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==Causes==
==Causes==
As stated, Sheehan's syndrome is caused by damage to the pituitary, thereby causing a decrease in one or more of the hormones it normally secretes. Sheehan's syndrome typically occurs because of excessive blood loss after delivery (post-partum hemorrhage), although there appear to be several risk factors that may contribute to its development.<ref name=":52">{{Cite journal |last=Halit |first=Diri |last2=Zuleyha |first2=Karaca |last3=Fatih |first3=Tanriverdi |last4=Kursad |first4=Unluhizarci |last5=Fahrettin |first5=Kelestimur |date=2016 |title=Sheehan's syndrome: new insights into an old disease |url=https://doi.org/10.1007/s12020-015-0726-3 |journal=Endocrine |volume=51 |issue=1 |pages=22-31 |doi=10.1007/s12020-015-0726-3}}</ref> This syndrome does not appear to be exclusively linked to childbirth, as Sheehan's syndrome has been reported in pregnant patients that experienced massive hemorrhage from non-obstetrical causes.<ref name=":52" /> The pituitary gland grows and has a higher metabolic demand during pregnancy, resulting in an increased demand for blood flow.<ref name=":52" /><ref name=":422">{{Cite journal |last=Keleştimur |first=Fahrettin |name-list-style=vanc |date=December 2003 |title=Sheehan's Syndrome |journal=Pituitary |language=en |volume=6 |issue=4 |pages=181–188 |doi=10.1023/B:PITU.0000023425.20854.8e |issn=1573-7403 |pmid=15237929 |s2cid=25547320}}</ref> One cause of pituitary growth in pregnancy is the proliferation of lactotroph cells which produce prolactin, the hormone responsible for milk production.<ref name=":43">{{Cite journal |last=Keleştimur |first=Fahrettin |name-list-style=vanc |date=December 2003 |title=Sheehan's Syndrome |journal=Pituitary |language=en |volume=6 |issue=4 |pages=181–188 |doi=10.1023/B:PITU.0000023425.20854.8e |issn=1573-7403 |pmid=15237929 |s2cid=25547320}}</ref> Other hormone-secreting cells of the pituitary undergo rapid growth in pregnant women as well, which contribute to the gland's enlargement.<ref name=":22">{{Citation |last=Schury |first=Mark P. |title=Sheehan Syndrome |date=2022 |url=http://www.ncbi.nlm.nih.gov/books/NBK459166/ |work=StatPearls |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=29083621 |access-date=2023-01-25 |last2=Adigun |first2=Rotimi}}</ref>
In the developed world Sheehan’s Syndrome is a rare complication of [[pregnancy]], usually manifesting after excessive blood loss after delivery. The presence of [[disseminated intravascular coagulation]] (i.e., in [[amniotic fluid embolism]] or [[HELLP syndrome]]) also appears to be a factor in its development. A retrospective study in Turkey found that the prevalence of Sheehan’s syndrome was directly proportional to the amount of at-home deliveries each decade.<ref name="Shivaprasad_2011">{{cite journal |vauthors=Shivaprasad C |date=September 2011 |title=Sheehan's syndrome: Newer advances |journal=Indian Journal of Endocrinology and Metabolism |volume=15 Suppl 3 |issue=7 |pages=S203-7 |doi=10.4103/2230-8210.84869 |pmc=3183525 |pmid=22029025}}</ref> This may be due to previously limited obstetric techniques present in a home environment. For example, an area of improvement in preventing the condition could be an increase in the efficacy of treatment to hypovolemic shock through blood transfusion.<ref name="Karaca_2016">{{cite journal |vauthors=Karaca Z, Laway BA, Dokmetas HS, Atmaca H, Kelestimur F |date=December 2016 |title=Sheehan syndrome |journal=Nature Reviews. Disease Primers |volume=2 |pages=16092 |doi=10.1038/nrdp.2016.92 |pmid=28004764 |s2cid=36776064}}</ref>


Thus, if the body enters a state of shock from excessive blood loss in post-partum delivery, the pituitary gland is more susceptible to injury.<ref name=":422" /> Although the vast majority of cases of Sheehan's syndrome occur in the setting of massive blood loss, cases have been documented of acute Sheehan's syndrome occurring with blood loss volumes that do not qualify as "massive".<ref>{{Cite journal |last=Matsuzaki |first=Shinya |last2=Endo |first2=Masayuki |last3=Ueda |first3=Yutaka |last4=Mimura |first4=Kazuya |last5=Kakigano |first5=Aiko |last6=Egawa-Takata |first6=Tomomi |last7=Kumasawa |first7=Keiichi |last8=Yoshino |first8=Kiyoshi |last9=Kimura |first9=Tadashi |date=2017 |title=A case of acute Sheehan’s syndrome and literature review: a rare but life-threatening complication of postpartum hemorrhage |url=http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-017-1380-y |journal=BMC Pregnancy and Childbirth |language=en |volume=17 |issue=1 |pages=188 |doi=10.1186/s12884-017-1380-y |issn=1471-2393}}</ref><ref name=":43" /> Some possible predisposing factors to Sheehan’s syndrome may include: [[Disseminated intravascular coagulation|disseminated blood coagulation]] (DIC), hypotension, small [[Sella turcica|sella]] turcica size, and blood clots from a pre-existing hypercoagulable disorder.<ref name=":52" /> [[Atony]] of the uterus is a leading cause of post-partum hemorrhage, therefore uterine atony could induce Sheehan’s syndrome. <ref name="Karaca_20162">{{cite journal |vauthors=Karaca Z, Laway BA, Dokmetas HS, Atmaca H, Kelestimur F |date=December 2016 |title=Sheehan syndrome |journal=Nature Reviews. Disease Primers |volume=2 |pages=16092 |doi=10.1038/nrdp.2016.92 |pmid=28004764 |s2cid=36776064}}</ref>
Pituitary necrosis may directly result from a lack of blood flow in the hypophyseal artery as a result of pituitary gland enlargement during pregnancy.<ref name=":4">{{Cite journal|last=Keleştimur|first=Fahrettin | name-list-style = vanc |date=December 2003 |title=Sheehan's Syndrome|journal=Pituitary|language=en|volume=6|issue=4|pages=181–188|doi=10.1023/B:PITU.0000023425.20854.8e|pmid=15237929 |s2cid=25547320 |issn=1573-7403}}</ref> One cause of pituitary growth associated with the risk of Sheehan’s syndrome is the hyperplasia of lactotrophs (responsible for prolactin production).<ref name="Aiguo_2007">{{Cite journal |last1=Aiguo |first1=Wu |last2=Guangren |first2=Duan |name-list-style=vanc |date=July 2006 |title=PMID Observer Design of Descriptor Linear Systems |journal=2007 Chinese Control Conference |publisher=IEEE |pages=161–165 |doi=10.1109/chicc.2006.4347343 |isbn=9787811240559 |s2cid=72187}}</ref> [[Ischemia]] may occur as a result of [[vasospasm]], [[thrombosis]], or vascular compression sometimes as a result of an increase in the amount of lactotroph cells throughout gestation (contributing to the enlargement of the pituitary gland).<ref name="Karaca_2016" /> Necrosis may occur as a result of severe hypotension or shock due to excessive uterine bleeding following childbirth.<ref name="Karaca_2016" /> Sheehan’s syndrome may occur as a result of the arterial constriction and abnormal hypotension in conjunction with an insufficiency to meet the increased demand in blood supply of the pituitary gland seen during pregnancy.<ref name="Karaca_2016" /> This increased blood-flow and metabolic demand is associated with the previously mentioned hyperplasia of lactotrophs.<ref name = "Aiguo_2007" />

Some possible predisposing factors to Sheehan’s syndrome may include: inherited or acquired [[Disseminated intravascular coagulation|disseminated blood coagulation]] (DIC), restriction pituitary blood supply, small [[Sella turcica|sella]] size, vasospasm, or thrombosis.<ref name="Karaca_2016" /> Post-Partum Hemorrhaging (PPH) is believed to be a predictor of Sheehan’s syndrome, so the symptoms of anemia, obesity, and advanced maternal age may increase the risk of Sheehan Syndrome.<ref name="Karaca_2016" /> [[Atony]] of the uterus may be related to PPH that could induce Sheehan’s syndrome. This results in the abnormally prolonged flow of blood to the placenta after delivery.<ref name="Karaca_2016" />


==Pathophysiology==
==Pathophysiology==


Sheehan's syndrome is caused by damage to the pituitary, thereby causing a decrease in one or more of the hormones it normally secretes. The anterior pituitary is supplied by a low pressure [[portal venous system]].<ref name="Karaca_2016" /> A 1995 study found that 56.2% of patients with diagnosed Sheehan’s syndrome experienced a loss of all pituitary hormones (with the remaining 43.8% having selective pituitary insufficiency). Since the growth hormone-secreting cells are located at the periphery of the pituitary (and are therefore most likely to be affected by ischemia), all of the patients experienced [[growth hormone deficiency]].<ref name="Shivaprasad_2011" />
Sheehan's syndrome is caused by damage to the pituitary, thereby causing a decrease in one or more of the hormones it normally secretes. The anterior pituitary is supplied by a low pressure [[portal venous system]].<ref name="Karaca_2016">{{cite journal |vauthors=Karaca Z, Laway BA, Dokmetas HS, Atmaca H, Kelestimur F |date=December 2016 |title=Sheehan syndrome |journal=Nature Reviews. Disease Primers |volume=2 |pages=16092 |doi=10.1038/nrdp.2016.92 |pmid=28004764 |s2cid=36776064}}</ref> A 1995 study found that 56.2% of patients with diagnosed Sheehan’s syndrome experienced a loss of all pituitary hormones (with the remaining 43.8% having selective pituitary insufficiency). Since the growth hormone-secreting cells are located at the periphery of the pituitary (and are therefore most likely to be affected by ischemia), all of the patients experienced [[growth hormone deficiency]].<ref name="Shivaprasad_2011">{{cite journal |vauthors=Shivaprasad C |date=September 2011 |title=Sheehan's syndrome: Newer advances |journal=Indian Journal of Endocrinology and Metabolism |volume=15 Suppl 3 |issue=7 |pages=S203-7 |doi=10.4103/2230-8210.84869 |pmc=3183525 |pmid=22029025}}</ref>


==Diagnosis==
==Diagnosis==

Revision as of 05:59, 26 January 2023

Sheehan's Syndrome
Other namesSimmond's syndrome, postpartum hypopituitarism, postpartum pituitary gland necrosis
Anatomy of Normal Pituitary Gland and Surrounding Structures
Empty Sella Turcica on MRI as seen in severe cases of Sheehan's Syndrome
SpecialtyEndocrinology, obstetrics and gynaecology Edit this on Wikidata

Sheehan's syndrome, also known as postpartum pituitary gland necrosis, occurs when the pituitary gland is damaged due to of significant blood loss and hypovolemic shock (ischemic necrosis) usually during or after childbirth leading to decreased functioning of the pituitary gland (hypopituitarism).[1] The pituitary gland is an endocrine organ, meaning it produces certain hormones and is involved in the regulation of various other hormones[2]. This gland is located in the brain and sits in a pocket of the sphenoid bone known as the sella turcica.[3] The pituitary gland works in conjunction with the hypothalamus, and other endocrine organs to modulate numerous bodily functions including growth, metabolism, menstruation, lactation, and even the "fight-or-flight" response.[2] Hence, damage to the pituitary gland can have downstream effects on any of these bodily functions.   

Signs and symptoms

The various signs and symptoms in Sheehan's syndrome are caused by damage to the pituitary, thereby causing a decrease in one or more of the hormones it normally secretes. Since the pituitary controls many glands in the endocrine system, partial or complete loss of a variety of functions may result.[4] Many of the signs and symptoms of Sheehan's are considered "nonspecific" in the medical community; in other words these signs and symptoms are seen in a number of different disease processes, and are not specific to a singular disease or syndrome.[5]

In some cases, a woman with Sheehan syndrome may be relatively asymptomatic initially; therefore, the diagnosis would not be made until years later when features of hypopituitarism become evident.[6] "Uncommonly, [Sheehan's syndrome] can present acutely with circulatory collapse, congestive cardiac failure or psychosis". [7] Hypopituitarism can cause secondary hypothyroidism (hypothyroidism due to pituitary dysfunction), adrenal insufficiency due to glucocorticoid deficiency, sex hormone deficiency (gonadotropin deficiency), prolactin deficiency (a hormone responsible for lactation), growth hormone deficiency, or rarely central diabetes insipidus (Anti-diuretic hormone deficiency). The most common initial symptoms of Sheehan's syndrome are difficulties with or total absence of lactation (agalactorrhea).[6] Another common sign is infrequent menstrual cycles (oligomenorrhea) or absent menstrual cycles (amenorrhea) following delivery.[8] In addition to menstrual irregularities other signs of gonadotropin deficiency are hot flashes, decreased libido, and breast involution.[5]

Symptoms of secondary hypothyroidism are exactly the same as primary hypothyroidism: tiredness, intolerance to cold, constipation, weight gain, hair loss and slowed thinking, as well as a slowed heart rate and low blood pressure.[9] Adrenal insufficiency can present acutely or chronically. In a more chronic case, it is similar to Addison's disease with symptoms including fatigue, weight loss, hypoglycemia (low blood sugar levels), low hemoglobin levels (anemia) and hyponatremia (low sodium levels) that develop over several months or years.[10] Acute adrenal insufficiency is referred to as an adrenal crisis, which can be life-threatening, and occurs very shortly after the inciting event i.e. significant blood loss post-partum in the context of Sheehan's syndrome.[11] Adrenal crisis signs and symptoms include hypoglycemia, hypotension, weakness, fatigue, and seizures from severe hyponatremia.[11]

Growth hormone deficiency is one of the most common hormone deficiencies of hypopituitarism seen in Sheehan’s syndrome.[9] Low levels of growth hormone may present with low energy, body aches, or subtle wrinkling of the skin around the eyes or mouth.[5][12] The symptoms of diabetes insipidus are increased thirst, excessive urination, headache, and fatigue. [13] Hematological changes might be seen as well such as anemia or low platelets (thrombocytopenia).[9] Hyponatremia is seen in many cases of Sheehan's syndrome because it can result from multiple etiologies. Drops in thyroid hormones and glucocorticoid/adrenal hormones can indirectly lead to hyponatremia through water retention, while blood loss can trigger hyponatremia through ADH secretion.[12] The development of Syndrome of Inappropriate Anti-Diuretic Hormone in patients with Sheehan's syndrome has been documented in the literature, although the mechanism is not well understood. [12]

Causes

As stated, Sheehan's syndrome is caused by damage to the pituitary, thereby causing a decrease in one or more of the hormones it normally secretes. Sheehan's syndrome typically occurs because of excessive blood loss after delivery (post-partum hemorrhage), although there appear to be several risk factors that may contribute to its development.[14] This syndrome does not appear to be exclusively linked to childbirth, as Sheehan's syndrome has been reported in pregnant patients that experienced massive hemorrhage from non-obstetrical causes.[14] The pituitary gland grows and has a higher metabolic demand during pregnancy, resulting in an increased demand for blood flow.[14][15] One cause of pituitary growth in pregnancy is the proliferation of lactotroph cells which produce prolactin, the hormone responsible for milk production.[16] Other hormone-secreting cells of the pituitary undergo rapid growth in pregnant women as well, which contribute to the gland's enlargement.[17]

Thus, if the body enters a state of shock from excessive blood loss in post-partum delivery, the pituitary gland is more susceptible to injury.[15] Although the vast majority of cases of Sheehan's syndrome occur in the setting of massive blood loss, cases have been documented of acute Sheehan's syndrome occurring with blood loss volumes that do not qualify as "massive".[18][16] Some possible predisposing factors to Sheehan’s syndrome may include: disseminated blood coagulation (DIC), hypotension, small sella turcica size, and blood clots from a pre-existing hypercoagulable disorder.[14] Atony of the uterus is a leading cause of post-partum hemorrhage, therefore uterine atony could induce Sheehan’s syndrome. [19]

Pathophysiology

Sheehan's syndrome is caused by damage to the pituitary, thereby causing a decrease in one or more of the hormones it normally secretes. The anterior pituitary is supplied by a low pressure portal venous system.[20] A 1995 study found that 56.2% of patients with diagnosed Sheehan’s syndrome experienced a loss of all pituitary hormones (with the remaining 43.8% having selective pituitary insufficiency). Since the growth hormone-secreting cells are located at the periphery of the pituitary (and are therefore most likely to be affected by ischemia), all of the patients experienced growth hormone deficiency.[21]

Diagnosis

Hormonal assays are conducted to determine a patient has low levels of T4, TSH, estrogen, gonadotropin, cortisol, and ACTH depending on the extent of necrosis.[21] It might be difficult to detect damage to these hormone pathways if hormone levels are at the borderline of the abnormal range. In this case, stimulation tests will be done to determine if the pituitary is responsive to hypothalamic hormones.[20] For example, to determine deficiencies in cortisol release, synthetic ACTH might be administered, and hormonal assays will be conducted to determine the strength of the response. Additionally, MRI of the pituitary and hypothalamus: this helps to exclude tumor or other pathologies.[22]

Treatment

Lifelong hormone replacement therapy for the hormones that are missing.[23] This may involve treatment with glucocorticoids. After hormone profiling, treatment with cortisol, ACTH, thyroid hormones, gonadotropins, and prolactin as seen in cases of hypopituitarism may occur.[23]

Epidemiology

In a study of 1,034 symptomatic adults, Sheehan’s syndrome was found to be the sixth-most frequent etiology of growth hormone deficiency, being responsible for 3.1% of cases (versus 53.9% due to a pituitary tumor).[21]

Sheehan syndrome is more prevalent in developing countries than developed countries.[20] Additionally, it was found that the majority of women who experienced Sheehan syndrome gave birth at home rather than in a hospital.[20]

History

The specific association with postpartum shock or hemorrhage was described in 1937 by the British pathologist Harold Leeming Sheehan (1900–1988).[24] The initial distinction was made in the research article “Post-Partum Necrosis of the Anterior Pituitary”.[25] In his research, Dr. Sheehan reviewed (through autopsy) the effects of pituitary necrosis on 12 cases of patients that experienced postpartum necrosis.[25] He observed cases where lesions and death occurred during or after pregnancy, as well as cases where death occurred in the late stage of necrosis (years later). This started the initial distinction of Sheehan’s syndrome from Simmonds’ disease (also known as hypopituitarism). Dr. Sheehan noted that significant feature of these patients' cases was hemorrhaging, which in his experience was most commonly caused by either: placenta Previa (low placenta), uterine rupture, cervical or uterine tears, post-partum atony, or retained placenta. Simmonds' disease, however, occurs in either sex due to causes unrelated to pregnancy.[20]

However, in his 1939 publication: “Simmonds’ Disease due to Post-partum Necrosis of the Anterior Pituitary”, Dr. Sheehan displays post-partum necrosis as a cause of Simmonds’ disease, thus establishing the relationship between the two conditions.[26] According to Sheehan in 1939 approximately 41% of survivors of severe postpartum hemorrhage (PPH) and/or hypovolemic shock experienced severe or partial hypopituitarism.[20]

References

  1. ^ Kaufman MS, Stead LG (2011). First aid for the obstetrics & gynecology clerkship. McGraw-Hill Professional. ISBN 9780071634199. OCLC 768527672.
  2. ^ a b Hammer, Gary; McPhee, Stephen (2019). "Disorders of the Hypothalamus & Pituitary Gland". Pathophysiology of Disease: An Introduction to Clinical Medicine (8 ed.). New York, NY: McGraw-Hill Education. ISBN 978-1-260-02650-4.
  3. ^ Chapman, Philip R.; Singhal, Aparna; Gaddamanugu, Siddhartha; Prattipati, Veeranjaneyulu (November 2020). "Neuroimaging of the Pituitary Gland". Radiologic Clinics of North America. 58 (6): 1115–1133. doi:10.1016/j.rcl.2020.07.009.
  4. ^ Keleştimur F (December 2003). "Sheehan's Syndrome". Pituitary. 6 (4): 181–188. doi:10.1023/B:PITU.0000023425.20854.8e. ISSN 1573-7403. PMID 15237929. S2CID 25547320.
  5. ^ a b c Laway, Bashir Ahmad; Baba, Mohammad Saleem (April 2021). "Sheehan Syndrome". Journal of the Pakistan Medical Association. 71 (4): 1282–12568.
  6. ^ a b Schrager S, Sabo L (September 2001). "Sheehan syndrome: a rare complication of postpartum hemorrhage". The Journal of the American Board of Family Practice. 14 (5): 389–91. PMID 11572546.
  7. ^ Shivaprasad C (September 2011). "Sheehan's syndrome: Newer advances". Indian Journal of Endocrinology and Metabolism. 15 Suppl 3 (7): S203-7. doi:10.4103/2230-8210.84869. PMC 3183525. PMID 22029025.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  8. ^ Halit, Diri; Zuleyha, Karaca; Fatih, Tanriverdi; Kursad, Unluhizarci; Fahrettin, Kelestimur (2016). "Sheehan's syndrome: new insights into an old disease". Endocrine. 51 (1): 22–31. doi:10.1007/s12020-015-0726-3.
  9. ^ a b c Schury, Mark P.; Adigun, Rotimi (2022), "Sheehan Syndrome", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 29083621, retrieved 2023-01-25
  10. ^ "Addison's disease - Symptoms and causes". Mayo Clinic. Retrieved 2019-04-29.
  11. ^ a b Elshimy, Ghada; Chippa, Venu; Jeong, Jordan M. (2022), "Adrenal Crisis", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 29763143, retrieved 2023-01-25
  12. ^ a b c Shivaprasad C (September 2011). "Sheehan's syndrome: Newer advances". Indian Journal of Endocrinology and Metabolism. 15 Suppl 3 (7): S203-7. doi:10.4103/2230-8210.84869. PMC 3183525. PMID 22029025.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  13. ^ Olmes, Gregor Leonhard; Solomayer, Erich-Franz; Radosa, Julia Caroline; Sklavounos, Panagiotis; Agne, Philipp; Schunk, Stefan J.; Haj Hamoud, Bashar (2021-11-15). "Acute Sheehan's syndrome manifesting initially with diabetes insipidus postpartum: a case report and systematic literature review". Archives of Gynecology and Obstetrics. 306 (3): 699–706. doi:10.1007/s00404-021-06294-2. ISSN 1432-0711. PMC 9411080. PMID 34779875.{{cite journal}}: CS1 maint: PMC format (link)
  14. ^ a b c d Halit, Diri; Zuleyha, Karaca; Fatih, Tanriverdi; Kursad, Unluhizarci; Fahrettin, Kelestimur (2016). "Sheehan's syndrome: new insights into an old disease". Endocrine. 51 (1): 22–31. doi:10.1007/s12020-015-0726-3.
  15. ^ a b Keleştimur F (December 2003). "Sheehan's Syndrome". Pituitary. 6 (4): 181–188. doi:10.1023/B:PITU.0000023425.20854.8e. ISSN 1573-7403. PMID 15237929. S2CID 25547320.
  16. ^ a b Keleştimur F (December 2003). "Sheehan's Syndrome". Pituitary. 6 (4): 181–188. doi:10.1023/B:PITU.0000023425.20854.8e. ISSN 1573-7403. PMID 15237929. S2CID 25547320.
  17. ^ Schury, Mark P.; Adigun, Rotimi (2022), "Sheehan Syndrome", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 29083621, retrieved 2023-01-25
  18. ^ Matsuzaki, Shinya; Endo, Masayuki; Ueda, Yutaka; Mimura, Kazuya; Kakigano, Aiko; Egawa-Takata, Tomomi; Kumasawa, Keiichi; Yoshino, Kiyoshi; Kimura, Tadashi (2017). "A case of acute Sheehan's syndrome and literature review: a rare but life-threatening complication of postpartum hemorrhage". BMC Pregnancy and Childbirth. 17 (1): 188. doi:10.1186/s12884-017-1380-y. ISSN 1471-2393.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  19. ^ Karaca Z, Laway BA, Dokmetas HS, Atmaca H, Kelestimur F (December 2016). "Sheehan syndrome". Nature Reviews. Disease Primers. 2: 16092. doi:10.1038/nrdp.2016.92. PMID 28004764. S2CID 36776064.
  20. ^ a b c d e f Karaca Z, Laway BA, Dokmetas HS, Atmaca H, Kelestimur F (December 2016). "Sheehan syndrome". Nature Reviews. Disease Primers. 2: 16092. doi:10.1038/nrdp.2016.92. PMID 28004764. S2CID 36776064.
  21. ^ a b c Shivaprasad C (September 2011). "Sheehan's syndrome: Newer advances". Indian Journal of Endocrinology and Metabolism. 15 Suppl 3 (7): S203-7. doi:10.4103/2230-8210.84869. PMC 3183525. PMID 22029025.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  22. ^ Morani, Ajaykumar; Parmar, Hemant; Ibrahim, Mohannad (2012-01-03). "Teaching NeuroImages: Sequential MRI of the pituitary in Sheehan syndrome". Neurology. 78 (1): e3–e3. doi:10.1212/WNL.0b013e31823ed07d. ISSN 0028-3878. PMID 22201118.
  23. ^ a b Errarhay S, Kamaoui I, Bouchikhi C, Châara H, Bouguern H, Tizniti S, Melhouf A, Banani A (June 2009). "Sheehan's Syndrome A Case Report and Literature Review". The Libyan Journal of Medicine. 4 (2): 81–2. doi:10.4176/081201. PMC 3066722. PMID 21483515.
  24. ^ Sheehan HL (January 1965). "The Repair of Post-Partum Necrosis of the Anterior Lobe of the Pituitary Gland". Acta Endocrinologica. 48 (1): 40–60. doi:10.1530/acta.0.0480040. PMID 14254773.
  25. ^ a b Sheehan HL (1937). "Post-partum necrosis of the anterior pituitary". The Journal of Pathology and Bacteriology. 45 (1): 189–214. doi:10.1002/path.1700450118. ISSN 0368-3494.
  26. ^ Cooke RT (October 1945). "Simmonds's Disease due to Post-partum Necrosis of Anterior Pituitary". British Medical Journal. 2 (4423): 493–4. doi:10.1093/oxfordjournals.qjmed.a069138. PMC 2059949. PMID 20786336.

External links

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