Neonatal adrenal hemorrhage (draft of clinical recommendations)

  • D.O. Ivanov Saint Petersburg State Pediatric Medical University. 2 Lithuania, Saint Petersburg 194100 Russian Federation
  • A.S. Panchenko Saint Petersburg State Pediatric Medical University. 2 Lithuania, Saint Petersburg 194100 Russian Federation
  • E.N. Balashova Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
  • T.V. Belousova Novosibirsk State Medical University, Novosibirsk, Russia
  • E.V. Bem Saint Petersburg State Pediatric Medical University. 2 Lithuania, Saint Petersburg 194100 Russian Federation
  • D.S. Dodrov Ekaterinburg Clinical Perinatal Center, Ekaterinburg, Russia
  • N.M. Zelenin Saint Petersburg State Pediatric Medical University. 2 Lithuania, Saint Petersburg 194100 Russian Federation
  • O.L. Ksenofontova Ekaterinburg Clinical Perinatal Center, Ekaterinburg, Russia
  • M.I. Levadneva Saint Petersburg State Pediatric Medical University. 2 Lithuania, Saint Petersburg 194100 Russian Federation
  • I.V. Myznikova Saint Petersburg State Pediatric Medical University. 2 Lithuania, Saint Petersburg 194100 Russian Federation
  • S.E. Pavlova Saint Petersburg State Pediatric Medical University. 2 Lithuania, Saint Petersburg 194100 Russian Federation
  • E.V. Plotnikova Saint Petersburg State Pediatric Medical University. 2 Lithuania, Saint Petersburg 194100 Russian Federation
  • L.A. Romanova Saint Petersburg State Pediatric Medical University. 2 Lithuania, Saint Petersburg 194100 Russian Federation
  • Yu.L. Skorodok Saint Petersburg State Pediatric Medical University. 2 Lithuania, Saint Petersburg 194100 Russian Federation
  • G.N. Chumakova Saint Petersburg State Pediatric Medical University. 2 Lithuania, Saint Petersburg 194100 Russian Federation
  • L.A. Fedorova Saint Petersburg State Pediatric Medical University. 2 Lithuania, Saint Petersburg 194100 Russian Federation
  • E.V. Shestak Ekaterinburg Clinical Perinatal Center, Ekaterinburg, Russia
DOI: https://doi.org/10.56871/PED.2025.17.78.001
Keywords: neonatal adrenal hemorrhage, newborns, acute adrenal insufficiency in newborns

Abstract

Adrenal hemorrhage (AH) in a newborn is a relatively rare pathological condition (0.2 to 3.0%) that occurs in the early neonatal period and is the most common adrenal formation. Damage to the right adrenal gland occurs more often due to the peculiarities of its anatomical location between the liver and the spine. Neonatal AH can lead to partial or complete loss of hormonal function of the organ. In most cases, adrenal gland damage in newborns develops secondarily against the background of the underlying disease; in some cases, the cause of hemorrhage cannot be determined. The most common risk factors are traumatic birth, macrosomia, hypoxia, arterial hypotension, coagulopathy, sepsis, and tumor. Early diagnostics of AH is difficult, since clinical symptoms of AH in most cases are absent or non-specific: intense jaundice, anemia, a palpable painful formation in the abdominal cavity with massive bleeding, possible edema and cyanotic discoloration of the scrotum with rupture of the adrenal capsule. In severe cases, AH may manifest itself with symptoms of adrenal insufficiency, hypovolemic shock, and even death is possible. Isolated AH in a newborn usually does not require medical or surgical treatment and is characterized by regression of symptoms within 12 weeks or more. Newborns who have experienced AH remain at risk of developing chronic adrenal insufficiency. The main method of preventing AH is to reduce the trauma of the birth process, choosing the most gentle tactics of delivery, based on the characteristics of each individual clinical situation.

References

Баиров Г.И., Кущ Н.Л. Родовая травма органов брюшной полости и забрюшинного пространства. В кн.: Повреждения органов брюшной полости и забрюшинного пространства у детей. Киев; 1975.

Диагностика и лечение эндокринных заболеваний у детей и подростков. Учебное пособие. Шабалов Н.П., ред. 6-е изд. М.: МЕДпресс-информ; 2022.

Иванов Д.О., Мавропуло Т.К. Клинические рекомендации по ведению и терапии новорожденных с заболеваниями надпочечников (проект). 2016.

Власюк В.В., Иванов Д.О. Клинические рекомендации по диагностике и лечению родовой травмы (проект). СПб.; 2016.

Корб Т.А., Чернина В.Ю., Блохин И.А. и др. Визуализация надпочечников: в норме и при патологии (обзор литературы). Проблемы эндокринологии. 2021;67(3):26–36. DOI: 10.14341/probl12752.

Пыков М.И., Макушева В.Г., Ефимов М.С. и др. Ультразвуковая оценка надпочечников у новорожденных детей. Ультразвуковая и функциональная диагностика. 2010;5:44–53.

Неонатология: национальное руководство: в 2 т. Н.Н. Володин, Д.Н. Дегтярев, ред. М.: ГЭОТАР-Медиа; 2023.

Неонатология: учебное пособие: в 2 т. Н.П. Шабалов, ред. 5-е изд., перераб. и доп. М.: ГЭОТАР-Медиа; 2020.

Панибратец К.А., Кенжебаева А.В., Тубина А.М., Ибраева Л.Г. Кровоизлияние в надпочечники у новорожденного при родовой травме. Медицина и экология. 2017;1:166–169.

Руководство по перинатологии: в 2 т. Д.О. Иванов, ред. Т. 2. 2-е изд., испр. и доп. СПб.: Информ-Навигатор; 2019.

Феоктистова Е.В., Ускова Н.Г., Варфоломеева С.Р. и др. Дифференциальная диагностика кистозной формы нейробластомы и кровоизлияния в надпочечник у детей первых месяцев жизни. Вопросы гематологии/онкологии и иммунопатологии в педиатрии. 2017;16(1):62–68.

Acharya S., Jayabose S., Kogan S.J. et al. Prenatally diagnosed neuroblastoma. Cancer. 1997;80(2):304–310. DOI: 10.1002/(sici)1097-0142(19970715)80:2<304:aid-cncr19>3.0.co;2-y.

Avolio L., Fusillo M., Ferrari G. et al. Neonatal adrenal hemorrhage manifesting as acute scrotum: timely diagnosis prevents unnecessary surgery. Urology. 2002;59(4):601. DOI: 10.1016/s0090-4295(01)01610-7.

Badawy M., Gaballah A.H., Ganeshan D. et al. Adrenal hemorrhage and hemorrhagic masses; diagnostic workup and imaging findings. Br J Radiol. 2021;94(1127):20210753. DOI: 10.1259/bjr.20210753.

Bergami G., Malena S., Di Mario M., Fariello G. L'ecografia nel follow-up dell'emorragia surrenalica in età neonatale. Presentazione di 14 casi [Echography in the follow-up of neonatal adrenal hemorrhage. The presentation of 14 cases]. Radiol Med. 1990;79(5):474–478. (In Italian).

Black J., Williams D.I. Natural history of adrenal haemorrhage in the newborn. Arch Dis Child. 1973;48(3):183–190. DOI: 10.1136/adc.48.3.183.

Chang T.A., Chen C.H., Liao M.F., Chen C.H. Asymptomatic neonatal adrenal hemorrhage. Clin Neonatol. 1998;5:23–26.

Chen C.H., Chang T.A. The value of ultrasound in the diagnosis and management of neonatal adrenal hemorrhage. Chin J Radiol. 1999;24:107–111.

Costa M.R., Costa T.R., Leite M.S. et al. Atipical presentation of intra-abdominal extralobar pulmonary sequestration detected in prenatal care: a case report. Rev Paul Pediatr. 2016;34(2):243–246. DOI: 10.1016/j.rpped.2015.10.003.

Cozzi D.A., Mele E., Ceccanti S. et al. Long-term follow-up of the “wait and see” approach to localized perinatal adrenal neuroblastoma. World J Surg. 2013;37(2):459–465. DOI: 10.1007/s00268-012-1837-0.

Davenport P., Sola-Visner M. Hemostatic Challenges in Neonates. Front Pediatr. 2021;9:627715. DOI: 10.3389/fped.2021.627715.

Demirel N., Baş A.Y., Zenciroğlu A., Taşci-Yildiz Y. Adrenal bleeding in neonates: report of 37 cases. Turk J Pediatr. 2011;53(1):43–47. PMID: 21534338.

Duman N., Oren H., Gülcan H. et al. Scrotal hematoma due to neonatal adrenal hemorrhage. Pediatr Int. 2004;46(3):360–362. DOI: 10.1111/j.1442-200x.2004.01898.x.

Eo H., Kim J.H., Jang K.M. et al. Comparison of clinico-radiological features between congenital cystic neuroblastoma and neonatal adrenal hemorrhagic pseudocyst. Korean J Radiol. 2011;12(1):52–58. DOI: 10.3348/kjr.2011.12.1.52.

Esslami G.G., Moienafshar A. Neonatal bilateral adrenal hemorrhage and adrenal insufficiency accompanied by Subgaleal hematoma: a case report with brief review of literature. BMC Pediatr. 2022;22(1):248. DOI: 10.1186/s12887-022-03314-1.

Folligan K., Bouvier R., Targe F. et al. Le développement de la surrénale humaine [Development of the human adrenal glands]. Ann Endocrino (Paris). 2005;66(4):325–332. (In French). DOI: 10.1016/s0003-4266(05)81789-5.

Hwang S.M., Yoo S.Y., Kim J.H., Jeon T.Y. Congenital adrenal neuroblastoma with and without cystic change: differentia­ting features with an emphasis on the of value of ultrasound. Am J Roentgenol. 2016; 207(5):1105–1111. DOI: 10.2214/AJR.16.16452.

Katar S., Oztürkmen-Akay H., Devecioğlu C., Taşkesen M. A rare cause of hyperbilirubinemia in a newborn: bilateral adrenal hematoma. Turk J Pediatr. 2008;50(5):485–487. PMID: 19102056.

Koplewitz B.Z., Daneman A., Cutz E., Hellmann J. Neonatal adrenal congestion: a sonographic-pathologic correlation. Pediatr Radiol. 1998;28(12):958–962. DOI: 10.1007/s002470050509.

Lakra M.S., Lakhkar B.B., Taksande A. et al. A rare and unusual case of hypernatremic dehydration in a newborn presenting with adrenal haemorrhage and leading to acute kidney injury. Cureus. 2024;16(5):e61265. DOI: 10.7759/cureus.61265.

Lee C., Hirschman L., York T., Newton P. Bilateral adrenal he­morrhage and severe anemia in a neonate. Endocrinol Diabetes Metab Case Rep. 2024;2024(1):23-0091. DOI: 10.1530/EDM-23-0091.

Lee M.C., Lin L.H. Ultrasound screening of neonatal adrenal hemorrhage. Acta Paediatr Taiwan. 2000;41(6):327–330. PMID: 11198940.

Miele V., Galluzzo M., Patti G. et al. Scrotal hematoma due to neonatal adrenal hemorrhage: the value of ultrasonography in avoi­ding unnecessary surgery. Pediatr Radiol. 1997;27(8):672–674. DOI: 10.1007/s002470050209.

Moon S.B., Shin H.B., Seo J.M., Lee S.K. Clinical features and surgical outcome of a suprarenal mass detected before birth. Pediatr Surg Int. 2010;26(3):241–246. DOI: 10.1007/s00383-009-2531-7.

Peng T., Shan Y., Zhang P., Cheng G. Bleeding in neonates with severe thrombocytopenia: a retrospective cohort study. BMC Pediatr. 2022;22(1):730. DOI: 10.1186/s12887-022-03802-4.

Postek G., Streich H., Narębski K. Assessment of diagnostic methods in adrenal gland hemorrhage in neonates on the basis of own material from the years 2007–2011. Pol J Radiol. 2011;76(3):62–64. PMID: 22802844.

Qureshi U.A., Ahmad N., Rasool A., Choh S. Neonatal adrenal hemorrhage presenting as late onset neonatal jaundice. J Indian Assoc Pediatr Surg. 2009;14(4):221–223. DOI: 10.4103/0971-9261.59607.

Roberts I., Murray N.A. Neonatal thrombocytopenia: causes and management. Arch Dis Child Fetal Neonatal Ed. 2003;88(5):F359-64. DOI: 10.1136/fn.88.5.f359.

Roupakias S., Papoutsakis M., Mitsakou P. Blunt adrenal gland trauma in the pediatric population. Asian J Surg. 2011;34(3):103–110. DOI: 10.1016/j.asjsur.2011.08.003.

Rumińska M., Welc-Dobies J., Lange M., Maciejewska J., Pyrzak B., Brzewski M. Wylew do nadnerczy u noworodków: czynniki ryzyka i postepowanie diagnostyczno-kliniczne [Adrenal haemorrhage in neonates: risk factors and diagnostic and clinical procedure]. Med Wieku Rozwoj. 2008 ;12(1):457–462. (In Polish). PMID: 18663265.

Sauvat F., Sarnacki S., Brisse H. et al. Outcome of suprarenal localized masses diagnosed during the perinatal period: a retrospective multicenter study. Cancer. 2002;94(9):2474–2480. DOI: 10.1002/cncr.10502.

Shimokaze T., Akaba K., Saito E. Late-onset glucocorticoid-responsive circulatory collapse in preterm infants: clinical characteristics of 14 patients. Tohoku J Exp Med. 2015;235(3):241–248. DOI: 10.1620/tjem.235.241.

Shulman D.I., Palmert M.R., Kemp S.F.; Lawson Wilkins Drug and Therapeutics Committee. Adrenal insufficiency: still a cause of morbidity and death in childhood. Pediatrics. 2007;119(2):e484-94. DOI: 10.1542/peds.2006-1612.

Simon D.R., Palese M.A. Clinical update on the management of adrenal hemorrhage. Curr Urol Rep. 2009;10(1):78–83. DOI: 10.1007/s11934-009-0014-y.

Singh J., Dalal P., Bhalla K., Rattan K.N. Neonatal adrenal he­morrhage presenting as prolonged hyperbilirubinemia. J Neonatal Surg. 2016;5(2):22. PMID: 27123406.

Słapa R.Z., Jakubowski W.S., Dobruch-Sobczak K. et al. Standards of ultrasound imaging of the adrenal glands. J Ultrason. 2015;15(63):377–387. DOI: 10.15557/JoU.2015.0035.

Smitthimedhin A., Rubio E.I., Blask A.R., Loomis J.M., Bulas D.I. Normal size of the fetal adrenal gland on prenatal magnetic resonance imaging. Pediatr Radiol. 2020;50(6):840–847. DOI: 10.1007/s00247-020-04629-w.

Tân T.J., Hung Y.L., Shen C.M., Hsieh W.S. Adrenal hemorrhage in neonates: Incidence, perinatal characteristics and follow-up outcomes. Pediatr Neonatol. 2025;66(1):66–70. DOI: 10.1016/j.pedneo.2023.11.013.

Tank E.S., Davis R., Holt J.F., Morley G.W. Mechanisms of trauma during breech delivery. Obstet Gynecol. 1971;38(5):761–767. PMID: 5165479.

Thompson D., Vo K.T., London W.B. et al. Identification of patient subgroups with markedly disparate rates of MYCN amplification in neuroblastoma: A report from the International Neuroblastoma Risk Group project. Cancer. 2016;122(6):935–945. DOI: 10.1002/cncr.29848.

Toti M.S., Ghirri P., Bartoli A. et al. Adrenal hemorrhage in newborn: how, when and why — from case report to literature review. Ital J Pediatr. 2019;45(1):58. DOI: 10.1186/s13052-019-0651-9.

Velaphi S.C., Perlman J.M. Neonatal adrenal hemorrhage: clinical and abdominal sonographic findings. Clin Pediatr (Phila). 2001;40(10):545–548. DOI: 10.1177/000992280104001002.

Wang C.H., Chen S.J., Yang L.Y., Tang R.B. Neonatal adrenal hemorrhage presenting as a multiloculated cystic mass. J Chin Med Assoc. 2008;71(9):481–484. DOI: 10.1016/S1726-4901(08)70153-9.

Xu R., Zhu Z., Tang W. et al. Zone-specific reference ranges of fetal adrenal artery Doppler indices: a longitudinal study. BMC Pregnancy Childbirth. 2020;20(1):774. DOI: 10.1186/s12884-020-03480-z.

Yiğit Ş., Türkmen M., Tuncer O., Taşkın E., Güran T., Abacı A., Çatlı G., Tarım Ö. Neonatal adrenal insufficiency: Turkish Neonatal and Pediatric Endocrinology and Diabetes Societies consensus report. Turk Pediatri Ars. 2018;53(Suppl 1):S239-S243. DOI: 10.5152/TurkPediatriArs.2018.01822.

Zessis N.R., Nicholas J.L., Stone S.I. Severe bilateral adrenal hemorrhages in a newborn complicated by persistent adrenal insufficiency. Endocrinol Diabetes Metab Case Rep. 2018; 2018:17-0165. DOI: 10.1530/EDM-17-0165.

Published
2025-07-08
Issue
Vol 16 No 2 (2025)
Section
EDITORIAL