Bilateral adrenal infarction and secondary haemorrhage in pregnancy: implications of factor V Leiden heterozygosity. A review of the literature and a case report

Abstract

Adrenal haemorrhage in pregnancy is rare but can lead to significant maternal and fetal morbidity if unrecognised. We present the case of a 25-year-old woman in her second pregnancy, who was admitted at 34 + 4 weeks of gestation with severe abdominal pain. Despite initial unremarkable assessments, further imaging revealed a left adrenal haemorrhage, with evidence of prior right adrenal infarction, resulting in primary adrenal insufficiency. Haematological investigations later confirmed heterozygous factor V Leiden as a likely contributing factor. This report underscores the diagnostic challenges of adrenal pathology in pregnancy, where symptoms may overlap with more common conditions. Immediate management with hydrocortisone therapy, supported by a multidisciplinary team (MDT), was employed, with a successful outcome for both mother and child following delivery by caesarean section.

Keywords: Acute abdomen; Adrenal haemorrhage; Adrenal insufficiency; Computed tomography; Factor V Leiden; Pregnancy.

Fig. 1

Ultrasound urinary tract: There is a trace of fluid at the upper pole of the left kidney, otherwise both kidneys demonstrate a smooth renal outline and good cortical thickness. No hydronephrosis, mass or visible calculi.

Fig. 2

(A&B) CT abdomen and pelvis PIVC: The left adrenal gland is swollen, ill-defined and contains areas of increased attenuation. The appearances suggest acute adrenal haemorrhage and possibly infarction. Additionally, the right adrenal gland is markedly atrophied.

Fig. 3

(A&B) CT abdomen and pelvis: Interval reduction in the size of the left adrenal gland and surrounding hyperattenuation of adipose tissue. Calcification noted within right adrenal gland. Both kidneys are normal in appearance.