FRI234 A Pregnancy With Two Special Surprises A Baby And A Nonhemorrhagic Adrenal Infarction During Pregnancy
Authors: Idriss Setana , Barua Nabonita , Jamal Issra , Jabiev Azad 
Published: October 2023

Abstract
Disclosure: S. Idriss: None. N. Barua: None. I. Jamal: None. A. Jabiev: None.
Introduction: Unilateral Acute adrenal infarction (AAI) is a rare cause of acute abdomen in pregnancy, with a reported incidence of 1.3%. It usually presents with sudden, severe, and unremitting flank pain. The most common cause of AAI is adrenal vein thrombosis. We present a 26-year-old pregnant female who presents with right flank and back pain, found to have AAI without hemorrhage. Case: 26-year-old female Primigravida without significant past medical history presented to the emergency room at 33 weeks of gestation with sudden onset of RUQ flank and back pain. She was afebrile and normotensive. Physical exam was positive for right flank point tenderness. She underwent multiple investigations including an abdominal US which did not reveal an acute pathology. She was admitted and started on opioids which failed to control her pain. An abdominal MRI was obtained subsequently revealing 4.6cm right adrenal gland lesion suspicious for AAI without hemorrhage and normal left adrenal gland. The pain was poorly controlled warranting Dilaudid drip and repeat imaging/CT showed adrenal gland mass with density of 41-52 HU suspicious for lipid poor adenoma versus adrenal hematoma on CT scan. Initial AM Cortisol level was 46 ug/dl, then it trended down to 31.7. DHEAS was low at 94.2 ug/dl. Plasma metanephrines and normetanephrines were normal. Course was complicated with hypotension and worsening pain on day 10 of admission, repeat MRI showed increase in right adrenal lesion size and cystic transformation, containing some T2 hypointense septations and debris without notable intrinsic T1 hyperintensity to suggest blood products, and restricted diffusion which is a finding compatible with AAI. Repeat AM Cortisol and DHEAS were low at 12 and 61.3 respectively. Despite normal left adrenal gland, clinical picture was consistent with adrenal insufficiency and she was started on stress steroids. Thrombophilia workup was negative. She ultimately underwent c-section on day 13 of admission. She was discharged on physiologic dose of steroids with a pending repeat MRI and outpatient follow up. Discussion: Adrenal glands, especially with preexisting nodules are predisposed to micro-vascular thrombosis and infarction during procoagulable states. Pregnancy is a hypercoagulable state that predisposes patients to thrombotic events. The relative risk of thrombosis is 5-6 times higher in pregnant than non-pregnant females of the same age. Our patient had evidence of adrenal insufficiency and required steroid replacement. Anticoagulation was not started due to possible subtle hematoma on CT scan on initial imaging. Follow up imaging is planned. Conclusion: Adrenal infarction is a rare cause of abdominal pain during pregnancy, and if missed, it can result in devastating clinical consequences for the mother and the child. Adrenal insufficiency if found should be addressed to prevent circulatory collapse.
Presentation: Friday, June 16, 2023