30 year old year lady, complains -extreme fatigue and myalgia since 2 days. The patient was unable to carry out activities of daily living.
- nausea (not accompanied by vomiting) since 2 days, was predominantly present after having her meals.
- bloating sensation, regurgitation after having her meal and constant abdominal discomfort since 2 days.
Known case of hypothyroidism, on medication.
(Tab. Thyroxine sodium 100mg BD)
History of similar incident
10 days back. She visited the hospital for a check up and was diagnosed with acute gastroenteritis. When the symptoms reappeared, she came back to the hospital. Even after correction of electrolytes, her sodium levels did not get corrected, suggestive of adrenal dysfunction.
Patient gives past history of excessive per vaginal bleeding post abortion.
Patient is a mother of three children. The fourth pregnancy was aborted. The abortion was followed by excessive vaginal bleeding for a few days.
General Physical Examination:
- moderately built and nourished, is alert, cooperative and well oriented.
- Postural hypotension.
-No pallor, no icterus, no clubbing, no cyanosis, no lymphadenopathy, no oedema.
S1 & S2 heard, No murmurs.
Bilateral normal vesicular breath sounds heard, No adventitious sounds.
Soft and non-tender with no organomegaly.
Conscious and oriented.
Urine routine examination, Liver Function Test, Serum creatinine and Blood urea: Normal.
In view of euvolemic hyponatremia and postural hypotension, serum cortisol and serum ACTH investigations done.
Serum cortisol: 1.12ug/dL
Serum ACTH: not detectable.
- Mild cerebral atrophy with bilateral discrete white matter hyperintensities
- Sella turcica is filled with cerebrospinal fluid and the infundibulum is seen traversing to the grossly atrophied pituitary gland seen flattened against the floor – Suggestive of Empty Sella Turcica.
- Hyponatremia secondary to adrenal insufficiency (Autoimmune polyglandular syndrome type II)
- Empty Sella Turcica syndrome.
- Tab. Thyroxine sodium 100mg to be continued
- Cap. Omeprazole and domperidone (once a week)
- Calcium with vitamin D tablets 500mg OD
- Tab. Prednisolone 20mg
- Tab. Fludrocortisone acetate 100mg
Sheehan syndrome is a state of postpartum hypopituitarism resulting from infarction of the pituitary secondary to postpartum hemorrhage or shock and is significant cause of morbidity and mortality in less developed countries 
The pituitary gland in pregnancy is more susceptible to ischemia owing to increased pituitary volume secondary to hyperplasia of lactotrophs and other cells of the anterior pituitary. Following post-partum hemorrhage and severe hypotension, there is partial or complete loss of the anterior pituitary hormones, namely the ACTH, FSH, LH, GH prolactin & TSH, thereby imparing their target organ functions 
Patients suffering from such pituitary atrophy are likely to present with adrenal insufficiency, agalactorrhea, oligomenorrhea and hypothyroidism (Clinically presenting as bradycardia, fatigue, hypotension, weight gain, constipation and loss of axillary and pubic hair). 
MRI of the pituitary:
- Early findings: Enlarged enhancing pituitary
- Late findings: Empty Sella
- Woodmansee WW. Pituitary Disorders in pregnancy. Neurol Clin. 2019 Feb;37(1):63-83. [PubMed]
- Wang CZ, Guo LL, Han BY, Su X, Guo QH, Mu YM. Pituitary Stalk Interruption Syndrome: From Clinical Findings to Pathogenesis. J. Neuroendocrinol. 2017Jan; 29(1) [PubMed]
- Karaca Z, Hacioglu A, Kelestimur F. Neuroendocrine changes after aneurysmal subarachnoid haemorrhage. Pituitary. 2019 Jan 2014 [PubMed]
- Karaca Z, Laway BA, Dokmetas HS, Atmaca H, Kelestimur F. Sheehan Syndrome. Nat Rev Dis Primers. 2016 Dec 22; 2:16092. [PubMed]
- Matsuazki S, Endo M, Ueda Y, Mimura K, Kakigano A, Egawa-Takata, et al. A case of acute Sheehan’s syndrome and literature review: a rare but life-threatening complication of post-partum haemorrhage. BMC Pregnancy and childbirth. 2017Jun14;17(1): 188. [PubMed]