Sheehan's syndrome presenting with early postpartum congestive heart failure

We report the case of a young woman with Sheehan's syndrome who presented with ventricular arrhythmia and congestive heart failure. The patient was admitted because of postpartum hemorrhage and hypovolemic shock; a massive blood transfusion was required to restore blood volume. After initial stabilization, the patient developed acute respiratory distress and congestive heart failure accompanied by hemodynamic instability 2 weeks after delivery. Episodes of ventricular tachycardia of the torsade de pointes type and a prolonged QT interval were noted on baseline electrocardiogram. A low cortisol level was found incidentally, which led to the suspicion of hypopituitarism. The diagnosis was later supported by laboratory findings of multiple pituitary hormone deficiencies. After administration of corticosteroids and thyroxine, the patient's clinical condition improved dramatically. A pituitary magnetic resonance imaging scan 32 days after delivery revealed a diminished and flattened pituitary gland with prominent intrasellar cerebrospinal fluid loculation, which was compatible with the clinical diagnosis of empty sella with panhypopituitarism. The syndrome of acute anterior pituitary necrosis secondary to postpartum hemorrhage and shock was first described by Sheehan in 1939. Although the occurrence of Sheehan's syndrome is now rare, it should still be considered in any woman with a history of peripartum hemorrhage who develops manifestations of pituitary hormone deficiency. Appropriate hormone replacement therapy is essential and always results in dramatic clinical improvement.