Adrenal Hemorrhage: A Review

ImportanceAdrenal hemorrhage in pregnancy is rare. The prevalence of pregnant patients whose pregnancies are complicated by preeclampsia or eclampsia is hypothesized to be slightly higher than the 0.4% to 1.1% occurrence rate in the nonpregnant population. However, the mortality rate of adrenal hemorrhage is reportedly as high as 15%. Therefore, it is critical for obstetric providers to have basic knowledge on the presentation, diagnosis, and management of adrenal hemorrhage in the pregnant population so that prompt diagnosis can be made.ObjectiveThis review highlights incidence, pathophysiology, risk factors, diagnosis, management, and complications of adrenal hemorrhage in the peripartum period.Evidence AcquisitionA literature search was undertaken by our research university librarian using the search engines of PubMed, CINAHL, and EMBASE (Medline items removed). The search terms used included "adrenal hemorrhage" OR "adrenal gland hemorrhage" AND "pregnancy" OR "maternal." The search was limited to articles in English, and the years searched were from January 1, 2015 to December 31, 2021.ResultsThere were 130 abstracts identified, and 30 of the articles were ultimately used as the basis for this review. Presenting signs and symptoms of adrenal hemorrhage were typically abdominal, back, and flank pain. Diagnosis was typically made with ultrasound and computed tomography or magnetic resonance imaging without contrast for confirmation. Management options include conservative management versus surgical management with adrenalectomy or interventional radiology embolization in the unstable patient. For patients with evidence of adrenal insufficiency, steroid replacement was used. Most patients with adrenal hemorrhage in the literature had unilateral adrenal hemorrhage; however, several cases of bilateral adrenal hemorrhage have been reported. Patients with bilateral adrenal hemorrhage were more likely to require steroids for adrenal insufficiency. There are no known contraindications to vaginal delivery in this group of patients, and patients who were managed conservatively were often able to continue the pregnancy to term.ConclusionsEarly recognition and management are integral in decreasing the morbidity and mortality associated with adrenal hemorrhage.Relevance StatementThis is an evidence-based review of adrenal hemorrhage in pregnancy and how to diagnose and manage a pregnancy complicated by adrenal hemorrhage.Target AudienceObstetricians and gynecologists, family physicians.Learning ObjectivesAfter completing this learning activity, the participant should be able to identify the pregnancy-related risk factors for adrenal hemorrhage; interpret the presenting signs and symptoms of an adrenal hemorrhage in pregnancy; describe the imaging modalities available to diagnose adrenal hemorrhage; and outline treatment options including conservative and surgical management.