Pregnancy and thrombosis: Adrenal vein thrombosis. A retrospective descriptive study of 14 cases

Acute spontaneous non-hemorrhagic adrenal infarction in pregnancy: case-report and literature review

Unilateral non-hemorrhagic adrenal infarction (NHAI) is a very uncommon cause of acute abdomen in pregnancy. Diagnosis is highly challenging due to its rarity, heterogeneity of clinical presentation, and inconclusiveness of the initial workup. Timely recognition is pivotal to ensuring optimal outcomes. Here we describe a case of spontaneous unilateral NHAI diagnosed in a singleton pregnant woman at 32 weeks' gestation at our centre and provide the findings of an extensive literature review on the topic. We identified 22 articles describing 31 NHAI cases in 30 obstetric patients: NHAI occurs more frequently on the right side and in the third trimester, and diagnosis is formulated more than 24 h after clinical presentation in 50% of cases; second-level imaging is always necessary to reach a definitive diagnosis and start appropriate treatment. A high degree of clinical suspicion is needed to promptly recognize NHAI in pregnancy, thus allowing appropriate multidisciplinary management and timely treatment initiation. Promotion of knowledge and awareness of NHAI as a potential cause of acute abdomen in pregnancy is mandatory to improve clinical practice and, ultimately, perinatal outcomes.

[Spontaneous adrenal hematomas. Retrospective analysis of 20 cases from a tertiary center]

INTRODUCTION

Spontaneous adrenal hemorrhages (AH) are a rare condition with no consensus about their management.

METHODS

Patients were identified using the Medicalization of the Information System Program database, imaging software and a call for observations to internists, intensivists and obsetricians working at our institution. Adult patients whose medical records were complete and whose diagnosis was confirmed by medical imaging were included.

RESULTS

From 2000 to 2007, 20 patients were identified, including 15 were women. The clinical onset of AH was non-specific. In five cases, AH occurred during pregnancy; four of them were unilateral and right sided. The etiology of the other fifteen (bilateral adrenal hemorrhage in 11) were as follows: antiphospholipid syndrome (n=8), heparin-induced thrombocytopenia (n=4), essential thrombocythemia (n=3), spontaneous AH due to oral anticoagulants (n=1), complication of a surgical act (n=3), and sepsis (n=3). In seven cases, two causes were concomitant. The diagnosis of AH was often confirmed by abdominal CT. An anticoagulant treatment was initiated in 16 cases. Ten of the eleven patients presenting with bilateral adrenal hematomas were treated using a long-term substitute opotherapy. One patient died because of a catastrophic antiphospholipid syndrome.

CONCLUSION

The clinical onset of HS is heterogeneous and non-specific. The confirmatory diagnosis is often based on abdominal CT. The search for an underlying acquired thrombophilia is essential and we found in this study etiological data comparable to the main series in the literature. Adrenal insufficiency is most of the time definitive in cases of bilateral involvement.

CT and MR imaging of acute adrenal disorders

The adrenal glands may be overlooked when evaluating acutely ill patients. Acute adrenal disorders may result from complications of an underlying systemic disease, which may be unsuspected clinically. Various acute adrenal emergencies including trauma, spontaneous hemorrhage, infarction and infection can be diagnosed using CT and MRI; however, in uncertain cases follow-up to resolution of imaging findings or histological sampling may be required for diagnosis.

The effect of positioning on maternal anatomy and hemodynamics during late pregnancy

INTRODUCTION

Supine positioning during late pregnancy causes dramatic compression of maternal abdominal vasculature and is a risk factor for stillbirth. The azygos vein has been shown to provide collateral circulation in this scenario. There are many well-known anatomical differences in abdominal vasculature between the left and right sides of the body. However, the effect of left and right positioning in pregnancy has not been well studied.

MATERIALS AND METHODS

After obtaining ethics approval, 10 women with uncomplicated pregnancies between 34 and 38 weeks gestation underwent magnetic resonance imaging in the left and right lateral positions. Phase contrast images were evaluated to measure blood flow through the abdominal aorta, inferior vena cava, and azygos vein.

RESULTS

No significant differences between left and right lateral positions were found in blood flow through the IVC at its formation (mean difference -0.15 L/min [CI -0.47, 0.18], p = .34) or through the azygos vein (mean difference 0.02 L/min [CI -0.22, 0.26], p = .87). Blood flow through the IVC just above the level of the renal veins was found to be reduced by 35% in the right lateral position when compared to the left (mean difference 1.01 L/min [CI 0.25, 1.43], p = .03). There were no significant differences in cardiac output or blood flow through the abdominal aorta.

CONCLUSIONS

While it was noted that blood flow through the IVC immediately above the level of the renal veins was reduced in the right lateral position, this did not appear to impact significantly on maternal cardiac output or blood flow through the azygos vein.