The customarily stern face of the director is split by a grin which would shame the Cheshire Cat. "Of course! I knew from the day you started working here that you'd bring great honors upon this hospital!", he proclaims. "Wh-why are you all here?", you manage to ask. "My dear fellow!", says the director effusively, "You've been awarded the Wolf Prize in medicine!" The crowd breaks into applause. You begin to feel ecstatic. "I do deserve it", you think, as you gaze around the room at your beaming colleagues. Your attention is suddenly drawn to the head nurse, who looks worried and slightly annoyed. Nearly drowned out by the thunderous applause, she is shouting "Doctor! Doctor!! Wake up!!" And thus, you are rudely awakened from your delightful daydream ....
"Doctor, Mrs. Wolfe has developed vaginal bleeding. You had better come take a look", she says, after making sure you're fully awake. You recall that Mrs. Wolfe, a 32-year-old stay-at-home mom, delivered her fifth child vaginally four hours ago, following an uncomplicated pregnancy. The delivery was significant for a prolonged second stage of labor. The placenta and products were completely expelled. The child weighed 2.9 kg, and was doing well. Mrs. Wolfe's medical, surgical and obstetric histories were equally unremarkable. You head to her room immediately.
You note that Mrs. Wolfe's pulse is 100 bpm, while her blood pressure is 100/70 mmHg. You quickly flip through her charts to find that her pulse was 82 bpm and blood pressure 120/80 mmHg when last recorded, around an hour ago. Fearing primary postpartum hemorrhage, you alert your team, insert a wide-bore cannula, start a normal saline drip and call the blood bank to reserve two units of A positive packed red cells.
Mrs. Wolfe's uterus feels boggy and poorly contracted when palpated abdominally. You note an active vaginal bleed, and proceed to exclude any local trauma. Her lab results are as follows: WBC: 10.2 x 10^3/mm3 (5.6 - 16.9) RBC: 4.2 x 10^6/ mm3 (2.7 - 4.4) Hemoglobin: 11.2 g/dL (9.5 - 15) Platelets: 170 x10^3/mm3 (146 - 430) Blood urea nitrogen: 10 mg/dL (3-11)
You decide that the best option at this stage is to pack the uterus tightly with gauze, so as to arrest the bleeding, and advise the nursing staff to make preparations for this procedure.
One nurse gives you a puzzled look. "Doctor, isn't packing the uterus a last resort to control the bleeding, until the patient can be taken in for surgery? I may be wrong, but this looks to me like an atonic uterus. Shouldn't we start with oxytocin and a uterine massage?" You realize she is right, and thank her.
Since the uterus is still boggy and uncontracted, you begin a uterine massage. You simultaneously administer a bolus of oxytocin, but the atonicity persists. You then start an oxytocin drip and explore the uterus manually for any retained pieces of placenta; none are to be found.
You prepare to apply bimanual pressure, and instruct the nurses to place Mrs. Wolfe under strict observation. "But doctor!", the nurse interjects, "that's just a temporary measure to stop the bleeding if we plan for surgery or uterine artery embolization". "We don't intend any of those yet, right?" she inquires. You realize that she is right; surgery would be premature at this early stage. The bleeding may be amenable to simpler means, such as a massage, and uterotonics.
Despite your efforts, the uterus is still atonic, and the bleeding continues. Mrs. Wolfe's pulse is now feeble, with a rate of 124 bpm; her blood pressure is 94/66 mmHg.
As Mrs. Wolfe's hemodynamic state is compromised, and you have failed to achieve hemostasis, you urgently prep her for uterine artery embolization. You advise the nurses to prepare to pack the uterus, to stabilize her for the time being.
You decide to continue the oxytocin drip, and prepare for hemostatic brace suturing. The nurses look unconvinced, but reluctantly follow your advice nonetheless. However, it doesn't take too long for you to realize that Mrs. Wolfe's hemodynamic status is deteriorating rapidly. You decide that she urgently requires surgical intervention.
You inform your team to prepare her for a hysterectomy, but the nurse shoots you an alarmed look.
"Doctor", she says, a tad horrified, "Isn't a hysterectomy too extreme? Why not try other options first?" Realizing that she is right, you thank her, and consider a uterine artery embolization before rushing into a hysterectomy.
The procedure is successful, and the bleeding finally subsides. Mrs. Wolfe has an uneventful recovery, and is discharged in a couple of days.
Around two months later, a familiar face appears at your clinic door. It's Mrs. Wolfe, accompanied by her husband. You realize that she looks worried and lethargic ....
"Doctor, I'm having trouble breastfeeding my baby. This didn't happen with any of my other children. We have started feeding her formula now."
Mrs. Wolfe attributes her lethargy to the stresses of caring for a newborn. On closer questioning, she confirms that she has not had any changes in her mood, such as anxiety, sadness, irritability or lability; neither does she have problems with her sleep, appetite or concentration. You also perform a thorough physical exam, which is unremarkable.
You fear that Mrs. Wolfe might be suffering from postpartum depression. Considering the potential hazards to both mother and child, you immediately refer her to a psychiatrist.
In what seems like just a few minutes, you receive a call from the psychiatrist. "I'm glad that you are aware of the importance of postpartum depression, but you also need to consider medical conditions. In my opinion, Mrs. Wolfe's current condition is more likely due to a hormonal imbalance"
You realize that you should indeed have excluded a medical cause first. You thank the psychiatrist, and request that Mrs. Wolfe be sent back to you. A short while later, Mrs. Wolfe is back in your office now, looking somewhat annoyed. You quickly explain the situation to her and apologize, then proceed to decide on which investigations might be most useful.
Which tests will you perform?
You request a pituitary hormone panel, and ask Mrs. Wolfe to turn up on the day the results will be available. She dutifully returns on the due date, and you peruse the following investigation results: Thyroid stimulating hormone (TSH): 0.35 mIU/L (0.5 - 5.0) Follicular stimulating hormone (FSH): 3 IU/L (5 - 20, follicular or luteal phase) Leutinizing hormone (LH): 4 IU/L (5 - 22, follicular or luteal phase)
After going over her labs, and considering her current symptoms and history of postpartum hemorrhage, you arrive at the diagnosis of Sheehan's syndrome.
Suspecting a pituitary abnormality, you decide to order an MRI of the brain, so as to exclude a pituitary tumor. However, the images are negative for a pituitary mass. It dawns on you that although Mrs. Wolfe's pituitary appears normal structurally, there may yet be a functional issue.
You explain the situation to the Wolfes. They seem rather worried, but you gently reassure them - the condition is entirely treatable. "How is it treated, doctor? Will I need brain surgery?", she asks, perturbed. "Of course not!", you reassure her, "You will only need to take some hormones" "Hormones! Oh my - won't they affect the baby, and the breastmilk? I've read on the internet that hormones can be quite dangerous."
How do you respond?
You explain that hormone replacement therapy will induce hydrocortisone, thyroid hormones, estrogen and progesterone, and that it will have no adverse effects on her child or on the breastfeeding. Mrs. Wolfe nods her head in understanding, and thanks you for clarifying matters. She and her husband leave your office happily.
You start to inform Mrs. Wolfe that there may be certain side effects, but then (fortunately) recall that correcting her hormone levels would actually pose no harm.
"The benefits of this therapy far outweigh the risk to the baby…", you do not get to finish your sentence. An alarmed Mrs. Wolfe practically jumps out of her chair. "Risks?! What risks, doctor? Tell me!", she implores. Thinking rapidly, you reply - "Just a second, Mrs. Wolfe, let me finish..."
Mrs. Wolfe responds well to the hormones, and has her levels monitored and adjusted regularly. A couple of weeks later, while out for a jog, you come across Mrs. Wolfe with her children. Even from afar you can tell they are content. Recalling your daydream on that first day, it strikes you that being able to contribute to the happiness of a family is a far greater reward than any prize .... Well done!