituitarism as showed
previously by hypothyroidism and possibly hypocortisolism
Sheehan’s syndrome is highly entertained.
 P> Bisacodyl 5mg/tab, 1 tab before bedtime
 Methylpredinisolone 4mg/tab BID
 KCl tab discontinue
 8th day of hospitalization
 S> No subjective complaints
 O> Stable vital signs
 Patient is conscious, conversant, coherent
 Cortisol- 46.84 nmol/L (171-536 nmol/L)
 A> Hypopituitarism secondary to Sheehan’s Syndrome
 P> C/C Methylpredinisolone 4mg/tab, 2 tab BID
 Cont. Omeprazole 20mg/tab OD for 9 more days
 9th day of hospitalization
 S> No subjective complaints
 O> BP 120/80 CAR 86 RR 19
 Patient is conscious, conversant, not in distress
 A> Hypopituitarism secondary to Sheehan’s Syndrome
 Hypertensive Atherosclerotic Cardiovascular Disease, not in failure
 Diabetes mellitus, type II
 Chronic Kidney Disease secondary to DM nephropathy
 P> C/C NaCl tab, 1 tab BID
 MGH:
 1. Levothyroxine 100mg/tab, 1 tab OD
 2. Methylprednisolone 4mg/tab, 1 tab OD
 3. Cont Amlodipine 5mg/tab, 1 tab OD
 4. Folic Acid + Vit. B complex tab, 1 tab OD
 5. Cont. EDA/DHA tab, 1 tab TID
 Physiologic hyperplasia of the pituitary
Estrogen
Pregnancy gland due to increase demand of
lactotrophs (2nd
nd tri up to 1st
st week

pospartum)

Peurperium: Increased blood loss

due to uterine atony

Hypotension and vasospasm of

hypophyseal arteries

Compromised blood supply of the

pituitary gland
 Ischemia of the gland

Partial/Complete loss of the

gland endocrine function

Thyroid Leutinizing Adrenocortico-

Hormone (LH) Growth Prolactin (PRL) tropic Hormone
Stimulating
and Follicle Hormone (ACTH)
Hormones
Stimulating
(TSH)
Hormone (FSH)

T3, T4 Low sex Dec protein Failure to Dec serum

decrease hormone synthesis lactate cortisol
concentrations Inc water, Na, Dec serum
K excretion aldosternone
Dec IGF Low sex
hormone
concentration
Tiredness Amenorrhea -Dec energy Fatigability
Weakness Infertility and drive Weakness
Dry skin Dec vaginal -Dec lean Hyponatremia
Cold secretion body mass Hyperkalemia
intolerance Dec libido -Abnormal Hypertension
Hair loss Breast lipid profile
Bradycardi atrophy - IGF leads
a Reduced to inc blood
Puffy face, body hair glucose
hands, and growth
feet
 Partial/Complete loss of the
gland endocrine function

Oxytocin Antidiuretic Hormone (ADH)

Patient lacks the signs and symptoms of

an anterior pituitary gland loss of
function
Sheehan’s Syndrome

Discussion
Pituitary Gland

 An endocrine gland about
the size of a pea and
weighing 0.5 g (0.02 oz.)
 Major endocrine gland.
“Master gland”
Pituitary Gland

 The blood supply of the

pituitary arises from 2
sets of vessels:
 The superior hypophyseal
arteries, from the internal
carotid arteries and circle
of Willis.
 The inferior hypophyseal
arteries, from the internal
carotid arteries alone.
 Most of the anterior lobe of
the pituitary has no direct
arterial supply.
 Sheehan’s syndrome, first
described by Sheehan in
1937, is a well-known cause
of panhypopituitarism
secondary to pituitary
apoplexy.
 This syndrome generally
occurs after an intra- or
postpartum bleeding
episode characterized by
severe hypotension or
hemorrhagic shock.
 During pregnancy, the
pituitary gland enlarges and
is vulnerable to ischemic
insults.
 The mechanism of ischemia
is not clear.
 Hypotension, along with
vasospasm of the
hypophyseal arteries is
currently believed to
compromise arterial
perfusion of the anterior
pituitary.
 Damage to the anterior
pituitary causes partial or
complete loss of thyroid,
adrenocortical or gonadal
function.
 The extent of pituitary
damage determines the
rapidity of onset as well as
the magnitude of pituitary
hypofunction.
 The prevalence of Sheehan’s syndrome in 1965 was
estimated to be 100 to 200 per 1,000,000 women.
 With advances in obstetric care, this disease is becoming
rare in the developed countries.
 There are currently no available literature on the
prevalence of Sheehan’s syndrome in the Philippines.
Phil. J. Internal Medicine, 46: 295-298, Nov.-Dec., 2008. SHEEHAN’S
SYNDROME IN A 44-YEAR OLD FILIPINO FEMALE
 The gland has a great secretory reserve, and more than
75% must be destroyed before clinical manifestations
become evident.
 Most patients, however, have mild disease and remain
undiagnosed and untreated for years.
 The reported percentage for hormone deficiencies
following ischemic infarction of pituitary include:
 growth hormone (88%)
 gonadotropin (58 -76%)
 corticotrophin (66%)
 secondary hypothyroidism (4-5. 3%)
 prolactin deficiency (67-100%).

Veldhuis J, Hammond J: Endocrine Function After

Spontaneous Infarction of the Human Pituitary: Report,
Review, and Reappraisal. Endocr Rev. 1: 100, Winter 1980.
 In 1995, Justiniano (unpublished) reviewed the medical
records of the Philippine General Hospital from January 1,
1987 to October 31, 1995 for patients diagnosed with this
disease entitity.
 There were 21 cases of Sheehan’s syndrome recorded for
the said census period.
 Eight women (38 %) had hyponatremia, with serum
sodium levels ranging from 120-128 mmol/L.
 This data is comparable to a cohort of patients in Turkey
reviewed by Sert, et. al.1where nine (32%) out of 28
women had disturbances in sensorium associated with
hyponatremia.

1
Sert, M, Sert M, Tetiker T, Kirim S, Kocak M: Clinical Report
of 28 patients with SheehanÊs Syndrome. Endocr J. 50(3):
297, 2003.
 The mechanisms responsible for the development of
hyponatremia in patients with hypopituitarism have been
shown to be multifactorial:
 (1) increased secretion of vasopressin because of glucocorticoid
deficiency or other factors, such as decreased volume or cardiac
output;
 (2) urinary loss of sodium caused by aldosterone deficiency;
 (3) impaired water excretion because of thyroid hormone
deficiency
 (4) impaired water excretion caused by vasopressin
independent factors, such as decreased tubular fluid delivery to
the diluting site.
CONCLUSION
 The most important clues for diagnosis of Sheehan’s
syndrome are lack of lactation and failure of menstrual
resumption after delivery that was complicated with
severe hemorrhage.

 The aim of treatment is to replace deficient hormones.

 A high index of suspicion and a meticulous history and

physical examination are important in recognizing
Sheehan’s syndrome.
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