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Spontaneous Adrenal Hemorrhage (SAH) and Preeclampsia: A Case Report
Abstract Number: FCH-510
Abstract Type: Case Report Case Series
A 22-year old female G2P0010 at 36 weeks of gestation presented with a 24-hour history of left flank pain and nausea. The pain was sharp, stabbing, constant, and radiated to the left mid abdomen. She denied fever, chills, dysuria, hematuria, urinary frequency, or urgency. She underwent a CT scan at an outside hospital that was concerning for adrenal hemorrhage. She then developed severe range blood pressure and was found to have normal preeclampsia labs and negative urine spot. She underwent an MRI that confirmed left adrenal hemorrhage. No history of trauma or anticoagulation to explain hemorrhage. Subsequently, she was transferred to our hospital. Past medical history is noticeable for migraines, anxiety, and depression (not on medications). Past surgical history was significant for right laparoscopic oophorectomy for a large simple cyst. On admission, her heart rate was 92 and her blood pressure was 168/110 mmHg, despite 3 doses of IV anti-hypertensives. Her abdominal exam: soft, non-tender gravid abdomen. Labs were notable for WBC of 19 K/uL, Hematocrit (Hct) of 30.8 % and Spot Protein/Creatinine Ratio of 0.3 g/day. The rest of the lab work was not significant. The plan was made for conservative management and control her blood pressure. Serial Hct checks had been stable. She was diagnosed with preeclampsia with severe features due to severe range blood pressure despite receiving IV anti-hypertensives. The patient was offered an external cephalic version for fetal breech presentation, but she declined. The decision was made to proceed with cesarean delivery. A combined spinal-epidural was placed successfully. The patient tolerated the procedure well and was discharged 5 days later.
Spontaneous adrenal hemorrhage is a rare condition in the general population. The incidence of SAH ranges from 0.14 to 1.1% in autopsy studies1 but its incidence during pregnancy is unknown2. The differential diagnosis for adrenal hemorrhage includes: infectious causes (Waterhouse-Friderichsen syndrome), bleeding secondary to a mass (such as pheochromocytoma), trauma and coagulopathy. The anesthetic considerations for this patient were: preeclampsia with sever features, hemodynamic instability after delivery (due to the loss of the tamponading effect of the gravid uterus), the inability to rule out adrenal tumor with vasoactive mediators and the risk for adrenal insufficiency.
1.J Reprod Med 1988;33:233–235
2. Obstet Gynecol Surv. 2005;60:191-5