[Headache in puerperium]. / Een kraamvrouw met hoofdpijn.

BACKGROUND: Sheehan's syndrome is a rare complication of excessive postpartum hemorrhage with impaired function of the pituitary gland (hypopituitarism). Clinical presentation includes headache, fatigue, nausea, symptoms due to electrolyte imbalance and pituitary hormone insufficiency. Cranial imaging can support the diagnosis if pituitary gland ischemia or empty sella sign is detected. Therapy is based on correction of hypovolemia in the acute setting, symptom reduction and chronic hormone replacement treatment. CASE: We report a case of a patient who developed Sheehan's syndrome as a result of severe blood loss during cesarean section. Brain imaging in this case was initially performed with an alternative differential diagnosis in mind. CONCLUSION: Differential diagnosis of headache in puerperium is comprised of a spectrum of syndromes, in which attention for medical and patient history are key. In Sheehan's syndrome early diagnosis is of crucial prognostic importance.

Elevated early follicular progesterone levels and in vitro fertilization outcomes: a prospective intervention study and meta-analysis.

OBJECTIVE: To assess the impact of elevated early follicular progesterone (P) levels in gonadotropin-releasing hormone (GnRH) antagonist cycles on clinical outcome using prospective data in combination with a systematic review and meta-analysis. DESIGN: Nested study within a multicenter randomized controlled trial and a systematic review and meta-analysis. SETTING: Reproductive medicine center in an university hospital. PATIENT(S): 158 in vitro fertilization/intracytoplasmic sperm injection (IVF-ICSI) patients. INTERVENTION(S): Recombinant follicle-stimulating hormone (FSH) (150-225 IU) administered daily from cycle day 2 onward; GnRH antagonist treatment randomly started on cycle day 2 or 6; assignment into two groups according to P level on cycle day 2: normal or elevated (>4.77 nmol/L or >1.5 ng/mL, respectively). MAIN OUTCOME MEASURE(S): Ongoing pregnancy rate (OPR) per started cycle. RESULT(S): The incidence of elevated P was 13.3%. A non-statistically-significant difference in OPR was present between the normal and elevated P groups (27.0% vs. 19.0%). No differential impact of early or late GnRH antagonist initiation on the effect of elevated or normal P on OPR was observed. A systematic search of Medline and EMBASE from 1972-2013 was performed to identify studies analyzing elevated early P levels in GnRH antagonists. The meta-analysis (n=1,052) demonstrated that elevated P levels statistically significantly decreased the OPR with 15% (95% CI -23, -7 %). Heterogeneity across the studies, presumably based on varying protocols, may have modulated the effect of elevated P. CONCLUSION(S): From the present meta-analysis it appears that early elevated P levels are associated with a lower OPR in GnRH antagonists. The incidence of such a condition, however, is low. CLINICAL TRIAL REGISTRATION NUMBER: NCT00866034.