Spontaneous adrenal haemorrhage is a very rare condition. To date there have been only 13 reported cases associated with pregnancy.Case history
A 29 year old para 2+5 presented at 38 weeks gestation with severe right loin pain. She had an otherwise uneventful pregnancy, and no significant medical history. Her observations were normal and urine dipstick was clear. She had marked right renal angle tenderness and a high CRP. She was started on empirical antibiotics for suspected pyelonephritis, and regular opiates for analgesia.Investigations
An abdominal/renal ultrasound and MRI were performed. They showed a 60mm heterogenous mass within the right adrenal and a soft tissue reaction around the left adrenal gland. A diagnosis of ‘spontaneous asymmetrical bilateral adrenal haemorrhages with a large right haematoma’ was made. There was no evidence of adrenal insufficiency and her blood pressure was normal.Management
After discussion with endocrinology team, it was decided to induce labour. She had intravenous Hydrocortisone 100mg QDS in labour. She had a normal vaginal delivery and was discharged home next day, with endocrine and radiological follow up. MRI three months post-natally showed marked resolution of the previous findings.Discussion
Conservative management is probably appropriate during pregnancy, if possible. Occasionally, adrenalectomy may be necessary depending on the patients’ clinical condition.Conclusion
A high index of suspicion is essential, because if unrecognised, it may result in maternal mortality. Close surveillance and follow-up with post-natal MRI is important, to ensure resolution of the lesion, to exclude recurrent haemorrhage and underlying neoplasm.