Sheehan's syndrome overview: Difference between revisions
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{{Sheehan's syndrome}} | {{Sheehan's syndrome}} | ||
{{CMG}}; {{AE}} {{IQ}} | {{CMG}}; {{AE}}{{IQ}} | ||
==Overview== | ==Overview== | ||
Sheehan's syndrome is a life threatening complication of severe postpartum hemorrhage (PPH) | Sheehan's syndrome is a life-threatening [[complication]] of severe [[Postpartum haemorrhage|postpartum hemorrhage (PPH)]] that results in mild to severe maternal [[hypopituitarism]]. Sheehan's syndrome is less prevalent in developed countries, but it is still one of the most common causes of [[hypopituitarism]] in underdeveloped and developing countries. During [[pregnancy]], enlarged size of the [[pituitary gland]] and decreased blood supply due to any cause can result in [[ischemic necrosis]] of [[pituitary gland]]. Severe [[Postpartum Hemorrhage|PPH]], [[Glandular tissue|glandular]] [[hypertrophy]] and [[hyperplasia]], smaller [[Sella turcica|sella]] size, [[autoimmunity]], and [[Disseminated Intravascular Coagulation|disseminated vascular coagulation (DIC)]] are thought to play an important role in the [[pathogenesis]] of Sheehan's syndrome. The most common causes of Sheehan's syndrome include [[massive hemorrhage]] during [[parturition]], [[vascular]] compression, and vascular [[occlusion]]. Sheehan's syndrome needs to be differentiated from [[diseases]] causing [[hypopituitarism]] and other diseases like [[lymphocytic hypophysitis]], [[pituitary apoplexy]], [[hypothyroidism]], [[addison's disease]], [[empty sella syndrome]], [[Hypogonadotrophic hypogonadism|hypogonadotropic hypogonadism]], [[Simmond's Disease|simmond's disease]], hypoprolactinemia, and [[menopause]]. [[Risk factors]] for Sheehan's syndrome include [[pregnancy]], [[Massive hemorrhage|severe/massive PPH]], pituitary mass, pre-existing [[Vascular disease|vascular diseases]], smaller and rigid [[Sella turcica|sella]], traumatic delivery, multiple [[Gestation|gestations]], [[placental]] abnormalities, and [[type 1 Diabetes|type 1 diabetes]]. If left untreated, Sheehan's syndrome can lead to [[panhypopituitarism]] and [[empty sella syndrome]]. Common [[complications]] of Sheehan's syndrome include [[adrenal crisis]], [[hypotension]], [[hypothyroidism]], and [[hypopituitarism]]. [[Prognosis]] is generally excellent, providing early [[diagnosis]] and management may result in complete reversal of [[symptoms]]. [[Diagnosis]] of Sheehan's syndrome is made on clinical basis with a recent/remote history of traumatic [[delivery]] or delivery complicated by [[hypotension]]. The most common presentations include [[postpartum]] lactation failure, [[amenorrhea]], loss of sexual hair, [[fatigue]], [[anorexia]], and [[weight loss]]. Clinical features depend on the severity of [[hypopituitarism]] that results from Sheehan's syndrome. Almost all the patients have [[Growth hormone|growth hormone (GH)]], [[prolactin]], and [[gonadotropin]] deficiency; and the majority of the patients have [[Adrenocorticotropic hormone|ACTH]] and [[TSH]] deficiency. Laboratory evaluation in patients with Sheehan's syndrome gives a picture of partial or [[panhypopituitarism]]. Other laboratory findings include [[hyponatremia]], [[hypokalemia]], [[hypocalcemia]], [[hypomagnesemia]], [[hypophosphatemia]], [[anemia]], [[pancytopenia]], [[eosinophilia]], [[hypoalbuminemia]], low [[fasting plasma glucose]], and decreased levels of [[anterior pituitary]] [[hormones]] (free [[thyroxine]], [[estradiol]], and [[cortisol]] levels). The most sensitive test is inadequate [[prolactin]] and [[gonadotropin]] response to stimulation. [[ECG]] findings associated with [[Sheehan's syndrome]] include [[QT interval prolongation]], [[Brugada Syndrome|type-1 Brugada-like ECG pattern]] (due to [[adrenal crisis]]), findings suggestive of [[cardiac tamponade]] ([[sinus tachycardia]], [[Low QRS voltage|low voltage QRS]], and [[electrical alternans]]), and [[dilated cardiomyopathy]]. [[Computed tomography|CT]] scan findings in case of [[acute]] Sheehan's syndrome may show non-[[hemorrhagic]] [[pituitary gland]] enlargement, while [[chronic]] presentation may show an [[empty sella]] or decreased [[Sella turcica|sella]] volume. Findings on [[Magnetic resonance imaging|MRI]] suggestive of [[Sheehan's syndrome]] include decreased [[Sella turcica|sella]] volume, [[empty sella]], [[pituitary]] remnant tissue or [[Cerebrospinal fluid|CSF]] in the [[sella]]. The treatment of Sheehan's syndrome involves appropriate [[hormone replacement therapy]], which must be taken for the rest of the patient's life, results in significant improvement and reversal of not only the physical symptoms, but also the [[psychological]] symptoms. | ||
==Historical Perspective== | ==Historical Perspective== | ||
Sheehan's syndrome was first discovered by Leon Konrad Gliński about a century ago and it was named after Harold Sheehan (1900-1988). | |||
==Classification== | ==Classification== | ||
Sheehan's syndrome may be classified based on the onset or presentation of [[symptoms]] and the degree of [[glandular]] damage. Sheehan's syndrome may be classified into acute and chronic subtypes based on the time period after [[delivery]] and also extent of [[Gland|glandular]] damage. | |||
==Pathophysiology== | ==Pathophysiology== | ||
It is | It is believed that Sheehan's syndrome is the result of [[ischemic necrosis]] of [[pituitary gland]], due to [[pituitary gland]] [[Enlargement of organs|enlargement]] during [[parturition]] that is 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 turcica|sella]] play a contributing role in [[pathogenesis]] of Sheehan's syndrome. [[Occlusion]] and other [[Vascular anomaly|vascular anomalies]] of the [[hypophyseal portal system]] can also complicate the exchange of [[hormones]] between the [[hypothalamus]] and the [[pituitary gland]], leading to [[hypopituitarism]]. Sheehan's syndrome may result in mild to severe [[pituitary]] dysfunction (partial or [[panhypopituitarism]]), which is identified with growth hormone ([[GH|GH)]], [[thyroid hormone]], [[glucocorticoid]], [[gonadotropins]], and [[prolactin]] [[Hormone|hormone deficiencies]], and manifests as a wide spectrum of presentation. Usually, [[Growth hormone|GH]] deficiency is the earliest one to develop. | ||
==Causes== | ==Causes== | ||
Common causes of Sheehan's syndrome include [[massive hemorrhage]], [[Hypotension|hypotensio]]<nowiki/>n during pregnancy, [[vascular]] compression, and vascular [[occlusion]] ([[thrombosis]], [[DIC]]). Less common causes | Common causes of Sheehan's syndrome include [[massive hemorrhage]], [[Hypotension|hypotensio]]<nowiki/>n during pregnancy, [[vascular]] compression, and vascular [[occlusion]] ([[thrombosis]], [[DIC]]). Less common causes are [[vascular insufficiency]] due to [[CABG|coronary artery bypass grafting (CABG)]] in older patients and [[Snake bite|snake bites]] (Russell's [[viper]] bites). | ||
==Differentiating | ==Differentiating Sheehan's syndrome from Other Diseases== | ||
Sheehan syndrome must be differentiated from [[lymphocytic hypophysitis]], [[pituitary apoplexy]], [[hypothyroidism]], [[Addison's disease]], [[panhypopituitarism]], [[empty sella syndrome]], [[hypogonadotropic hypogonadism]], [[Simmond's Disease|Simmond's disease]], hypoprolactinemia and [[menopause]] | Sheehan's syndrome must be differentiated from [[lymphocytic hypophysitis]], [[pituitary apoplexy]], [[hypothyroidism]], [[Addison's disease]], [[panhypopituitarism]], [[empty sella syndrome]], [[hypogonadotropic hypogonadism]], [[Simmond's Disease|Simmond's disease]], hypoprolactinemia, and [[menopause]] on the basis of hypo-functioning of the pituitary. | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
The incidence of Sheehan's syndrome is difficult to assess. | The [[incidence]] of Sheehan's syndrome is difficult to assess. It was found to be the 6th most common cause of [[Growth hormone|growth hormone (GH)]] deficiency with an [[incidence]] of 3.1% of cases. In 2009, the [[prevalence]] of Sheehan's syndrome was estimated to be 5.1 per 100,000 women. Sheehan's syndrome is less [[Prevalence|prevalent]] in [[Developed country|developed countries]] due to better [[obstetrical]] care and [[maternal health]] awareness. Sheehan's syndrome is one of the most common [[causes]] of [[hypopituitarism]] in developing countries. | ||
==Risk Factors== | ==Risk Factors== | ||
Common risk factors in the development of Sheehan's syndrome include pregnancy, severe/massive PPH, pituitary mass, pre-existing vascular diseases, autoimmunity, | Common risk factors in the development of Sheehan's syndrome include [[pregnancy]], severe/massive [[Postpartum hemorrhage|postpartum hemorrhage (PPH)]], [[pituitary]] mass, pre-existing [[Vascular disease|vascular diseases]], [[autoimmunity]], [[Disseminated intravascular coagulation|DIC]], smaller and rigid [[sella]], and traumatic [[Childbirth|delivery]]. | ||
==Screening== | ==Screening== | ||
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==Natural History, Complications, and Prognosis== | ==Natural History, Complications, and Prognosis== | ||
Sheehan's syndrome | If left untreated, Sheehan's syndrome leads to [[hypopituitarism]] and [[empty sella syndrome]]. Common complications are [[adrenal crisis]], [[hypotension]], [[hypothyroidism]], and [[hypopituitarism]]. [[Prognosis]] is generally excellent; early [[diagnosis]] and management often results in a complete reversal of symptoms. | ||
==Diagnosis== | ==Diagnosis== | ||
Diagnosis is made on clinical basis with a recent | Diagnosis of Sheehan's syndrome is made on clinical basis with a recent or remote history of traumatic delivery or delivery complicated by [[hypotension]]. Diagnosis is mostly clinical but detailed medical history, measurement of [[pituitary hormone]] levels in blood, [[pituitary hormone]] stimulation tests and imaging ([[MRI]] preferred on [[CT]]) studies can help in making the diagnosis. | ||
===History and Symptoms=== | ===History and Symptoms=== | ||
The most common symptoms of Sheehan's sydrome | The most common symptoms of Sheehan's sydrome are agalactorrhea and failure to resume [[menstruation]] after [[parturition]]. Common symptoms are [[hot flushes|hot flashes]], decreased [[Pubic hair|pubic]] or [[axillary hair]], [[hypotension]], [[hypoglycemia]], features of [[hypothyroidism]], [[hypoadrenalism]], and [[hypogonadism]]. | ||
===Physical Examination=== | ===Physical Examination=== | ||
Patients with syndrome usually appear fatigued and lethargic. Physical examination is | Patients with Sheehan's syndrome usually appear [[Fatigue|fatigued]] and [[lethargic]]. Physical examination is remarkable for [[bradycardia]], [[hypotension]], [[pallor]], and signs suggestive of respective pituitary hormonal deficiency. | ||
===Laboratory Findings=== | ===Laboratory Findings=== | ||
Laboratory findings consistent with the diagnosis of Sheehan's syndrome include hyponatremia, hypokalemia, hypocalcemia, hypomagnesemia, hypophosphatemia, anemia, pancytopenia, eosinophilia, hypoalbuminemia | Laboratory findings consistent with the diagnosis of Sheehan's syndrome include [[hyponatremia]], [[hypokalemia]], [[hypocalcemia]], [[hypomagnesemia]], [[hypophosphatemia]], [[anemia]], [[pancytopenia]], [[eosinophilia]], [[hypoalbuminemia]] and low [[fasting plasma glucose]]. | ||
===Electrocardiogram=== | ===Electrocardiogram=== | ||
ECG findings associated with Sheehan's syndrome | [[ECG|Electrocardiogram (ECG)]] findings associated with Sheehan's syndrome may include [[QT interval prolongation]], [[Brugada Syndrome|type-1 Brugada-like]] [[ECG]] pattern (due to [[adrenal crisis]]), or findings suggestive of [[cardiac tamponade]] or [[dilated cardiomyopathy]]. | ||
===X-ray=== | ===X-ray=== | ||
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===CT scan=== | ===CT scan=== | ||
CT scans in patients with Sheehan's syndrome shows non-hemorrhagic [[pituitary]] gland enlargement in acute cases while chronic cases present as an [[empty sella]] or decreased [[Sella turcica|sella]] volume. | |||
===MRI=== | ===MRI=== | ||
Findings on MRI suggestive of Sheehan's syndrome | Findings on [[MRI]] suggestive of Sheehan's syndrome are decreased [[sella]] volume, [[empty sella]], [[pituitary]] remnant tissue, or [[CSF|cerebrospinal fluid (CSF)]] in [[sella]]. | ||
===Ultrasound=== | ===Ultrasound and Echocardiography=== | ||
[[Echocardiography]] findings associated with Sheehan's syndrome may include reversible [[dilated cardiomyopathy]] and [[pericardial effusion]]. | |||
===Other Imaging Findings=== | ===Other Imaging Findings=== | ||
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===Other Diagnostic Studies=== | ===Other Diagnostic Studies=== | ||
Surgical intervention may be considered when there is emergency presentation, such as [[pituitary apoplexy]] or [[subarachnoid hemorrhage]] causing Sheehan's syndrome to prevent [[hypopituitarism]]. | |||
==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
The treatment of Sheehan's syndrome involves [[hormone replacement therapy]], which generally results in complete recovery and reversal of symptoms. | |||
===Surgery=== | ===Surgery=== | ||
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===Primary Prevention=== | ===Primary Prevention=== | ||
Effective measures for the primary prevention of Sheehan's syndrome include | Effective measures for the primary prevention of Sheehan's syndrome include improved [[obstetrical]] care and [[perinatal]] monitoring, prevention of [[pregnancy]] related complications such as [[hypotension]] or [[hemorrhage]], maternal awareness about risk factors of Sheehan's syndrome, and post-puerperal follow up. | ||
===Secondary Prevention=== | ===Secondary Prevention=== | ||
Effective measures for the secondary prevention | Effective measures for the secondary prevention of sheehan's syndrome are early [[diagnosis]] and treatment to prevent life-threatening complications, such as [[adrenal]] crisis and [[infertility]]. Other measures of secondary prevention include frequent prenatal visits and prevention of development of [[hypotension]] due to any reason. | ||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
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{{WikiDoc Help Menu}} | {{WikiDoc Help Menu}} | ||
{{WikiDoc Sources}} | {{WikiDoc Sources}} | ||
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[[Category:Up-To-Date]] | |||
[[Category:Emergency medicine]] | |||
[[Category:Obstetrics]] | |||
Latest revision as of 00:09, 30 July 2020
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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
Sheehan's syndrome is a life-threatening complication of severe postpartum hemorrhage (PPH) that results in mild to severe maternal hypopituitarism. Sheehan's syndrome is less prevalent in developed countries, but it is still one of the most common causes of hypopituitarism in underdeveloped and developing countries. During pregnancy, enlarged size of the pituitary gland and decreased blood supply due to any cause can result in ischemic necrosis of pituitary gland. Severe PPH, glandular hypertrophy and hyperplasia, smaller sella size, autoimmunity, and disseminated vascular coagulation (DIC) are thought to play an important role in the pathogenesis of Sheehan's syndrome. The most common causes of Sheehan's syndrome include massive hemorrhage during parturition, vascular compression, and vascular occlusion. Sheehan's syndrome needs to be differentiated from diseases causing hypopituitarism and other diseases like lymphocytic hypophysitis, pituitary apoplexy, hypothyroidism, addison's disease, empty sella syndrome, hypogonadotropic hypogonadism, simmond's disease, hypoprolactinemia, and menopause. Risk factors for Sheehan's syndrome include pregnancy, severe/massive PPH, pituitary mass, pre-existing vascular diseases, smaller and rigid sella, traumatic delivery, multiple gestations, placental abnormalities, and type 1 diabetes. If left untreated, Sheehan's syndrome can lead to panhypopituitarism and empty sella syndrome. Common complications of Sheehan's syndrome include adrenal crisis, hypotension, hypothyroidism, and hypopituitarism. Prognosis is generally excellent, providing early diagnosis and management may result in complete reversal of symptoms. Diagnosis of Sheehan's syndrome is made on clinical basis with a recent/remote history of traumatic delivery or delivery complicated by hypotension. The most common presentations include postpartum lactation failure, amenorrhea, loss of sexual hair, fatigue, anorexia, and weight loss. Clinical features depend on the severity of hypopituitarism that results from Sheehan's syndrome. Almost all the patients have growth hormone (GH), prolactin, and gonadotropin deficiency; and the majority of the patients have ACTH and TSH deficiency. Laboratory evaluation in patients with Sheehan's syndrome gives a picture of partial or panhypopituitarism. Other laboratory findings include hyponatremia, hypokalemia, hypocalcemia, hypomagnesemia, hypophosphatemia, anemia, pancytopenia, eosinophilia, hypoalbuminemia, low fasting plasma glucose, and decreased levels of anterior pituitary hormones (free thyroxine, estradiol, and cortisol levels). The most sensitive test is inadequate prolactin and gonadotropin response to stimulation. ECG findings associated with Sheehan's syndrome include QT interval prolongation, type-1 Brugada-like ECG pattern (due to adrenal crisis), findings suggestive of cardiac tamponade (sinus tachycardia, low voltage QRS, and electrical alternans), and dilated cardiomyopathy. CT scan findings in case of acute Sheehan's syndrome may show non-hemorrhagic pituitary gland enlargement, while chronic presentation may show an empty sella or decreased sella volume. Findings on MRI suggestive of Sheehan's syndrome include decreased sella volume, empty sella, pituitary remnant tissue or CSF in the sella. The treatment of Sheehan's syndrome involves appropriate hormone replacement therapy, which must be taken for the rest of the patient's life, results in significant improvement and reversal of not only the physical symptoms, but also the psychological symptoms.
Historical Perspective
Sheehan's syndrome was first discovered by Leon Konrad Gliński about a century ago and it was named after Harold Sheehan (1900-1988).
Classification
Sheehan's syndrome may be classified based on the onset or presentation of symptoms and the degree of glandular damage. Sheehan's syndrome may be classified into acute and chronic subtypes based on the time period after delivery and also extent of glandular damage.
Pathophysiology
It is believed that Sheehan's syndrome is the result of ischemic necrosis of pituitary gland, due to pituitary gland enlargement during parturition that is 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 play a contributing role in pathogenesis of Sheehan's syndrome. Occlusion and other vascular anomalies of the hypophyseal portal system can also complicate the exchange of hormones between the hypothalamus and the pituitary gland, leading to hypopituitarism. Sheehan's syndrome may result in mild to severe pituitary dysfunction (partial or panhypopituitarism), which is identified with growth hormone (GH), thyroid hormone, glucocorticoid, gonadotropins, and prolactin hormone deficiencies, and manifests as a wide spectrum of presentation. Usually, GH deficiency is the earliest one to develop.
Causes
Common causes of Sheehan's syndrome include massive hemorrhage, hypotension during pregnancy, vascular compression, and vascular occlusion (thrombosis, DIC). Less common causes are vascular insufficiency due to coronary artery bypass grafting (CABG) in older patients and snake bites (Russell's viper bites).
Differentiating Sheehan's syndrome from Other Diseases
Sheehan's syndrome must be differentiated from lymphocytic hypophysitis, pituitary apoplexy, hypothyroidism, Addison's disease, panhypopituitarism, empty sella syndrome, hypogonadotropic hypogonadism, Simmond's disease, hypoprolactinemia, and menopause on the basis of hypo-functioning of the pituitary.
Epidemiology and Demographics
The incidence of Sheehan's syndrome is difficult to assess. It was found to be the 6th most common cause of growth hormone (GH) deficiency with an incidence of 3.1% of cases. In 2009, the prevalence of Sheehan's syndrome was estimated to be 5.1 per 100,000 women. Sheehan's syndrome is less prevalent in developed countries due to better obstetrical care and maternal health awareness. Sheehan's syndrome is one of the most common causes of hypopituitarism in developing countries.
Risk Factors
Common risk factors in the development of Sheehan's syndrome include pregnancy, severe/massive postpartum hemorrhage (PPH), pituitary mass, pre-existing vascular diseases, autoimmunity, DIC, smaller and rigid sella, and traumatic delivery.
Screening
There is insufficient evidence to recommend routine screening for Sheehan's syndrome.
Natural History, Complications, and Prognosis
If left untreated, Sheehan's syndrome leads to hypopituitarism and empty sella syndrome. Common complications are adrenal crisis, hypotension, hypothyroidism, and hypopituitarism. Prognosis is generally excellent; early diagnosis and management often results in a complete reversal of symptoms.
Diagnosis
Diagnosis of Sheehan's syndrome is made on clinical basis with a recent or remote history of traumatic delivery or delivery complicated by hypotension. Diagnosis is mostly clinical but detailed medical history, measurement of pituitary hormone levels in blood, pituitary hormone stimulation tests and imaging (MRI preferred on CT) studies can help in making the diagnosis.
History and Symptoms
The most common symptoms of Sheehan's sydrome are agalactorrhea and failure to resume menstruation after parturition. Common symptoms are hot flashes, decreased pubic or axillary hair, hypotension, hypoglycemia, features of hypothyroidism, hypoadrenalism, and hypogonadism.
Physical Examination
Patients with Sheehan's syndrome usually appear fatigued and lethargic. Physical examination is remarkable for bradycardia, hypotension, pallor, and signs suggestive of respective pituitary hormonal deficiency.
Laboratory Findings
Laboratory findings consistent with the diagnosis of Sheehan's syndrome include hyponatremia, hypokalemia, hypocalcemia, hypomagnesemia, hypophosphatemia, anemia, pancytopenia, eosinophilia, hypoalbuminemia and low fasting plasma glucose.
Electrocardiogram
Electrocardiogram (ECG) findings associated with Sheehan's syndrome may include QT interval prolongation, type-1 Brugada-like ECG pattern (due to adrenal crisis), or findings suggestive of cardiac tamponade or dilated cardiomyopathy.
X-ray
There are no x-ray findings associated with Sheehan's syndrome.
CT scan
CT scans in patients with Sheehan's syndrome shows non-hemorrhagic pituitary gland enlargement in acute cases while chronic cases present as an empty sella or decreased sella volume.
MRI
Findings on MRI suggestive of Sheehan's syndrome are decreased sella volume, empty sella, pituitary remnant tissue, or cerebrospinal fluid (CSF) in sella.
Ultrasound and Echocardiography
Echocardiography findings associated with Sheehan's syndrome may include reversible dilated cardiomyopathy and pericardial effusion.
Other Imaging Findings
There are no other imaging findings associated with Sheehan's syndrome.
Other Diagnostic Studies
Surgical intervention may be considered when there is emergency presentation, such as pituitary apoplexy or subarachnoid hemorrhage causing Sheehan's syndrome to prevent hypopituitarism.
Treatment
Medical Therapy
The treatment of Sheehan's syndrome involves hormone replacement therapy, which generally results in complete recovery and reversal of symptoms.
Surgery
Surgical intervention is not recommended for the management of Sheehan's syndrome.
Primary Prevention
Effective measures for the primary prevention of Sheehan's syndrome include improved obstetrical care and perinatal monitoring, prevention of pregnancy related complications such as hypotension or hemorrhage, maternal awareness about risk factors of Sheehan's syndrome, and post-puerperal follow up.
Secondary Prevention
Effective measures for the secondary prevention of sheehan's syndrome are early diagnosis and treatment to prevent life-threatening complications, such as adrenal crisis and infertility. Other measures of secondary prevention include frequent prenatal visits and prevention of development of hypotension due to any reason.
References