Bilateral Spontaneous Adrenal Hemorrhage in Pregnancy: A Lesson in Recognizing Rare Diagnoses

Presentation Number: SUN 409
Date of Presentation: April 2nd, 2017

Asma Al-Zougbi*1, Katherine Ryken2 and Joseph Stephen Dillon3
1University of Iowa Hospitals and Clinics, Iowa City, IA, 2University of Iowa, Iowa City, IA, 3University of Iowa Hospital and Clinics, Iowa City, IA

Abstract

Introduction: Spontaneous adrenal hemorrhage (SAH) is a rare condition that may occur in association with pregnancy. It is rarely recognized due to its obscure nature, thus little is known about its incidence in pregnancy. Here we present two cases of bilateral SAH during pregnancy which were treated conservatively with supportive care and with steroids for possible adrenal insufficiency, with excellent outcomes for mother and baby.

Cases: A 25 year old G1P0 at 33w1d gestation presented with intractable right-sided flank pain radiating to the right shoulder, nausea and vomiting. CT of the abdomen showed an enlarged right adrenal gland with adjacent fat strand representing adrenal infarction versus sub-acute hemorrhage. Work up for hypercoagulable state was unremarkable. She received betamethasone for acceleration of fetal lung maturity. She was managed conservatively with IV fluids and pain management and was discharged 48 hours later. She presented 24 hours later with acute onset of severe left flank pain. Retroperitoneal ultrasound showed mild enlargement of left adrenal gland suggestive of left adrenal hemorrhage. 250 mcg ACTH stimulation test was performed and her cortisol increased from 1.6 mcg/dL to 4.3 mcg/dL at 30 minutes to 4.7 mcg/dL at 60 minutes.

A 27 y.o. G2P0 at 34w3d gestation presented with acute onset abdominal pain, nausea, vomiting. Retroperitoneal ultrasound showed right sided adrenal hemorrhage. Work up for hypercoagulable state was unremarkable. She received 2 doses of betamethasone for acceleration of fetal lung maturity. She was managed conservatively with IV fluids and pain management and was discharged 48 hours later. She presented 24 hours later with left-sided abdominal and flank pain, associated with vomiting. Abdominal ultrasound revealed a small, irregular-shaped fluid collection near the superior pole of the left kidney, suspicious for a left adrenal hemorrhage. 250 mcg ACTH stimulation test was performed and her cortisol increased from 2.8 mcg/dL to 3.4 mcg/dL at 30 minutes to 4.3 mcg/dL at 60 minutes.

Both patients were treated with physiologic doses of hydrocortisone for the remainder of their pregnancies, as the administration of betamethasone two days prior made it impossible to rule out adrenal suppression. They received stress doses of steroid at delivery, which were uncomplicated. Both patients had decrease in the size of the right adrenal hematoma and a normal left adrenal gland on follow up imaging three months postpartum.

Conclusion: Our cases illustrate the importance of considering SAH in the differential of abdominal pain when managing pregnant women. They also illustrate how conservative management, with administration of steroids if there is any concern for adrenal insufficiency, is often sufficient for excellent outcomes for mother and baby.

 

Nothing to Disclose: AA, KR, JSD