Endocrine Abstracts

Bilateral adrenal haemorrhage (BAH) is uncommon in pregnancy; most cases are thought to be secondary to trauma, anti-coagulation, pre-eclampsia, tumour or sepsis, rather than spontaneous. Management is usually conservative, but adrenalectomy may be required in uncontrolled haemorrhage. We discuss two cases of spontaneous BAH presenting in the third trimester.

Case 1: A 23-year-old female with BMI 33kg/m ² presented at 37 weeks’ gestation with a two-week history of worsening right flank pain. Renal ultrasound revealed a 5.5x2.3x5.1cm complex mass superior to the right kidney. She underwent an emergency caesarean section for foetal distress at 37+4, blood pressure was normal throughout. Post-natally CT demonstrated sub-acute spontaneous BAH and hydrocortisone was commenced. Functional testing including plasma catecholamines, aldosterone, renin, androgen screen, urine 5-HIAA and pituitary function tests were normal. She has required glucocorticoid and mineralocorticoid replacement and follow-up MRI confirmed no underlying adrenal lesion.

Case 2: A 24-year-old female with BMI 37 kg/m ² and diet-controlled gestational diabetes presented with severe abdominal/chest pain and vomiting at 30+4 weeks gestation. Contrast CT was performed due to haemodynamic instability to exclude aortic dissection, revealing markedly enlarged adrenal glands with adjacent stranding. Elevated blood pressure settled with analgesia and pre-eclampsia screening was negative. Cortisol was 269 nmol/l and she was commenced on intravenous hydrocortisone. Functional testing was otherwise normal. Spontaneous BAH was confirmed on MRI adrenals three days later and she went on to have a spontaneous vaginal delivery at term. She remains glucocorticoid-dependent two months post-partum, with follow up imaging awaited. Spontaneous BAH in pregnancy is rare and has only been described in the literature as case reports, with true incidence unknown. Increased BMI and gestational diabetes have been suggested as potential additional risk factors in these cases. It remains an important consideration in the differential diagnosis of abdominal pain in pregnancy, particularly in the third trimester.