A 24-year-old woman presented at 33 weeks gestation with severe left-sided abdominal pain and orthopnoea. Ventilation-perfusion scan demonstrated two segmental mismatched defects consistent with bilateral pulmonary embolism. Anticoagulation with enoxaparin was commenced. MRI abdomen, carried out in view of abdominal pain, revealed a 4.5 cm left adrenal mass containing a fluid level. Appearances were in keeping with acute left adrenal haemorrhage. Importantly, both scans had been performed on the same day, so she had not been on prolonged anticoagulation prior to detection of the adrenal haemorrhage. There was no evidence of cortisol or androgen excess. She was normotensive.
Short Synacthen test (SST) was blunted with a baseline cortisol of 33 nmol/L, 30-minute cortisol 147 nmol/L and ACTH 8 mU/L (ref <20). SST was performed following administration of high dose betamethasone because of potential early delivery. True adrenal insufficiency was consequently unlikely. 24-hour urine collection revealed normal 5-HIAA and catecholamines. 24-hour urine steroid profile showed raised pregnanediol of 9044 ug/24 h (<1200) consistent with pregnancy. Serum sodium was 136 mmol/L (133146) and potassium 3.8 mmol/L (3.55.0). Thrombophilia screen was negative.
A diagnosis of left adrenal haemorrhage was made. Anticoagulation was continued in view of bilateral pulmonary emboli. The remainder of her pregnancy was uneventful. She delivered at 40 weeks gestation. Post-partum MRI showed a significant reduction in the size of the left adrenal mass, which now measured 1.1×1.8 cm. There were high T1 and T2 signals reflecting blood breakdown products. She was therefore likely to have undergone primary adrenal haemorrhage rather than haemorrhage into an underlying adenoma. Repeat adrenal functional testing was normal.
We illustrate a rare case of spontaneous adrenal haemorrhage in pregnancy. Adrenal cortex hyperplasia and hypertrophy, associated with pregnancy, is thought to predispose the gland to venous congestion resulting in haemorrhage. It should be considered as a potential diagnosis in a pregnant woman presenting with abdominal pain.