Imaging and outcomes of fetal adrenal hemorrhage: A systematic review

ObjectiveTo describe prenatal and postnatal imaging findings of fetal adrenal hemorrhage (FAH) and its associated perinatal outcomes, including frequency of postnatal surgical intervention.MethodA systematic literature review of seven electronic databases was conducted from inception until January 2022, with 2008 articles identified reporting prenatally identified fetal adrenal masses. Studies with confirmed FAH diagnosis were included. Quality and risk assessment were evaluated.ResultsThirty-five studies, including 102 FAH cases, were analyzed. FAH was commonly described as cystic (28/90, 31%), anechoic (25/90, 28%), or mixed echogenic (14/90, 16%) on ultrasound. Outcome data were available for 65 cases (64%) of FAH: 9% (6/65) resolved prenatally, 35% (23/65) resolved postnatally, 34% (22/65) regressed in size after birth, and 22% (14/65) persisted postnatally. Overall, 25% (16/65) of cases underwent postnatal surgical intervention. Neuroblastoma was suspected in all 16 surgical cases. Only one case (1/16, 6%) confirmed a cystic hematoma with microscopic islets of neuroblastoma in situ on pathology.ConclusionPrenatal diagnosis of FAH is challenging due to the significant heterogeneity of ultrasound findings. Final pathology did not support the need for surgical intervention. Persistent postnatal FAH warrants shared decision making for further management based on the clinical presentation. What is already known about this topic?There is a paucity of data to guide patient counseling regarding outcomes and management of fetal adrenal hemorrhage (FAH) identified prenatally.What does this study add?We demonstrate that FAH ultrasound findings vary, where most persist prenatally and the majority regress or resolve postnatally. FAH is rarely associated with neuroblastoma. The decision to pursue surgical intervention was reported in 25% of FAH cases and final pathology did not support the need for surgical intervention. Patient counseling of suspected prenatal FAH should emphasize the need for close prenatal and postnatal imaging follow-up.