Endocrine Abstracts

Section 1: Case history: Adrenal haemorrhage in pregnancy is rare but life threatening. We present the case of a 23-year-old woman who developed idiopathic spontaneous bilateral adrenal haemorrhages during pregnancy. The patient, without significant past medical history, presented at 35 weeks of gestation with right sided lower thoracic and abdominal pain which was thought to be musculoskeletal in nature; she was discharged home once the pain settled. She represented at 37 weeks with recurrent pain which was left-sided in association with breathlessness. Given concern for pulmonary thromboembolism she was anti-coagulated with enoxaparin but a V/Q scan the following day did not demonstrate pulmonary thromboembolism. However, owing to foetal distress an emergency caesarean section was performed at 37 +4 weeks and following this the patient became unwell. The patient was referred to the on-call medical team with suspected sepsis: she was hypotensive and blood tests revealed raised inflammatory markers and a low random cortisol level of 108 nmol/l. CT Abdomen demonstrated bilateral sub-acute adrenal haemorrhages and possible colitis. The patient was treated with IV Hydrocortisone and IV Antibiotics before making a recovery.

Section 2: Investigations and results: Adrenal insufficiency was confirmed during admission by ACTH stimulation test: basal cortisol was <30 nmol/l rising to 43 nmol/l at 30 min. There was no biochemical evidence of hormone excess. ACTH level as an inpatient was 9 mu/l (<20 mu/l) but increased above the reference range as an outpatient. In addition, her aldosterone level whilst an inpatient returned below the level of detection at <130 pmol/l and this did not improve. Repeat ACTH stimulation tests failed to show recovery. MRI adrenals had initially shown large adrenal glands bilaterally but these had become atrophied on repeat imaging at 6 months.

Section 3. Treatment: The patient remains well but continues on steroid replacement therapy.

Section 4: Conclusions and points for discussion: Bilateral adrenal haemorrhage in pregnancy is extremely rare. It is thought that adrenal cortex hyperplasia with hypertrophy during pregnancy predisposes the adrenal gland to venous congestion and therefore haemorrhage. The clinical history and the brief duration of anticoagulation lead us to believe that LMHW was not causative but that this was an idiopathic process. Adrenal haemorrhage should be considered as a potential diagnosis in a pregnant woman presenting with abdominal pain.