MON-493 - Atypical Course of Adrenal Insufficiency Due to Adrenal Hemorrhage in the Third Trimester of Pregnancy

Adrenal insufficiency in pregnancy is rare and difficult to diagnose, with adrenal hemorrhage representing an uncommon but potentially life-threatening cause.
Case - A 23 y/o G1P0 woman at 39 weeks’ gestation was admitted in 1/2026 for planned delivery. Her pregnancy was complicated by recurrent pyelonephritis, breech presentation, and suspected adrenal insufficiency treated with hydrocortisone and fludrocortisone after MRI in 12/2025 incidentally revealed bilateral subacute adrenal hemorrhage and a low 5AM cortisol (5.4 µg/dL).
On admission, she has normal vitals and metabolic panel. Prior to receiving iv stress-dose hydrocortisone, Cosyntropin test was performed after holding morning oral steroids dose. She subsequently delivered a healthy infant via c-section. Her Cosyntropin testing later reported baseline elevated ACTH (131 ng/dL) and inadequate cortisol response (13.9 → 17 µg/dL), below expected third-trimester thresholds. Her postpartum recovery was uncomplicated, and steroids were tapered to maintenance dosing at discharge.
Discussion - Diagnosis of adrenal insufficiency in pregnancy is challenging since cortisol concentrations rise progressively with gestational age driven by estrogen-induced high corticosteroid-binding globulin, and trimester-specific reference ranges are required. Cosyntropin testing in pregnancy is expected to have higher peak cortisol thresholds with minimum peak cortisol levels of 25 µg/dL (700 nmol/L), 29 µg/dL (800 nmol/L), and 32 µg/dL (900 nmol/L) in the 1st, 2nd, and 3rd trimester, respectively, following Cosyntropin administration.

Spontaneous adrenal hemorrhage in pregnancy is rare but may result from pregnancy-related adrenal hypertrophy, increased adrenal blood flow, hypercoagulability, and venous congestion. Reported triggers include trauma, sepsis, hypertension, antiphospholipid syndrome, and tuberculosis. Chart review revealed her h/o MVA with abdominal contusion in 9/2025, likely explaining the subacute adrenal hemorrhage on the initial MRI. Adrenal insufficiency due to hemorrhage is often considered permanent; however, partial or complete recovery of adrenal function were described in select cases.

In patients with existing adrenal insufficiency, hydrocortisone requirements typically increase by 20–40% beginning in the 2nd trimester. Stress-dose steroids are required during labor and delivery, and glucocorticoid doses can generally be rapidly tapered to baseline postpartum.

This case illustrates partial adrenal insufficiency due to bilateral adrenal hemorrhage in late pregnancy and underscores the importance of trimester-specific interpretation of cortisol testing and appropriate peripartum stress-dose steroid management.

Ref:
1. Bornstein SR et al. JCEM 2016.
2. Lindsay JR, Nieman LK. Endocr Rev. 2005.
3. Jung C et al. Clin Endocrinol (Oxf). 2011.
4. Rao RH et al. Ann Intern Med. 1989.

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