A 38-year-old woman comes to the office for evaluation of fatigue. The patient says that she has been "beyond exhausted" for the past 5 months since the birth of her twins. She has had difficulty keeping track of all of the new responsibilities and often forgets to eat. She feels "disappointed" that she was unable to breastfeed despite multiple visits with a lactation consultant. The patient had a vaginal delivery complicated by uterine atony and bleeding which required multiple transfusions. She also has a history of depression treated with an antidepressant that was discontinued against medical advice when she realized she was pregnant. Her last menstrual period was before her last pregnancy. Weight is 52 kg (116 lb), same as her pre-pregnancy weight. BMI is 18 kg/m². Blood pressure is 85/55 mm Hg and pulse is 65/min. Physical examination shows a thin, tired-appearing woman. Hemoglobin is 10.1 g/dL. Which of the following processes is most likely the primary cause of this patient's symptoms?

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11ec25c8_da40_32a7_bc81_6b135f15db28_MD0003_00 The pituitary is physiologically hypertrophic in pregnancy and, consequently, more susceptible to hypoxic injury. Sheehan syndrome (postpartum hypopituitarism) is a rare but potentially severe complication of massive obstetric hemorrhage and hypovolemic shock causing ischemic infarction and necrosis of the anterior pituitary. The resulting symptoms of hypopituitarism can occur in the immediate postpartum period or up to several years later. Manifestations include fatigue, weight loss, hypotension, inability to breastfeed, all of which are seen in this patient. In addition, non-lactating women typically resume menses within 10 weeks of birth, and this patient's amenorrhea is likely due to hypogonadotropic hypogonadism. Postpartum hemorrhage can also cause iron-deficiency anemia, which is the likely cause of anemia in this patient. Management involves evaluation of the pituitary hormones and replacement as needed. (Choice A) Postpartum thyroiditis is an autoimmune-mediated inflammatory destruction of the thyroid that results in hyper- or-hypothyroidism. Symptoms of hypothyroidism can be present in patients with Sheehan syndrome (as pituitary infarction can cause secondary hypothyroidism), but isolated thyroid dysfunction would not explain this patient's hypotension and lactation failure. (Choice C) Lymphocytic hypophysitis is caused by lymphocyte-mediated pituitary inflammation and destruction. It is not related to obstetrical hemorrhage. Patients typically present with headaches, visual disturbances, and hypopituitarism. (Choice D) Anorexia nervosa can lead to deficiencies of folate, iron, and vitamin B₁₂, which in turn can cause anemia and fatigue. Amenorrhea and bradycardia (pulse <60) may also occur. Although caloric and nutritional needs are greater in lactating women to maintain milk supply, malnutrition does not typically affect the quantity or quality of breast milk production. (Choice E) This patient's complicated delivery, stress of caring for twins, and history of depression could contribute to fatigue and weight loss. However, psychosocial impairment alone would not explain the patient's persistent hypotension, which is caused by an underlying medical problem. Educational objective: Sheehan syndrome is a complication of massive obstetrical hemorrhage. Ischemic pituitary necrosis may result in amenorrhea, lactational failure, and persistent hypotension. References: The changing face of Sheehan's syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/20944496)

A 38-Year-Old Woman Comes to the Office for Evaluation of Fatigue