Adrenal Hemorrhage in the Neonate
Abstract
Previously healthy 2 day old male born at 41 week GA, spontaneous vaginal delivery without complications, no maternal exposures, presented with hematuria and passing clots in urine on DOL #2.
Keywords
1844
Publication Date: 2013-11-14
History
Previously healthy 2 day old male born at 41 week GA, spontaneous vaginal delivery without complications, no maternal exposures, presented with hematuria and passing clots in urine on DOL #2.
Findings
Abnormal echogenicity of the right kidney. High resistance waveforms in both renal arteries, diminished or absent venous flow. Mixed echogenicity avascular mass in the left suprarenal region.
Diagnosis
Adrenal Hemorrhage associated with renal vein & IVC thrombosis
Discussion
The incidence of adrenal hemorrhage is 2 per 1,000 live births. The exact mechanism of pathogenesis is unknown but believe to be related to ACTH and normally limited venous drainage of the adrenals.
Stress of birth -> high ACTH -> increased adrenal blood flow -> overwhelms venous drainage -> stasis, spasm, & thrombosis -> hypoxia -> damage to endothelial cells -> hemorrhage
Risk factors include: Birth trauma related to difficult labor or delivery Asphyxia Septicemia Hemorrhagic disorders/Coagulopathies (Hypoprothrombinemia, HIT, APLABS (antiphospholipid, ATIII Deficiency, DIC).
It is not uncommonly associated with renal vein thrombosis & IVC thrombosis (15%) and AKI (abnormal echogenicity of the kidneys, loss of corticomedullary distinction, high arterial resistance waveforms and decreased venous outflow). Patient may have frank hematuria and passing blood clots at this stage.
Most patients do well. Conservative management is appropriate in most cases. May need supplemental cortisol, especially if bilateral. Cases associated with renal vein/IVC thrombosis require anticoagulation. The hemorrhage should shrink in size on follow up ultrasound. Surgical management is only indicated for unstable massive hemorrhage.
Our patient: The patient developed an ischemic stroke after the onset of heparin therapy. There was initially concern for venous sinus thrombosis, but an MRV was negative. The patient remained critically ill and intubated in the NICU on pressors for 2 weeks. He is now extubated and doing well and was found to have a contralateral adrenal hemorrhage on follow up US. a hypercoagulability panel was negative, however, the patient had a strong family history of frequent clots on his paternal side. additionally, significant doses of heparin were required to achieve therapeutic levels, suggesting a degree of heparin resistance which may be related to anti-thrombin III deficiency.
Comments
References
- Lau, KK, Stoffman, JM, et al. Neonatal Renal Vein Thrombosis: Review of the English-Language Literature between 1992 and 2006. Pediatrics. Nov 1, 2007.
- Adrenal Hemorrhage. http://emedicine.medscape.com/article/126806-overview#2. Accessed 10/09/13 at 4:00pm.
- Chang, T, Chen, CH, et al. Asymptomatic Neonatal Adrenal Hemorrhage. Clinical Neonatology. 1998;5:2. p23-26.
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