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Endgames Case Review

Severe postpartum headache

BMJ 2017; 357 doi: https://doi.org/10.1136/bmj.j1856 (Published 27 April 2017) Cite this as: BMJ 2017;357:j1856

Rapid Response:

Re: Severe postpartum headache

It is important to consider such devastating causes of postpartum headache as pituitary apoplexy.

Pituitary apoplexy is caused by either hemorrhage or infarction of the pituitary gland. Pregnancy causes pituitary gland (and underlying adenoma, if any) hypertrophy. This results in increased vascular requirements and hence renders the gland more susceptible to ischemia. On the other hand, in Sheehan syndrome, severe postpartum hemorrhage is postulated to trigger secondary arteriolar vasospasm of the anterior pituitary gland, causing infarction and pituitary apoplexy.

The patient will classically present with bitemporal superior quadrantopia and altered mental status.
Visual field and acuity defects are characteristic of this disease due to compression of the optic chiasm, tract or nerves.

The mortality rate of pituitary apoplexy is around 10%. The patient should be managed acutely with medical stabilization, corticosteroid replacement and surgical intervention as necessary. Following conservative management, there is usually spontaneous resolution of hemorrhage with pituitary shrinkage resulting in hypopituitarism requiring long term hormonal replacement.

Competing interests: No competing interests

30 May 2017
Jeremy Chee
Foundation Year 2 Doctor
National University Health System, Singapore
5 Lower Kent Ridge Road, Singapore 119074