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Perioperative management of a twin gestation parturient with preeclampsia complicated by acute bilateral adrenal hemorrhage
Abstract Number: SU-67
Abstract Type: Case Report/Case Series
Introduction: Acute adrenal hemorrhage (AH) is a potentially life-threatening condition that is difficult to diagnose due to its rarity and nonspecific presentation. The incidence of AH in pregnancy is unknown but there may be increased risk due to adrenal cortex hyperplasia and hypertrophy during pregnancy. Delayed recognition can lead to maternal circulatory collapse and mortality.
Case: A 33 yo G4P2A1L2 with di-di twins at 33+1 weeks presented to the assessment unit with 12 h of acute onset, constant, 10/10 epigastric pain radiating to bilateral flanks, back and left shoulder. Her pregnancy had been complicated by gestational diabetes treated with insulin, significant emotional stress due to her son’s recent diagnosis of leukemia and most recently preeclampsia diagnosed by elevated blood pressure and proteinuria. Initial ultrasound (US) investigations, fetal heart rates, complete blood count, liver and coagulation panels were all normal. Antenatal corticosteroids were initiated for fetal lung maturation. With a working diagnosis of musculoskeletal pain, IV fentanyl up to 600 mcg provided inadequate analgesia so lumbar epidural analgesia was initiated using 0.125% bupivacaine infusion. Despite a bilateral T4 sensory block to ice, intermittent boluses of 2% lidocaine were required for pain control. Without a clear diagnosis after 24 h, the epidural was discontinued and patient was transferred to another hospital for general surgery consultation. There, a repeat US revealed bilateral AH (up to 4.2 cm in diameter) not captured on initial imaging. Random serum cortisol was 2.8 mcg/dL and hydrocortisone 50 mg IV q6h was initiated. Given the diagnosis of bilateral AH in the face of progressive preeclampsia with SBP reaching 180 mmHg and severe ongoing pain, an emergency cesarean delivery was performed under general anesthesia with general surgery on standby. Both neonates were delivered without complication and admitted to NICU for observation. A transversus abdominis plane block was performed prior to emergence and IV hydromorphone PCA was used for postoperative pain control. The patient continued magnesium and nifedipine for hypertension and a tapering regimen of oral hydrocortisone postpartum. Repeat MRI on day 4 showed stable bilateral adrenal hematomas with no further expansion. The patient was discharged home on postpartum day 7.
Discussion: During pregnancy, AH has been associated with severe emotional stress, preeclampsia, sepsis and trauma. Awareness of these risk factors may aid in early detection of AH. We propose that AH be listed in the differential diagnosis of a parturient with abdominal pain. Bilateral AH in this patient may reflect the severity of her preeclampsia. The pain associated with bilateral AH was seen to break through epidural analgesia despite adequate sensory blockade, with significant improvement following delivery.
1. Vella et al. Mayo Clin Proc 2001
2. Bockorny et al. Obstet Gynecol 2012