Severe bilateral adrenal hemorrhages in a newborn complicated by persistent adrenal insufficiency

Bilateral adrenal hemorrhages rarely occur during the neonatal period and are often associated with traumatic vaginal deliveries. However, the adrenal gland has highly regenerative capabilities and adrenal insufficiency typically resolves over time. We evaluated a newborn female after experiencing fetal macrosomia and a traumatic vaginal delivery. She developed acidosis and acute renal injury. Large adrenal hemorrhages were noted bilaterally on ultrasound, and she was diagnosed with adrenal insufficiency based on characteristic electrolyte changes and a low cortisol (4.2 µg/dL). On follow-up testing, this patient was unable to be weaned off of hydrocortisone or fludrocortisone despite resolution of hemorrhages on ultrasound. Providers should consider bilateral adrenal hemorrhage when evaluating critically ill neonates after a traumatic delivery. In extreme cases, this may be a persistent process. LEARNING POINTS: Risk factors for adrenal hemorrhage include fetal macrosomia, traumatic vaginal delivery and critical acidemia. Signs of adrenal hemorrhage include jaundice, flank mass, skin discoloration or scrotal hematoma. Adrenal insufficiency often is a transient process when related to adrenal hemorrhage. Severe adrenal hemorrhages can occur in the absence of symptoms. Though rare, persistent adrenal insufficiency may occur in extremely severe cases of bilateral adrenal hemorrhage. Consider adrenal hemorrhage when evaluating a neonate for shock in the absence of an infectious etiology.