Spontaneous Adrenal Hemorrhage in Pregnancy: A Rare but Manageable Emergency

What Makes Spontaneous Adrenal Hemorrhage in Pregnancy Unique?

A rare case of spontaneous adrenal hemorrhage (SAH) during pregnancy has been successfully managed with conservative treatment at a tertiary care center. The 32-year-old woman presented at 33 weeks gestation with severe right-sided pain, ultimately diagnosed via MRI after initial investigations proved inconclusive. The case highlights the diagnostic challenges of this potentially life-threatening condition that carries a 15% mortality risk in the general population.

How Does Pregnancy Contribute to Adrenal Hemorrhage?

Spontaneous adrenal hemorrhage, defined as acute bleeding of the adrenal gland without prior trauma or anticoagulation therapy, represents an uncommon but serious diagnostic consideration in pregnant patients presenting with abdominal pain. The condition often goes unrecognized due to its rarity, with autopsy studies suggesting an incidence between 0.03% and 1.8% in the general population, rising to 25% following trauma. The association between pregnancy and adrenal hemorrhage has been documented in literature, though comprehensive data remains limited. The underlying pathophysiology likely involves pregnancy-induced adrenal cortical hyperplasia predisposing to venous congestion, combined with stress-related increases in ACTH levels that promote blood flow to the adrenal glands while catecholamine surges simultaneously constrict venous circulation. This hemodynamic stress can ultimately lead to vessel rupture and subsequent hemorrhage, particularly when compounded by the physiological changes of pregnancy that increase adrenal vascularity and blood flow.

How Was the Diagnosis Uncovered?

The clinical presentation in this case followed the typical pattern of non-specific symptoms, beginning with severe right subcostal pain radiating to the flank. Initial laboratory investigations were unremarkable, with normal hemoglobin, liver and renal function tests. The diagnostic breakthrough came after the patient experienced persistent pain with episodes of vomiting, prompting more comprehensive imaging. A significant drop in hemoglobin from 122 g/dL to 88 g/dL, alongside rising C-reactive protein levels reaching 233 mg/L, raised concerns for an evolving serious condition. While ultrasound is typically the first-line imaging modality in pregnancy, it proved insufficient in this case. The definitive diagnosis was ultimately made via MRI, which revealed a 44 × 54 × 25 mm lesion in the right adrenal gland with heterogeneous signal intensity compatible with acute hemorrhage. The imaging also demonstrated fluid surrounding the adrenal gland and right kidney, confirming SAH without evidence of underlying tumors or other pathologies that might have precipitated the bleeding.

Is Multidisciplinary Management the Key to Success?

Management was successfully coordinated through a multidisciplinary team approach involving obstetrics, anesthesia, general surgery, and endocrinology specialists. The patient's morning cortisol level of 550 nmol/L indicated preserved adrenal function, allowing a conservative approach without immediate steroid replacement. Treatment included prophylactic antibiotics, pain management with opioid analgesics, and close monitoring of vital signs and laboratory parameters. The decision to avoid surgical intervention was supported by the patient's hemodynamic stability and the unilateral nature of the hemorrhage, which preserved contralateral adrenal function. After one week of inpatient management, laboratory values normalized with hemoglobin returning to 121 g/L and C-reactive protein declining to 47 mg/L. The patient was discharged with outpatient follow-up arranged through a combined obstetrics and endocrinology clinic. The pregnancy ultimately culminated in an uncomplicated vaginal delivery at 38+4 weeks following induction of labor, with no recurrence of hemorrhage despite theoretical concerns about increased abdominal pressure during delivery.

What Do Patient Testimonies Reveal?

"The experience I went through was terrible and the intensity of pain was unbearable," the patient reported afterward. "When I was told that this condition is rare and requires multiple specialist care that actually reassured me and I was cared with meticulous broad team approach and recovered from this condition." The patient further expressed willingness to contribute to medical knowledge about this rare condition, recognizing the limited evidence available for optimal management. This perspective underscores the psychological impact of rare diagnoses and the importance of clear communication in managing patient anxiety. The clinical team recommended endocrinology follow-up at three months postpartum with repeat MRI to confirm complete resolution, emphasizing the importance of continued surveillance even after successful initial management.

How Do This Case and Literature Compare?

The literature offers no consensus on the optimal mode of delivery following SAH in pregnancy, with limited case reports available for comparison. Among nine previously reported cases of SAH during pregnancy, four patients underwent cesarean delivery while three experienced spontaneous labor. Two patients required adrenalectomy, highlighting the spectrum of management approaches. This case demonstrates that vaginal delivery can be safely achieved following conservative management of unilateral SAH, provided there is adequate resolution of the hemorrhage and no evidence of adrenal insufficiency. The multidisciplinary approach employed here represents an emerging standard of care for complex obstetric cases where evidence-based guidelines are lacking due to the rarity of the condition.

Why Must We Prioritize Differential Diagnosis in Pregnancy?

Of particular importance in this case was the differential diagnosis process, which initially included appendicitis, pyelonephritis, renal stones, pulmonary embolism, musculoskeletal pain, and pre-eclampsia. The complex diagnostic journey emphasizes the need for heightened awareness of SAH as a possible cause of abdominal or flank pain in pregnancy, especially when common etiologies have been ruled out. Bilateral adrenal hemorrhage presents an even more urgent scenario, as it can precipitate adrenal crisis with potentially fatal consequences for both mother and fetus if not promptly identified and treated with appropriate steroid replacement.

How Is Industry Context Shaping Maternal-Fetal Medicine?

Industry Context: This case exemplifies the growing trend toward precision diagnostics and multidisciplinary management in maternal-fetal medicine. As healthcare systems increasingly prioritize maternal safety and rare disease recognition, the importance of advanced imaging modalities like MRI in pregnancy becomes more evident, despite cost considerations. The successful conservative management aligns with the broader shift toward minimizing interventions in obstetric practice when safely possible. With maternal mortality receiving heightened attention globally, this case highlights how coordinated specialist care can successfully navigate potentially life-threatening conditions that might previously have resulted in emergency surgical intervention or adverse outcomes.

Summary

A 32-year-old pregnant woman at 33 weeks gestation presented with severe right-sided abdominal pain and was diagnosed with spontaneous adrenal hemorrhage (SAH), a rare and potentially life-threatening condition with a 15% mortality risk in the general population. The diagnosis was confirmed through MRI after initial tests proved inconclusive, revealing a 44 × 54 × 25 mm hemorrhagic lesion in the right adrenal gland. The condition is particularly associated with pregnancy due to adrenal cortical hyperplasia, increased ACTH levels, and hemodynamic stress that can lead to vessel rupture. A multidisciplinary team including obstetrics, anesthesia, general surgery, and endocrinology specialists successfully managed the case conservatively without surgical intervention. The patient's preserved adrenal function, indicated by normal cortisol levels, allowed for treatment with antibiotics, pain management, and close monitoring. After one week of hospitalization, laboratory values normalized and the patient was discharged. She subsequently delivered successfully via vaginal induction at 38+4 weeks without complications or recurrence of hemorrhage. The case underscores the importance of considering SAH in the differential diagnosis of abdominal pain during pregnancy, the value of advanced imaging techniques, and the effectiveness of coordinated specialist care in managing rare obstetric emergencies. Literature review revealed limited consensus on optimal delivery methods following SAH, with this case demonstrating that vaginal delivery can be safely achieved after conservative management of unilateral hemorrhage.