A 27-year-old G2P2 had massive postpartum haemorrhage requiring 6 units of packed cells during her last delivery. Six months later she reports failure of lactation since birth, persistent amenorrhoea, fatigue and loss of pubic hair. Her serum prolactin is low and cortisol response is blunted. What is the most likely diagnosis?

• A Lymphocytic hypophysitis
• B Sheehan syndrome ✓
• C Asherman syndrome
• D Empty sella syndrome

Explanation

Postpartum pituitary necrosis follows severe obstetric haemorrhage and hypotension because the enlarged gravid pituitary has a tenuous blood supply. Failure of lactation from absent prolactin is the earliest clue, followed by amenorrhoea, adrenal and thyroid insufficiency, and loss of axillary and pubic hair. Asherman syndrome causes amenorrhoea but lactation would be normal since the pituitary is intact. Empty sella is usually asymptomatic, and lymphocytic hypophysitis typically presents antepartum or later with mass effects rather than lactation failure immediately after haemorrhage.

Reference: Williams Obstetrics, 26th ed.

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