Bilateral adrenal thrombosis in pregnancy

Case contributed by Dr Fabien Ho

Presentation

27 weeks' gravida. Past history of 3 spontaneous abortions. Acute abdominal epigastric pain radiating to back, no fever, normal urinalysis strips, normal lipase on blood sampling. WBC 20 G/L, CRP 100. Hypothesis of ovarian vein thrombosis.

Patient Data

Age: 30 years
Gender: Female

Bilateral adrenal gland oedema and enlargement on portal venous phase CT scan.
Unfortunately, the inferior vena cava and ovarian veins are not opacified.
Current pregnancy and radioprotection standards did not allow for a multiphasic CT protocol.

MRI

Oriented MRI after CT scan results

Both T1w fast gradient echo and T2-FSw sequences showed material within the IVC lumen suspicious for partial thrombosis.
In the upper image, there is probably a right adrenal vein thrombus bulging into the retrohepatic IVC lumen.
Unfortunately, because of movement artifacts, the left renal vein (which drains the left adrenal vein) could not be imaged.

Ultrasound

Oriented US scan after MRI

US showed the same material within the retrohepatic IVC, consistent with partial thrombosis.

Case Discussion

Bilateral adrenal gland enlargement in the setting of acute pain in pregnancy is consistent with either hemorrhage or thrombosis.
In this case, pregnancy did not allow multiphased CT; hence, non-contrast CT was not performed.

However, several clinical and imaging clues facilitated the confident diagnosis of bilateral adrenal thrombosis:

  • a past history of 3 miscarriages suspicious for an underlying thrombophilic disease, associated with current pregnancy at 27WG.
  • adrenals density was 20HU on average after contrast media administration.
  • partial thrombi in the IVC, one closely related to the anatomical junction with the right adrenal gland.
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Case information

rID: 58182
Published: 5th Feb 2018
Last edited: 16th Jul 2018
Inclusion in quiz mode: Included

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