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Sheehan’s syndrome in Saudi Arabia
International Journal of Gynecology & Obstetrics 66 Ž1999. 181]182
Brief communication
Sheehan’s syndrome in Saudi Arabia S. Banzal, E.A. AyoolaU , S. Banzal Department of Medicine, King Fahd Central Hospital, Gizan, Saudi Arabia Received 31 December 1998; received in revised form 5 April 1999; accepted 8 April 1999
Keywords: Sheehans syndrome; Hypopituitarism; Saudi Arabia
Postpartum hypopituitarism due to pituitary infarction wSheehan syndrome ŽSS.x remains an important cause of maternal morbidity in the developing world w1,2x. Despite recent and rapid socioeconomic progress and availability of free and efficient health services in Saudi Arabia, a proportion of deliveries in rural areas are domicilliary. Consequently, peri-partum complications are not infrequent. Over a 6-year period Ž1990]1995., 30 patients Ž29 Saudis and one Yemeni. with SS were diagnosed and treated in King Fahd Central Hospital Gizan. Located on the Red Sea approximately 1000 km south-west of Riyadh, Gizan region is inhabited by approximately 1 million people, scattered in villages and small towns. A third of the population are Bedouins with a nomadic life style. SS was diagnosed in the presence of appropriate clinical features of hypopituitarism and biochemical evidence of secondary failure of one or more pituitary-dependent endocrine glands w2,3x. Thyroid function tests ŽT3, T4, TSH., estimation of plasma levels of cortisol, luteinizing U
Corresponding author. Fax: q966-7-3250009.
hormone ŽLH., follicule-stimulating hormone ŽFSH., and growth hormone ŽGH., prolactin, and estradiol were obtained by standard radioimmunoassay. Metoclopramide and insulin stimulation tests w3x were performed in some patients, but not in others according to the levels of basal cortisol w4x. The ages of the patients at the time of diagnosis ranged between 23 and 60 years, with a mean of 38.5 ŽS.D.s 9.5. years. Nineteen of these patients were - 40 years of age and 26 patients delivered at home. A definite history of significant postpartum hemorrhage requiring blood transfusion was confirmed in 29 patients and three of these had ruptured uterus. The interval between last delivery and diagnosis were - 5, 6]10 and more than 10 years in 10, 12 and eight cases, respectively. Twenty-two of the patients had more than five children before the occurrence of the SS. On CT scan of the brain seven showed empty sellae. Table 1 summarizes the clinical features and serum levels of hormones in the patients. Metaclopramide and insulin stimulation tests obtained in 10 patients were abnormal. The clinical presentation of hypopituitarism vary, depending on the extent and severity of the
0020-7292r99r$20.00 Q 1999 International Federation of Gynecology and Obstetrics. PII: S 0 0 2 0 - 7 2 9 2 Ž 9 9 . 0 0 0 6 5 - X
S. Banzal et al. r International Journal of Gynecology & Obstetrics 66 (1999) 181]182
182
Table 1 Clinical features and serum hormones levels in 30 patients with SS Symptoms
n
Signs
n
Amenorrhearoligomenorrhea Failure of lactation Fatiguerweakness Loss of weight Anorexia GIT symptoms Cold intolerance
30 30 29 26 21 15 11
Absentrsparse axillary pubic hair Breast atrophy Hypotension Depression Confusionrcoma Bradycardia Cachexia
22 21 17 8 7 7 6
Hormone le¨ els Tests Žreference values.
No. abnormal values
Mean " S.D.
T3 Ž0.8]2.7 nmolrl. T4 Ž62]165 nmolrl. TSH Ž0]7 mUrl. FSH Ž0.9]9.8 IUrl. LH Ž2.0]15.4 IUrl. Cortisol Ž65]500 nmolrl. Prolactin Ž120]500 ml.
23 29 29a 30b 30b 27 28
0.53" 0.14 24.6" 13.3 1.5" 1.2 5.1" 3.5 3.8" 3.3 54.9" 28.5 57.5" 39.2
a b
The values were considered inappropriately low for amenorrheic patients. Inappropriate for the respective T3 and T4 levels.
pituitary hormone deficiency w2x. The diagnosis of complete deficiency is straight-forward when features of adrenocortical and thyrotrophin deficiencies co-exist with invariable gonadotrophin and lactotropic deficiencies w2x. All our patients had clinical features related to all aspects of target organ hormonal deficiencies. For cultural and religious reasons, the symptoms of ovarian failure such as decreased libido, vaginal dryness, and dyspareunia were unavailable in many cases. One of our patients presented with diabetes insipidus, in consistence with the low incidence of this complication Ž2]3%. in reported cases of SS w2x. The delay between the onset of symptoms and confirmation of the diagnosis was significant. Only two patients were diagnosed within 1 year and 20 patients had symptoms for over 6 years before diagnosis and appropriate treatment. Although the delay can be attributed to late presentations in the hospital, some of the primary care physicians did not consider SS during the initial evaluation.
The consequences of untreated hypopituitarism include infertility, sexual dysfunction, osteoporosis and pathological fractures. Estrogen deficiency in women may constitute a risk for coronary artery disease. Shock induced by infection or stress is a major cause of death in patients with hypoadrenalism. Improvement in obstetric care in developing countries would reduce the frequency of SS.
References w1x Sheehan HL. The frequency of postpartum hypopituitarism. J Obstet Gynaecol Br Commonw 1965;72: 103]111. w2x Vance ML. Hypopituitarism. N Engl J Med 1994; 330:1651]1662. w3x Dizerage G, Kletzkyo, Misheil D. Diagnosis of Sheehan’s syndrome using a sequential pituitary stimulation test. Am J Obstet Gynaecol 1978;132:348]353. w4x Oelkers W. Adrenal insufficiency. New Engl J Med 1996;335:1206]1212.
Brief communication
Sheehan’s syndrome in Saudi Arabia S. Banzal, E.A. AyoolaU , S. Banzal Department of Medicine, King Fahd Central Hospital, Gizan, Saudi Arabia Received 31 December 1998; received in revised form 5 April 1999; accepted 8 April 1999
Keywords: Sheehans syndrome; Hypopituitarism; Saudi Arabia
Postpartum hypopituitarism due to pituitary infarction wSheehan syndrome ŽSS.x remains an important cause of maternal morbidity in the developing world w1,2x. Despite recent and rapid socioeconomic progress and availability of free and efficient health services in Saudi Arabia, a proportion of deliveries in rural areas are domicilliary. Consequently, peri-partum complications are not infrequent. Over a 6-year period Ž1990]1995., 30 patients Ž29 Saudis and one Yemeni. with SS were diagnosed and treated in King Fahd Central Hospital Gizan. Located on the Red Sea approximately 1000 km south-west of Riyadh, Gizan region is inhabited by approximately 1 million people, scattered in villages and small towns. A third of the population are Bedouins with a nomadic life style. SS was diagnosed in the presence of appropriate clinical features of hypopituitarism and biochemical evidence of secondary failure of one or more pituitary-dependent endocrine glands w2,3x. Thyroid function tests ŽT3, T4, TSH., estimation of plasma levels of cortisol, luteinizing U
Corresponding author. Fax: q966-7-3250009.
hormone ŽLH., follicule-stimulating hormone ŽFSH., and growth hormone ŽGH., prolactin, and estradiol were obtained by standard radioimmunoassay. Metoclopramide and insulin stimulation tests w3x were performed in some patients, but not in others according to the levels of basal cortisol w4x. The ages of the patients at the time of diagnosis ranged between 23 and 60 years, with a mean of 38.5 ŽS.D.s 9.5. years. Nineteen of these patients were - 40 years of age and 26 patients delivered at home. A definite history of significant postpartum hemorrhage requiring blood transfusion was confirmed in 29 patients and three of these had ruptured uterus. The interval between last delivery and diagnosis were - 5, 6]10 and more than 10 years in 10, 12 and eight cases, respectively. Twenty-two of the patients had more than five children before the occurrence of the SS. On CT scan of the brain seven showed empty sellae. Table 1 summarizes the clinical features and serum levels of hormones in the patients. Metaclopramide and insulin stimulation tests obtained in 10 patients were abnormal. The clinical presentation of hypopituitarism vary, depending on the extent and severity of the
0020-7292r99r$20.00 Q 1999 International Federation of Gynecology and Obstetrics. PII: S 0 0 2 0 - 7 2 9 2 Ž 9 9 . 0 0 0 6 5 - X
S. Banzal et al. r International Journal of Gynecology & Obstetrics 66 (1999) 181]182
182
Table 1 Clinical features and serum hormones levels in 30 patients with SS Symptoms
n
Signs
n
Amenorrhearoligomenorrhea Failure of lactation Fatiguerweakness Loss of weight Anorexia GIT symptoms Cold intolerance
30 30 29 26 21 15 11
Absentrsparse axillary pubic hair Breast atrophy Hypotension Depression Confusionrcoma Bradycardia Cachexia
22 21 17 8 7 7 6
Hormone le¨ els Tests Žreference values.
No. abnormal values
Mean " S.D.
T3 Ž0.8]2.7 nmolrl. T4 Ž62]165 nmolrl. TSH Ž0]7 mUrl. FSH Ž0.9]9.8 IUrl. LH Ž2.0]15.4 IUrl. Cortisol Ž65]500 nmolrl. Prolactin Ž120]500 ml.
23 29 29a 30b 30b 27 28
0.53" 0.14 24.6" 13.3 1.5" 1.2 5.1" 3.5 3.8" 3.3 54.9" 28.5 57.5" 39.2
a b
The values were considered inappropriately low for amenorrheic patients. Inappropriate for the respective T3 and T4 levels.
pituitary hormone deficiency w2x. The diagnosis of complete deficiency is straight-forward when features of adrenocortical and thyrotrophin deficiencies co-exist with invariable gonadotrophin and lactotropic deficiencies w2x. All our patients had clinical features related to all aspects of target organ hormonal deficiencies. For cultural and religious reasons, the symptoms of ovarian failure such as decreased libido, vaginal dryness, and dyspareunia were unavailable in many cases. One of our patients presented with diabetes insipidus, in consistence with the low incidence of this complication Ž2]3%. in reported cases of SS w2x. The delay between the onset of symptoms and confirmation of the diagnosis was significant. Only two patients were diagnosed within 1 year and 20 patients had symptoms for over 6 years before diagnosis and appropriate treatment. Although the delay can be attributed to late presentations in the hospital, some of the primary care physicians did not consider SS during the initial evaluation.
The consequences of untreated hypopituitarism include infertility, sexual dysfunction, osteoporosis and pathological fractures. Estrogen deficiency in women may constitute a risk for coronary artery disease. Shock induced by infection or stress is a major cause of death in patients with hypoadrenalism. Improvement in obstetric care in developing countries would reduce the frequency of SS.
References w1x Sheehan HL. The frequency of postpartum hypopituitarism. J Obstet Gynaecol Br Commonw 1965;72: 103]111. w2x Vance ML. Hypopituitarism. N Engl J Med 1994; 330:1651]1662. w3x Dizerage G, Kletzkyo, Misheil D. Diagnosis of Sheehan’s syndrome using a sequential pituitary stimulation test. Am J Obstet Gynaecol 1978;132:348]353. w4x Oelkers W. Adrenal insufficiency. New Engl J Med 1996;335:1206]1212.