Introduction:

Vaginal examination found her cervix to be 0 cm dilated and 2.5 cm long. A multidisciplinary team discussion was conducted and it was decided that she was suitable for cesarean section.During operation her  Hb dropped to 76 mg/dL and she was transfused with 2 units of red blood cells.Given the evidence of ongoing bleeding, a second multidisciplinary team discussion was held. Interventional radiology were undergoed after cesarean section.Angiography and embolization of the bleeding lesion provided better outcomes.During follow-up in the Endocrine clinic after 3 months, additional tests were sent (cortisol level after 1 mg dexamethasone suppression test and repeated metanephrines), which were noted all to be negative. An abdomen CT was scan was performed and showed interval resolution of the previously seen right adrenal mass (Figure 2), which was likely representing pregnancy-related non-traumatic hemorrhage. The patient was counseled about her condition and reassured.

Discussion

Adrenal hemorrhage is a relatively rare disorder, estimated to be present in roughly 0.14% to 1.8% of postmortem examinations.Overall, it is associated with a 15% mortality rate, which varies according to the severity of the underlying cause of hemorrhage. A 55-60% mortality rate has been reported in patients with Waterhouse-Friderichsen syndrome (adrenal hemorrhage is frequently due to meningococcal sepsis)[5][6]. However, the incidence may be much higher since the vague presentation, associated comorbid conditions, and variable lab findings can make diagnosis difficult.The exact pathophysiology of acute adrenal hemorrhage remains uncertain. It has been hypothesized that certain specific anatomic and physiological characteristics predispose to bleeding into the adrenals.

Adrenal hemorrhage can present in a myriad of clinical contexts, and diagnosis remains challenging. Disease familiarity and a high index of suspicion are required for early diagnosis and prompt treatment. Since critically ill individuals represent a subset of patients who are at risk of developing adrenal hemorrhage, early recognition is crucial in these subsets of patients. Most cases are discovered incidentally, however, nonspecific abdominal, or loin pain is an important presenting symptom. Other nonspecific symptoms include malaise, weakness, lethargy, nausea, vomiting, and diarrhea. Symptoms may correlate to the severity of hemorrhage, with extensive bilateral hemorrhage heralding the development of acute adrenal insufficiency.The examination may reveal signs of exsanguination, such as tachycardia and hypotension, or nonspecific findings like abdominal or flank tenderness [7][8][9][10].

Most patients have normal lab parameters, just as our case,possibly reflecting minor adrenal bleeding.Imaging remains the most important diagnostic tool, with computed tomography scan being an important modality. The appearance of imaging varies with the age of the hematoma. Adrenal hemorrhage on computed tomography scan appears as a round-to-ovoid lesion. There may be peri-adrenal fat stranding, and bleeding may extend into the peri-nephric space. Fresh hematomas demonstrate high attenuation, which decreases over time. Ultrasonography is the modality of choice in infants due to their small bodies and relatively large adrenal size.Magnetic resonance imaging (MRI) is the most accurate diagnostic modality. It can differentiate acute from chronic hematomas and ascertain an underlying tumor's presence.