Spontaneous adrenal haemorrhage in pregnancy is an uncommon clinical condition. Symptoms varies from abdominal pain, with associated nausea and vomiting to shock with life-threatening deterioration. Non-specific presentations make clinical diagnosis challenging and failure to recognize could result in fatal outcome.1,2
A 31-year-old nulliparous lady at 38-week-gestation presented to Dunedin Hospital with severe right upper quadrant (RUQ) and central back pain. There was no history of trauma, anticoagulant therapy or hypertension at presentation and no significant past medical history. The pregnancy had been uncomplicated except mild nausea since late first trimester.
Examination revealed a pregnant lady in distress with severe pain. She was clinically stable with normal obstetric findings and foetal monitoring evaluation. On abdominal examination, she had a tender RUQ but no sign of peritonitis. Blood and urine test results were unremarkable. Abdominal ultrasound (USS) showed cholelithiasis without evidence of cholecystitis or biliary duct dilatation. She was conservatively managed in a surgical ward and discharged 24-hours later. Six hours from being discharged, she represented with spontaneous rupture of membrane along with worsening RUQ pain and progressive contractions. There was no concern regarding foetal wellbeing but proceeded with emergency caesarean section for maternal distress.
Post-operatively the patient continued to report ongoing RUQ pain and new onset right pleuritic chest pain. Clinical observation noted increasing heart rate and respiratory rate. One therapeutic dose of low molecular weight heparin was administered for suspected pulmonary embolism (PE). Subsequently, urgent computed tomography pulmonary angiography was performed which excluded PE but uncovered a spontaneous adrenal haemorrhage. Repeat USS findings were in keeping with a diagnosis of right-sided adrenal haemorrhage.
Post-partum six-week follow-up CT scan demonstrated retraction of the right adrenal lesion and the left adrenal gland remained normal.
This case is to remind the clinician that adrenal haemorrhage should be included in the differential diagnosis of the non-specific abdominal pain in pregnancy. If the patient is stable and obstetric findings are normal, conservative management is safe and vaginal delivery may be appropriate. Steroid should be commenced in case of adrenal insufficiency to prevent circulatory collapse. Surgical intervention is the next step if clinically deteriorate.3