Sheehan's syndrome pathophysiology: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Sheehan's syndrome}} | {{Sheehan's syndrome}} | ||
{{CMG}}; {{AE}} | {{CMG}}; {{AE}}{{IQ}} | ||
==Overview== | ==Overview== | ||
It is thought that [[Sheehan's syndrome]] is the result of [[ischemic necrosis]] of [[pituitary gland]] due to its enlargement during [[parturition]]; precipitated by [[hypotension]] due to massive [[hemorrhage]]. Apart from [[pituitary gland]] enlargement during and before [[parturition]], [[vasospasm]], [[Schwartzman reaction|generalized Schwartzman phenomenon]], [[thrombosis]] and compression of the hypophyseal arteries, [[autoimmunity]], [[DIC]], and smaller size of [[sella]] are thought to play a contributing role in [[pathogenesis]] of sheehan's syndrome.[[Occlusion]] and other [[Vascular anomaly|vascular abnormalities]] of the [[hypophyseal portal system]] can also cause [[complications]] in the exchange of [[hormones]] between the [[hypothalamus]] and the [[pituitary gland]], leading to [[hypopituitarism]]. [[Sheehan's syndrome]] results in mild to severe [[pituitary]] dysfunction (partial or [[panhypopituitarism]]), which may cause growth hormone ([[GH]]), [[thyroid hormone]], [[glucocorticoid]], [[gonadotropins]] ([[LH]], [[FSH]]), and [[prolactin]] hormone deficiencies, manifests as a wide [[spectrum]] of [[presentation]]. Usually, [[GH]] is the earliest one to be lost. | |||
==Pathophysiology== | ==Pathophysiology== | ||
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‡[[Disseminated Intravascular Coagulation|Disseminated intravascular coagulation (DIC)]] due to [[Amniotic fluid embolism]] or [[HELLP syndrome|HELLP Syndrome]]. | ‡[[Disseminated Intravascular Coagulation|Disseminated intravascular coagulation (DIC)]] due to [[Amniotic fluid embolism]] or [[HELLP syndrome|HELLP Syndrome]]. | ||
<br> | <br> | ||
†[[Postpartum Hemorrhage|Postpartum hemorrhage (PPH)]] i.e. >500 ml after [[Vaginal|vaginal delivery]] or 1000 ml after [[C-section]]. | †[[Postpartum Hemorrhage|Postpartum hemorrhage (PPH)]] i.e., >500 ml after [[Vaginal|vaginal delivery]] or 1000 ml after [[C-section]]. | ||
<br> </small></small> | <br> </small></small> | ||
===Pathogenesis=== | ===Pathogenesis=== | ||
*[[Pituitary gland]] is amongst the most vascularized [[tissues]] in the body that normally weighs about 0. | *[[Pituitary gland]] is amongst the most vascularized [[tissues]] in the body that normally weighs about 0.5 g but gets doubled in size during pregnancy.<ref name="pmid8325288">{{cite journal |vauthors=Rolih CA, Ober KP |title=Pituitary apoplexy |journal=Endocrinol. Metab. Clin. North Am. |volume=22 |issue=2 |pages=291–302 |year=1993 |pmid=8325288 |doi= |url=}}</ref> | ||
*[[Pituitary gland]] enlargement due to [[hypertrophy]] and [[hyperplasia]] of [[Lactotrophs|lactotrophic cells]] in [[anterior pituitary]] | *[[Pituitary gland]] enlargement due to [[hypertrophy]] and [[hyperplasia]] of [[Lactotrophs|lactotrophic cells]] in [[anterior pituitary]] result in [[superior hypophyseal artery]] compression which is complicated by decreased portal pressure and [[vasospasm]] during delivery, play an important role in the [[pathogenesis]] of [[Sheehan syndrome|Sheehan's syndrome]].<ref name="pmid2159093">{{cite journal |vauthors=Scheithauer BW, Sano T, Kovacs KT, Young WF, Ryan N, Randall RV |title=The pituitary gland in pregnancy: a clinicopathologic and immunohistochemical study of 69 cases |journal=Mayo Clin. Proc. |volume=65 |issue=4 |pages=461–74 |year=1990 |pmid=2159093 |doi= |url=}}</ref> | ||
*Apart from [[Pituitary gland]] enlargement during and before [[parturition]], [[vasospasm]], [[Schwartzman reaction|generalized Schwartzman phenomenon]] , [[thrombosis]] and compression of the hypophyseal arteries, [[autoimmunity]], [[DIC]] and smaller size of [[sella]] are understood to play a role in the [[pathogenesis]] of [[Sheehan syndrome]].<ref name="pmid15237929">{{cite journal |vauthors=Keleştimur F |title=Sheehan's syndrome |journal=Pituitary |volume=6 |issue=4 |pages=181–8 |year=2003 |pmid=15237929 |doi= |url=}}</ref><ref name="McKayMerrill1953">{{cite journal|last1=McKay|first1=Donald G.|last2=Merrill|first2=Samuel J.|last3=Weiner|first3=Albert E.|last4=Hertig|first4=Arthur T.|last5=Reid|first5=Duncan E.|title=The pathologic anatomy of eclampsia, bilateral renal cortical necrosis, pituitary necrosis, and other acute fatal complications of pregnancy, and its possible relationship to the generalized Shwartzman phenomenon|journal=American Journal of Obstetrics and Gynecology|volume=66|issue=3|year=1953|pages=507–539|issn=00029378|doi=10.1016/0002-9378(53)90068-4}}</ref><ref>{{cite journal |last=Apitz |first=Kurt |date=September 1, 1935 |title=A Study of the Generalized Shwartzman Phenomenon|url=http://www.jimmunol.org/content/29/3/255.short|journal=The Journal of Immunology |volume=29 |issue=3 |pages=255-266}}</ref> | *Apart from [[Pituitary gland]] enlargement during and before [[parturition]], [[vasospasm]], [[Schwartzman reaction|generalized Schwartzman phenomenon]], [[thrombosis]] and compression of the hypophyseal arteries, [[autoimmunity]], [[DIC]], and smaller size of [[sella]] are understood to play a role in the [[pathogenesis]] of [[Sheehan syndrome|Sheehan's syndrome]].<ref name="pmid15237929">{{cite journal |vauthors=Keleştimur F |title=Sheehan's syndrome |journal=Pituitary |volume=6 |issue=4 |pages=181–8 |year=2003 |pmid=15237929 |doi= |url=}}</ref><ref name="McKayMerrill1953">{{cite journal|last1=McKay|first1=Donald G.|last2=Merrill|first2=Samuel J.|last3=Weiner|first3=Albert E.|last4=Hertig|first4=Arthur T.|last5=Reid|first5=Duncan E.|title=The pathologic anatomy of eclampsia, bilateral renal cortical necrosis, pituitary necrosis, and other acute fatal complications of pregnancy, and its possible relationship to the generalized Shwartzman phenomenon|journal=American Journal of Obstetrics and Gynecology|volume=66|issue=3|year=1953|pages=507–539|issn=00029378|doi=10.1016/0002-9378(53)90068-4}}</ref><ref>{{cite journal |last=Apitz |first=Kurt |date=September 1, 1935 |title=A Study of the Generalized Shwartzman Phenomenon|url=http://www.jimmunol.org/content/29/3/255.short|journal=The Journal of Immunology |volume=29 |issue=3 |pages=255-266}}</ref> | ||
*It is believed that [[Necrosis|tissue necrosis]] results in release of sequestered [[antigens]], precipitating [[autoimmunity]] of the [[Pituitary gland]] and [[hypopituitarism]] in [[Sheehan's syndrome]].<ref name="pmid12213861">{{cite journal |vauthors=Goswami R, Kochupillai N, Crock PA, Jaleel A, Gupta N |title=Pituitary autoimmunity in patients with Sheehan's syndrome |journal=J. Clin. Endocrinol. Metab. |volume=87 |issue=9 |pages=4137–41 |year=2002 |pmid=12213861 |doi=10.1210/jc.2001-020242 |url=}}</ref><ref name="urlAUTOANTIBODIES IN SHEEHANS SYNDROME - ScienceDirect">{{cite web |url=http://www.sciencedirect.com/science/article/pii/S0140673665913619?via%3Dihub |title=AUTOANTIBODIES IN SHEEHAN'S SYNDROME - ScienceDirect |format= |work= |accessdate=}}</ref><ref name="pmid24434361">{{cite journal |vauthors=Falorni A, Minarelli V, Bartoloni E, Alunno A, Gerli R |title=Diagnosis and classification of autoimmune hypophysitis |journal=Autoimmun Rev |volume=13 |issue=4-5 |pages=412–6 |year=2014 |pmid=24434361 |doi=10.1016/j.autrev.2014.01.021 |url=}}</ref> | *It is believed that [[Necrosis|tissue necrosis]] results in release of sequestered [[antigens]], precipitating [[autoimmunity]] of the [[Pituitary gland]] and [[hypopituitarism]] in [[Sheehan's syndrome]].<ref name="pmid12213861">{{cite journal |vauthors=Goswami R, Kochupillai N, Crock PA, Jaleel A, Gupta N |title=Pituitary autoimmunity in patients with Sheehan's syndrome |journal=J. Clin. Endocrinol. Metab. |volume=87 |issue=9 |pages=4137–41 |year=2002 |pmid=12213861 |doi=10.1210/jc.2001-020242 |url=}}</ref><ref name="urlAUTOANTIBODIES IN SHEEHANS SYNDROME - ScienceDirect">{{cite web |url=http://www.sciencedirect.com/science/article/pii/S0140673665913619?via%3Dihub |title=AUTOANTIBODIES IN SHEEHAN'S SYNDROME - ScienceDirect |format= |work= |accessdate=}}</ref><ref name="pmid24434361">{{cite journal |vauthors=Falorni A, Minarelli V, Bartoloni E, Alunno A, Gerli R |title=Diagnosis and classification of autoimmune hypophysitis |journal=Autoimmun Rev |volume=13 |issue=4-5 |pages=412–6 |year=2014 |pmid=24434361 |doi=10.1016/j.autrev.2014.01.021 |url=}}</ref> | ||
*[[Type 1 diabetes]], pre-existing [[vascular]] diseases and any pituitary masses are associated with increased risk of developing [[Sheehan's syndrome]] in pregnancy. <ref name="Abourawi2006">{{cite journal|last1=Abourawi|first1=F|title=Diabetes Mellitus and Pregnancy|journal=Libyan Journal of Medicine|volume=1|issue=1|year=2006|pages=28–41|issn=19932820|doi=10.4176/060617}}</ref> | *[[Type 1 diabetes]], pre-existing [[vascular]] diseases and any [[pituitary]] masses are associated with increased risk of developing [[Sheehan's syndrome]] in pregnancy.<ref name="Abourawi2006">{{cite journal|last1=Abourawi|first1=F|title=Diabetes Mellitus and Pregnancy|journal=Libyan Journal of Medicine|volume=1|issue=1|year=2006|pages=28–41|issn=19932820|doi=10.4176/060617}}</ref> | ||
=== '''Anterior pituitary''' === | === '''Anterior pituitary''' === | ||
| Line 40: | Line 40: | ||
=== '''Posterior pituitary''' === | === '''Posterior pituitary''' === | ||
*Posterior pituitary has its own blood supply via [[inferior hypophyseal artery]] and is less commonly affected as compared to [[anterior pituitary]]. | *[[Posterior pituitary]] has its own blood supply via [[inferior hypophyseal artery]] and is less commonly affected as compared to [[anterior pituitary]]. | ||
*If posterior pituitary is affected, it can result in [[Neurohypophysis|neurohypophseal]] dysfunction and [[ischemic necrosis]] of thirst center leading to increased osmotic threshold for thirst onset.<ref name="pmid17468192">{{cite journal |vauthors=Atmaca H, Tanriverdi F, Gokce C, Unluhizarci K, Kelestimur F |title=Posterior pituitary function in Sheehan's syndrome |journal=Eur. J. Endocrinol. |volume=156 |issue=5 |pages=563–7 |year=2007 |pmid=17468192 |doi=10.1530/EJE-06-0727 |url=}}</ref> | *If [[posterior pituitary]] is affected, it can result in [[Neurohypophysis|neurohypophseal]] dysfunction and [[ischemic necrosis]] of thirst center leading to increased osmotic threshold for thirst onset.<ref name="pmid17468192">{{cite journal |vauthors=Atmaca H, Tanriverdi F, Gokce C, Unluhizarci K, Kelestimur F |title=Posterior pituitary function in Sheehan's syndrome |journal=Eur. J. Endocrinol. |volume=156 |issue=5 |pages=563–7 |year=2007 |pmid=17468192 |doi=10.1530/EJE-06-0727 |url=}}</ref> | ||
*Severe [[Postpartum hemorrhage|PPH]] (loss of >500ml of blood during the first 24hr) leading to [[hypotension]] and [[ischemic necrosis]] of [[pituitary gland]] is the most common cause of [[Sheehan's syndrome]].<ref name="pmid15237929">{{cite journal |vauthors=Keleştimur F, Chow YW, Pietranico R, Mukerji A, Wiesmann UN, DiDonato S, Herschkowitz NN, Voigt WG, Johnson CR, Moroi K, Sato T, Keleştimur F, Goswami R, Kochupillai N, Crock PA, Jaleel A, Gupta N, Wrightstone RN, Smith LL, Wilson JB, Vella F, Huisman TH, Marniemi J, Parkki MG, Ward CW, Stellwagen E, Babul J, Pogodina VV, Goswami R, Kochupillai N, Crock PA, Jaleel A, Gupta N, Schmoldt A, Benthe HF, Haberland G, Lyons HA, Thomas JS, Heurich AE, Shepherd DA, Wetmore SD, Mekler LB, Sealey JE, White RP, Laragh JH, Rubin AL, Makar AB, McMartin KE, Palese M, Tephly TR, Frankle RT, Makar AB, McMartin KE, Palese M, Tephly TR, Makar AB, McMartin KE, Palese M, Tephly TR, Makar AB, McMartin KE, Palese M, Tephly TR, Makar AB, McMartin KE, Palese M, Tephly TR, Frankle RT, Thornton JA, Harrison MJ, Stellwagen E, Babul J, Leroy M, Loas G, Perez-Diaz F, Schmoldt A, Benthe HF, Haberland G, Coller BS, Franza BR, Gralnick HR |title=Sheehan's syndrome |journal=Pituitary |volume=6 |issue=4 |pages=181–8 |year=2003 |pmid=15237929 |doi=10.1210/jc.2001-020242 |url=}}</ref> | *Severe [[Postpartum hemorrhage|PPH]] (loss of >500ml of blood during the first 24hr) leading to [[hypotension]] and [[ischemic necrosis]] of [[pituitary gland]] is the most common cause of [[Sheehan's syndrome]].<ref name="pmid15237929">{{cite journal |vauthors=Keleştimur F, Chow YW, Pietranico R, Mukerji A, Wiesmann UN, DiDonato S, Herschkowitz NN, Voigt WG, Johnson CR, Moroi K, Sato T, Keleştimur F, Goswami R, Kochupillai N, Crock PA, Jaleel A, Gupta N, Wrightstone RN, Smith LL, Wilson JB, Vella F, Huisman TH, Marniemi J, Parkki MG, Ward CW, Stellwagen E, Babul J, Pogodina VV, Goswami R, Kochupillai N, Crock PA, Jaleel A, Gupta N, Schmoldt A, Benthe HF, Haberland G, Lyons HA, Thomas JS, Heurich AE, Shepherd DA, Wetmore SD, Mekler LB, Sealey JE, White RP, Laragh JH, Rubin AL, Makar AB, McMartin KE, Palese M, Tephly TR, Frankle RT, Makar AB, McMartin KE, Palese M, Tephly TR, Makar AB, McMartin KE, Palese M, Tephly TR, Makar AB, McMartin KE, Palese M, Tephly TR, Makar AB, McMartin KE, Palese M, Tephly TR, Frankle RT, Thornton JA, Harrison MJ, Stellwagen E, Babul J, Leroy M, Loas G, Perez-Diaz F, Schmoldt A, Benthe HF, Haberland G, Coller BS, Franza BR, Gralnick HR |title=Sheehan's syndrome |journal=Pituitary |volume=6 |issue=4 |pages=181–8 |year=2003 |pmid=15237929 |doi=10.1210/jc.2001-020242 |url=}}</ref> | ||
*[[Sheehan's syndrome]] results in mild to severe pituitary dysfunction resulting in partial or [[panhypopituitarism]] such as [[Growth hormone|GH]], [[thyroid hormone]], [[glucocorticoid]], [[gonadotropins]] ([[LH]], [[FSH]]) and [[prolactin]] hormone deficiencies that manifest as a wide spectrum of presentation.<ref name="pmid8043090">{{cite journal |vauthors=Vance ML |title=Hypopituitarism |journal=N. Engl. J. Med. |volume=330 |issue=23 |pages=1651–62 |year=1994 |pmid=8043090 |doi=10.1056/NEJM199406093302306 |url=}}</ref> | *[[Sheehan's syndrome]] results in mild to severe pituitary dysfunction resulting in partial or [[panhypopituitarism]] such as [[Growth hormone|GH]], [[thyroid hormone]], [[glucocorticoid]], [[gonadotropins]] ([[LH]], [[FSH]]), and [[prolactin]] hormone deficiencies that manifest as a wide spectrum of presentation.<ref name="pmid8043090">{{cite journal |vauthors=Vance ML |title=Hypopituitarism |journal=N. Engl. J. Med. |volume=330 |issue=23 |pages=1651–62 |year=1994 |pmid=8043090 |doi=10.1056/NEJM199406093302306 |url=}}</ref> | ||
*Usually, [[Growth hormone|GH]] levels decrease first before others.<ref name="pmid15237929">{{cite journal |vauthors=Keleştimur F |title=Sheehan's syndrome |journal=Pituitary |volume=6 |issue=4 |pages=181–8 |year=2003 |pmid=15237929 |doi= |url=}}</ref> | *Usually, [[Growth hormone|GH]] levels decrease first before others.<ref name="pmid15237929">{{cite journal |vauthors=Keleştimur F |title=Sheehan's syndrome |journal=Pituitary |volume=6 |issue=4 |pages=181–8 |year=2003 |pmid=15237929 |doi= |url=}}</ref> | ||
==Genetics== | ==Genetics== | ||
There is no genetic association found to be associated with | There is no genetic association found to be associated with Sheehan's syndrome. | ||
==Associated Conditions== | ==Associated Conditions== | ||
| Line 56: | Line 56: | ||
==Gross Pathology== | ==Gross Pathology== | ||
*On [[Gross examination|gross]] pathology, [[pituitary gland]] | *On [[Gross examination|gross]] pathology, [[pituitary gland]] follows sequential changes of enlarged [[pituitary gland]] to a small shrunken/[[Atrophy|atrophic]] gland later on replaced by remnants of [[pituitary]] or [[Cerebrospinal fluid|CSF]]. | ||
==Microscopic Pathology== | ==Microscopic Pathology== | ||
| Line 62: | Line 62: | ||
*[[Ischemic necrosis]] leading to [[Scar|scarring]] of [[neurohypophysis]] | *[[Ischemic necrosis]] leading to [[Scar|scarring]] of [[neurohypophysis]] | ||
*[[Scarring]] of [[Paraventricular nucleus of hypothalamus|paraventricular]] and [[Supraoptic nucleus|supraoptic nuclei]] | *[[Scarring]] of [[Paraventricular nucleus of hypothalamus|paraventricular]] and [[Supraoptic nucleus|supraoptic nuclei]] | ||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
Revision as of 15:15, 1 September 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Iqra Qamar M.D.[2]
Overview
It is thought that Sheehan's syndrome is the result of ischemic necrosis of pituitary gland due to its enlargement during parturition; precipitated by hypotension due to massive hemorrhage. Apart from pituitary gland enlargement during and before parturition, vasospasm, generalized Schwartzman phenomenon, thrombosis and compression of the hypophyseal arteries, autoimmunity, DIC, and smaller size of sella are thought to play a contributing role in pathogenesis of sheehan's syndrome.Occlusion and other vascular abnormalities of the hypophyseal portal system can also cause complications in the exchange of hormones between the hypothalamus and the pituitary gland, leading to hypopituitarism. Sheehan's syndrome results in mild to severe pituitary dysfunction (partial or panhypopituitarism), which may cause growth hormone (GH), thyroid hormone, glucocorticoid, gonadotropins (LH, FSH), and prolactin hormone deficiencies, manifests as a wide spectrum of presentation. Usually, GH is the earliest one to be lost.
Pathophysiology
| DIC‡ | Severe PPH† | Glandular hypertrophy and hyperplasia | Small sella size | Autoimmunity | |||||||||||||||||||||||||||||||||||||||||||||
| Hypotension/Shock | Pituitary enlargement | Pituitary compression | |||||||||||||||||||||||||||||||||||||||||||||||
| Blood supply compression | |||||||||||||||||||||||||||||||||||||||||||||||||
| Ischemic necrosis | |||||||||||||||||||||||||||||||||||||||||||||||||
| Hypopituitarism | |||||||||||||||||||||||||||||||||||||||||||||||||
| Amenorrhea | Agalactorrhea | Secondary adrenal insufficiency | Hypothyroidism | ||||||||||||||||||||||||||||||||||||||||||||||
‡Disseminated intravascular coagulation (DIC) due to Amniotic fluid embolism or HELLP Syndrome.
†Postpartum hemorrhage (PPH) i.e., >500 ml after vaginal delivery or 1000 ml after C-section.
Pathogenesis
- Pituitary gland is amongst the most vascularized tissues in the body that normally weighs about 0.5 g but gets doubled in size during pregnancy.[1]
- Pituitary gland enlargement due to hypertrophy and hyperplasia of lactotrophic cells in anterior pituitary result in superior hypophyseal artery compression which is complicated by decreased portal pressure and vasospasm during delivery, play an important role in the pathogenesis of Sheehan's syndrome.[2]
- Apart from Pituitary gland enlargement during and before parturition, vasospasm, generalized Schwartzman phenomenon, thrombosis and compression of the hypophyseal arteries, autoimmunity, DIC, and smaller size of sella are understood to play a role in the pathogenesis of Sheehan's syndrome.[3][4][5]
- It is believed that tissue necrosis results in release of sequestered antigens, precipitating autoimmunity of the Pituitary gland and hypopituitarism in Sheehan's syndrome.[6][7][8]
- Type 1 diabetes, pre-existing vascular diseases and any pituitary masses are associated with increased risk of developing Sheehan's syndrome in pregnancy.[9]
Anterior pituitary
- Anterior pituitary does not have a direct blood supply and is supplied by hypophyseal portal system.
- The hypophyseal portal system is a fenestrated set of capillaries and allows rapid exchange of hormones between hypothalamus and anterior pituitary.
- Occlusion and other vascular abnormalities of the hypophyseal portal system can also cause complications in the exchange of hormones between the hypothalamus and the pituitary gland leading to hypopituitarism.
Posterior pituitary
- Posterior pituitary has its own blood supply via inferior hypophyseal artery and is less commonly affected as compared to anterior pituitary.
- If posterior pituitary is affected, it can result in neurohypophseal dysfunction and ischemic necrosis of thirst center leading to increased osmotic threshold for thirst onset.[10]
- Severe PPH (loss of >500ml of blood during the first 24hr) leading to hypotension and ischemic necrosis of pituitary gland is the most common cause of Sheehan's syndrome.[3]
- Sheehan's syndrome results in mild to severe pituitary dysfunction resulting in partial or panhypopituitarism such as GH, thyroid hormone, glucocorticoid, gonadotropins (LH, FSH), and prolactin hormone deficiencies that manifest as a wide spectrum of presentation.[11]
- Usually, GH levels decrease first before others.[3]
Genetics
There is no genetic association found to be associated with Sheehan's syndrome.
Associated Conditions
Sheehan's syndrome is associated with:
Gross Pathology
- On gross pathology, pituitary gland follows sequential changes of enlarged pituitary gland to a small shrunken/atrophic gland later on replaced by remnants of pituitary or CSF.
Microscopic Pathology
On microscopy, the following findings may be observed:
- Ischemic necrosis leading to scarring of neurohypophysis
- Scarring of paraventricular and supraoptic nuclei
References
- ↑ Rolih CA, Ober KP (1993). "Pituitary apoplexy". Endocrinol. Metab. Clin. North Am. 22 (2): 291–302. PMID 8325288.
- ↑ Scheithauer BW, Sano T, Kovacs KT, Young WF, Ryan N, Randall RV (1990). "The pituitary gland in pregnancy: a clinicopathologic and immunohistochemical study of 69 cases". Mayo Clin. Proc. 65 (4): 461–74. PMID 2159093.
- ↑ 3.0 3.1 3.2 Keleştimur F (2003). "Sheehan's syndrome". Pituitary. 6 (4): 181–8. PMID 15237929.
- ↑ McKay, Donald G.; Merrill, Samuel J.; Weiner, Albert E.; Hertig, Arthur T.; Reid, Duncan E. (1953). "The pathologic anatomy of eclampsia, bilateral renal cortical necrosis, pituitary necrosis, and other acute fatal complications of pregnancy, and its possible relationship to the generalized Shwartzman phenomenon". American Journal of Obstetrics and Gynecology. 66 (3): 507–539. doi:10.1016/0002-9378(53)90068-4. ISSN 0002-9378.
- ↑ Apitz, Kurt (September 1, 1935). "A Study of the Generalized Shwartzman Phenomenon". The Journal of Immunology. 29 (3): 255–266.
- ↑ Goswami R, Kochupillai N, Crock PA, Jaleel A, Gupta N (2002). "Pituitary autoimmunity in patients with Sheehan's syndrome". J. Clin. Endocrinol. Metab. 87 (9): 4137–41. doi:10.1210/jc.2001-020242. PMID 12213861.
- ↑ "AUTOANTIBODIES IN SHEEHAN'S SYNDROME - ScienceDirect".
- ↑ Falorni A, Minarelli V, Bartoloni E, Alunno A, Gerli R (2014). "Diagnosis and classification of autoimmune hypophysitis". Autoimmun Rev. 13 (4–5): 412–6. doi:10.1016/j.autrev.2014.01.021. PMID 24434361.
- ↑ Abourawi, F (2006). "Diabetes Mellitus and Pregnancy". Libyan Journal of Medicine. 1 (1): 28–41. doi:10.4176/060617. ISSN 1993-2820.
- ↑ Atmaca H, Tanriverdi F, Gokce C, Unluhizarci K, Kelestimur F (2007). "Posterior pituitary function in Sheehan's syndrome". Eur. J. Endocrinol. 156 (5): 563–7. doi:10.1530/EJE-06-0727. PMID 17468192.
- ↑ Vance ML (1994). "Hypopituitarism". N. Engl. J. Med. 330 (23): 1651–62. doi:10.1056/NEJM199406093302306. PMID 8043090.