Patient handout

Sheehan syndrome (postpartum hypopituitarism)

PRODUCTION

1. Your condition

This handout is for sheehan syndrome (postpartum hypopituitarism). Your care team identified this based on: failure to lactate after delivery complicated by severe pph (fleseriu jcem 2016; karaca pituitary 2021).

Other reasons your team may use this plan: postpartum hypotension/shock not responding to fluids and pressors (fleseriu jcem 2016; diri endocrine 2016); delayed: agalactia + failure to resume menses + fatigue/cold intolerance months–years after obstetric hemorrhage (karaca pituitary 2021; kilicli j endocrinol invest 2023); low target hormone with inappropriately low/normal trophic hormone — central pattern (fleseriu jcem 2016).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
hydrocortisone	100 mg IV/IM bolus STAT, then 50 mg IV q6h OR 200 mg/24h continuous infusion	IV	q6h or continuous infusion	Fleseriu JCEM 2016 — central adrenal insufficiency drives the crisis; empiric stress-dose glucocorticoid is the single most important and mortality-reducing intervention; do NOT delay for cortisol/ACTH
dexamethasone	4 mg IV bolus (only if hydrocortisone unavailable AND a diagnostic cortisol/ACTH window must be preserved)	IV	single dose	Does not cross-react with the cortisol assay; bridge until hydrocortisone available (Fleseriu JCEM 2016)
0.9% sodium chloride resuscitation + glucose correction	1 L 0.9% NaCl IV over 1h then 2–3 L over 24h; D50 25 g IV push for glucose <70; correct Na with rate ceiling <8 mEq/L per 24h	IV	continuous + PRN	Volume + glucose + cautious Na correction concurrent with steroid; high-dose hydrocortisone covers mineralocorticoid effect; Adrogué–Madias ceiling prevents osmotic demyelination (Fleseriu JCEM 2016)
obstetric hemorrhage source control	Uterotonics / tamponade / arterial embolization / surgical hemostasis + transfusion per obstetric protocol when peripartum hemorrhage is ongoing	procedural	as required	The ischemic insult is hemorrhage-driven — controlling the bleed and restoring perfusion is part of the acute bundle (Karaca Pituitary 2021)

Plan: Sheehan replacement — acute crisis stabilization FIRST, then ordered axis replacement (GC before T4) (Fleseriu JCEM 2016)

3. When to call your provider

Contact your care team if any of the following happen:

Intercurrent illness with inadequate stress dosing → ED + IV hydrocortisone (Fleseriu JCEM 2016; Karaca Pituitary 2021)
New shock/hyponatremia/hypoglycemia → treat as adrenal crisis, route to ED (Fleseriu JCEM 2016)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Postpartum (or delayed) hypotension/shock not responding to fluids and vasopressors in a Sheehan substrate — secondary adrenal crisis (Fleseriu JCEM 2016; Diri Endocrine 2016)(life-threatening)
Sodium <125 with neuro symptoms in a Sheehan crisis (Fleseriu JCEM 2016)
Symptomatic hypoglycemia (glucose <70 with neuroglycopenia) from cortisol +/- GH deficiency (Fleseriu JCEM 2016)
Central hypothyroidism identified with glucocorticoid replacement NOT yet established — levothyroxine initiation is contraindicated until GC on board (Fleseriu JCEM 2016)
Known/occult Sheehan with chronic under-replacement decompensating during intercurrent illness/surgery/stress (Karaca Pituitary 2021)(life-threatening)

5. Follow-up

Lifelong individualized replacement, sick-day rules + emergency hydrocortisone IM kit + steroid card + medical alert ID, preconception counseling for future pregnancies, transition to chronic hypopituitarism management, family/obstetric documentation (Fleseriu JCEM 2016; Karaca Pituitary 2021)

6. Sources

Guideline: 2016 Endocrine Society Hormonal Replacement in Hypopituitarism in Adults (Fleseriu JCEM 2016); Sheehan syndrome reviews (Diri/Karaca Endocrine 2015; Kilicli Gynecol Endocrinol 2012); 2018 ETA Guidelines on Central Hypothyroidism (Persani Eur Thyroid J 2018)