Thrombotic Thrombocytopenic Purpura and Hemolytic-Uremic Syndrome in the Postpartum Period

Abstract

Thrombotic thrombocytopenic purpura and hemolytic-uremic syndrome are rare complications that may develop in pregnancy and that mimic common obstetric complications, including severe preeclampsia, eclampsia, and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome. Delay in diagnosis and treatment can lead to increased mortality. A 25-year-old primigravida presented at term with contractions and decreased fetal movement. Her prenatal care and medical history were unremarkable. A prolonged fetal bradycardia prompted an emergency cesarean birth of a healthy male newborn. The woman’s postpartum recovery was unremarkable. On postoperative day 3, her blood pressure increased to 146/99 mmHg, and she developed a nose bleed with small clots, increased vaginal bleeding, and low urine output with hematuria. During the next few days, her hematocrit decreased while her blood urea nitrogen increased. She remained alert and normotensive. She was transfused with packed red blood cells, platelets, and fresh frozen plasma. Differential diagnosis indicated a ureteral injury or HELLP syndrome. On postoperative day 4, her hematocrit was 9.2, platelets were 48 with giant platelets observed, and lactate dehydrogenase was 3,258 (91 to 180). There was a lack of improvement on postpartum day 5: hematocrit was 6.9, platelets were 42, and blood urea nitrogen was 89. This prompted transfer of care to a regional tertiary center at which she received aggressive plasma exchange therapy. Knowledge of unusual syndromes should prompt nurses to advocate for women by recommending differentiating tests and transfer to higher level of care. Follow-up case study presentations will increase knowledge in staff at community facilities to reduce maternal morbidity and mortality.