Sheehan syndrome is a state of partial or complete hypopituitarism resulting from infarction of the pituitary gland secondary to postpartum hemorrhage or shock. The syndrome may present immediately postpartum with failure of lactation and amenorrhea but may also present years later with hormone deficiency–related or nonspecific symptoms that lead to diagnostic delay. This case report aims to describe a 57-year-old woman who presented with decrease in sensorium, recurrent severe hyponatremia and hypoglycemia, two decades after a severe postpartum hemorrhage.

Clinical assessment, laboratory evaluation including serum electrolytes, glucose, morning cortisol, ACTH, prolactin, FT3, FT4, and TSH, and cranial MRI with pituitary protocol were performed. Management involved glucocorticoid replacement followed by thyroid hormone supplementation.

Laboratory investigations revealed severe hyponatremia, hypoglycemia, low prolactin, low FT3 and FT4 with normal TSH, and an inappropriately normal morning cortisol with low-normal ACTH. Cranial MRI demonstrated an empty sella with the infundibulum traversing the space. These findings, supported by a history of severe postpartum hemorrhage, confirmed hypopituitarism secondary to Sheehan syndrome. Following glucocorticoid replacement and subsequent levothyroxine therapy, the patient’s clinical condition improved gradually and sodium levels returned to normal. She was discharged stable and was able to return to work.

This case highlights a delayed presentation of Sheehan syndrome occurring two decades after postpartum hemorrhage, manifesting as recurrent severe hyponatremia and hypoglycemia. A high index of suspicion, thorough obstetric history, complete hormonal evaluation, and appropriate imaging are essential for timely diagnosis. Hormone replacement, initiated in the correct sequence, results in substantial clinical improvement.