A 34-year-old woman, gravida 1 para 1, comes to the office for postpartum follow-up. She had a vaginal delivery 6 weeks ago that was complicated by severe postpartum bleeding requiring aggressive volume resuscitation and transfusion of 5 units of packed red blood cells. Since the delivery, the patient has been very fatigued with poor appetite. She is "very concerned" about having little energy to bond with her child; her family has been helping with the baby. The patient has been formula feeding her infant due to lack of milk production. Her prepregnancy weight was 63.5 kg (140 lb), weight at delivery was 82.5 kg (182 lb), and current weight is 56.2 kg (124 lb). Blood pressure is 90/69 mm Hg and pulse is 88/min. Examination shows a well-healed perineal laceration scar. Which of the following is the most likely cause of this patient's current symptoms?

Question

A 34-year-old woman, gravida 1 para 1, comes to the office for postpartum follow-up.  She had a vaginal delivery 6 weeks ago that was complicated by severe postpartum bleeding requiring aggressive volume resuscitation and transfusion of 5 units of packed red blood cells.  Since the delivery, the patient has been very fatigued with poor appetite.  She is "very concerned" about having little energy to bond with her child; her family has been helping with the baby.  The patient has been formula feeding her infant due to lack of milk production.  Her prepregnancy weight was 63.5 kg (140 lb), weight at delivery was 82.5 kg (182 lb), and current weight is 56.2 kg (124 lb).  Blood pressure is 90/69 mm Hg and pulse is 88/min.  Examination shows a well-healed perineal laceration scar.  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

11ec25c8_d998_a8e4_bc81_cb9f5603e7ec_MD0003_00 This patient's massive postpartum hemorrhage with subsequent lactation failure, hypotension, and weight loss are concerning for Sheehan syndrome (ischemic necrosis of the pituitary gland). During pregnancy, the pituitary gland is physiologically enlarged and vulnerable to ischemia from hemorrhagic shock. This potentially life-threatening complication is characterized by anterior pituitary dysfunction; deficiencies in multiple hormone systems (ie, panhypopituitarism) are common. Sheehan syndrome typically presents after delivery with failure of postpartum lactation due to prolactin deficiency and lactotroph cell necrosis. Secondary adrenal insufficiency (eg, persistent hypotension, weight loss, lethargy) is also a common complication due to impaired ACTH secretion. Amenorrhea (hypogonadotropic hypogonadism) and central hypothyroidism may also occur. Management involves replacing the deficient hormones, but there is no effective treatment to restore lactation. (Choices A and C) Lactation failure is a risk factor for adjustment disorder with depressed mood ("postpartum blues") and postpartum depression. Although fatigue and poor appetite are common symptoms of mood disorders, hypotension and significant weight loss suggest an underlying medical disorder. (Choice D) Postpartum thyroiditis is characterized by autoimmune inflammation and destruction of the thyroid within a year of delivery. It causes transient hyperthyroid symptoms (eg, weight loss, palpitations, tremor) followed by a self-limited hypothyroid state. However, it is not associated with hypotension or lactation failure. (Choice E) Primary adrenal insufficiency manifests with similar symptoms such as fatigue, hypotension, and weight loss. However, most patients with primary adrenal insufficiency have hyperpigmentation (due to increased melanocyte-stimulating hormone) but not lactation failure. (Choice F) Pituitary apoplexy generally refers to spontaneous hemorrhage into the pituitary gland and occurs most commonly in patients with a pituitary adenoma. Typical symptoms include acute headache, visual field defects, and decreased visual acuity. Symptomatic deficiencies of pituitary hormones are less common. Educational objective: Sheehan syndrome (postpartum ischemic necrosis of the anterior pituitary) is a potentially life-threatening complication of massive postpartum hemorrhage. It typically presents with lactation failure (prolactin deficiency) as well as hypotension and anorexia (secondary adrenal insufficiency). References: Sheehan's syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/23245206) Characteristic features of 20 patients with Sheehan's syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/16785150)

A 34-Year-Old Woman, Gravida 1 Para 1, Comes to the Office