Abdominal pain, a common complaint during pregnancy, has a broad differential diagnosis which includes spontaneous adrenal hemorrhage (SAH). While autopsy reports reveal that between 0.03 and 1.8% of unselected cases demonstrate adrenal hemorrhage, the incidence among pregnant women is unknown [
A 35-year-old nulliparous patient at 36 weeks of gestation presented to labor and delivery complaining of sudden onset, left sided back pain which radiated anteriorly. She denied any other gastrointestinal or urinary symptoms. The patient had a past medical history significant only for chronic hypertension and a past surgical history of laparoscopic Roux en Y gastric bypass two years priorly. She denied any prior complications related to this surgical history. The pregnancy was further complicated by gestational diabetes class A1. On presentation the patient had a blood pressure of 162/80 and heart rate of 70 beats per minute and was saturating 99% on room air. Initial exam revealed the abdomen to be tender to palpation in left upper quadrant with no guarding and no peritoneal signs. There were no symptoms of labor and fetal status was reassuring.
Complete blood count, coagulation studies, liver function tests, amylase, and lipase were all within normal limits with a hemoglobin of 12.4 g/dL. A urinalysis demonstrated rare bacteria and calcium oxalate crystals, but no blood. A renal ultrasound showed no evidence of hydronephrosis, mass, or stone. An obstetrical ultrasound revealed a live singleton fetus with a normal appearing anterior placenta and appropriate fetal growth. Intravenous narcotics were required for adequate pain control. General surgery was consulted given her history of gastric bypass and concern for a possible related complication. A CT scan of the abdomen demonstrated a mildly enlarged left adrenal gland with areas of hyperdensity consistent with acute left adrenal hemorrhage (Figure
CT scan findings with arrow pointing at left adrenal hemorrhage.
A 27-year-old multiparous patient presented to labor and delivery at 38 weeks of gestation for evaluation of sudden onset, left upper quadrant pain that radiated to the midline. The patient also reported regular, painful contractions. She had a past medical history significant for nephrolithiasis during her previous pregnancy, bipolar disease, and migraines. Prior surgeries included a diagnostic laparoscopy for chronic pelvic pain, Loop Electrosurgical Excision Procedure, and 2 elective terminations of pregnancy. The patient was a 5-6-cigarette/day smoker. On admission vital signs were within normal limits. Physical examination revealed her abdomen to be soft and minimally tender to palpation. A complete blood count was within normal limits with a hemoglobin of 12.4 g/dL. A urine drug screen was negative and a urinalysis revealed no blood or evidence of infection. Fetal status was reassuring and an obstetric ultrasound revealed no apparent pathology. The patient’s pain improved with intravenous narcotics, antacids, and a muscle relaxer and was attributed to a likely musculoskeletal etiology. However, the patient was found to be in spontaneous labor and progressed to deliver a male infant without complication. Intrapartum pain relief was provided via epidural. On the first postpartum day the patient again complained of left sided flank and upper abdominal pain and was presumptively treated for nephrolithiasis, given the clinical presentation and history, with intravenous narcotics and hydration. Despite treatment, the pain worsened and was associated with nausea and two episodes of emesis. A CT scan of the abdomen revealed enlargement and mild heterogeneity of the left adrenal gland with surrounding fat stranding consistent with acute left adrenal hemorrhage. An MRI performed at the request of the attending physician confirmed these findings as seen in Figure
MRI findings of left adrenal hemorrhage.
If unrecognized, adrenal hemorrhage can lead to adrenal crisis, shock, and theoretically death for both mother and fetus and should be considered in the differential diagnosis of abdominal pain in pregnancy [
While the initial abdominal imaging study in pregnancy is typically ultrasound, sonographic findings of adrenal hemorrhage are nonspecific. MRI or CT scan is needed to confirm the diagnosis and to evaluate for potential underlying etiology such as pheochromocytoma or malignant tumor [
Appropriate management of SAH in pregnancy depends on the stability of the patient. Conservative management includes supportive therapy with intravenous fluids, pain control, and serial hemoglobin assessments with blood transfusion and correction of coagulopathy as indicated [
SAH, although rare, is an important consideration when evaluating abdominal and flank pain in pregnancy. Diagnosis requires a high index of suspicion, particularly when more common etiologies of pain are excluded as was demonstrated in the two cases presented in this report. Diagnosis can be made by MRI or CT scan. In a clinically stable pregnant patient with SAH conservative management and vaginal delivery are safe and appropriate.
The abstract for this manuscript was presented at the ACOG annual clinical meeting in Washington DC on May 14–17, 2016.
The authors declare that there are no conflicts of interest regarding the publication of this paper.
The authors would like to thank Dr. David Ginsburg for obtaining informed consent.