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Acute postpartum headache due to Sheehan's syndrome: a case report
Abstract Number: T-05
Abstract Type: Case Report/Case Series
Postpartum headache is a common occurrence with a broad differential diagnosis. With the increased use of neuraxial techniques, the obstetric anesthesiologist is frequently involved in the work up of postpartum headache. Sheehan's syndrome, or postpartum pituitary necrosis, is not typically recognized as a cause of postpartum headache and is not listed in the differential diagnosis of this condition in major obstetric anesthesia textbooks. We present a case of Sheehan's syndrome that initially presented as severe headache after vaginal delivery complicated by retained placenta and postpartum hemorrhage.
A previously healthy 31 year old G1P0 at 40w3d presented for post-dates induction of labor. An epidural was placed uneventfully for labor analgesia. Spontaneous delivery occurred 23 hours labor. This was complicated by a retained placenta requiring manual extraction and postpartum hemorrhage of 1500 ml. During the procedure the patient experienced a brief episode of hypotension with systolic blood pressure in the 70s mmHg, persistent tachycardia with heart rate of 100-150 beats per minute, a short period of nausea and mild headache. She was adequately resuscitated with crystalloids, colloids, and packed red blood cells with temporary improvement in headache. A few hours later, the patient had return of severe headache. The anesthesia team was called twice to evaluate for possible postdural puncture headache, but symptoms were not consistent with this diagnosis. The patient was discharged home on postpartum day 3 but continued to have headaches and returned on postpartum day 6 with severe headache, failure to lactate, edema, dizziness, fatigue, nausea, and emesis. Head MRI revealed pituitary infarction consistent with the diagnosis of Sheehan's syndrome. Laboratory evaluation revealed hypoosmolar hyponatremia and hypochloremia, low-normal thyroid-stimulating hormone, free thyroxine, and free triiodothyronine, and low random cortisol, adrenocorticotropic hormone, follicle-stimulating hormone, luteinizing hormone, and prolactin. Eight weeks later, she developed diabetes insipidus.
Sheehan's syndrome is pituitary necrosis after postpartum hemorrhage and hypovolemia. It is rarely diagnosed within the acute peripartum period and often presents months to years after delivery with symptoms of hypopituitarism. Only a few cases of Sheehan's syndrome have been reported in the literature as presenting with severe headache suggestive of acute onset pituitary apoplexy. Thus, Sheehan's syndrome is not typically considered in the differential diagnosis of postpartum headache. Early diagnosis and treatment is important in preventing or at least minimizing associated morbidity and mortality, particularly adrenal insufficiency crisis, myxedematous coma, and severe hyponatremia. Early imaging should be considered in the work up of refractory postpartum headache.