Thrombotic microangiopathies of pregnancy: Differential diagnosis

• Published in: Pregnancy hypertension Vol. 12; pp. 29 - 34
• Main Authors: Gupta, M., Feinberg, B.B., Burwick, R.M.
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier B.V 01-04-2018
• Subjects: Atypical hemolytic uremic syndrome; HELLP (hemolysis, Elevated liver enzymes, Low platelet count syndrome); Preeclampsia with severe features; Pregnancy; Thrombotic microangiopathy; Pregnancy; Atypical hemolytic uremic syndrome; Thrombotic microangiopathy; Preeclampsia with severe features; HELLP (hemolysis, Elevated liver enzymes, Low platelet count syndrome)
• ISSN: 2210-7789; 2210-7797
• DOI: 10.1016/j.preghy.2018.02.007

•Timely diagnosis of thrombotic microangiopathy in pregnancy reduces maternal harm.•Check ADAMTS13 activity to help rule out thrombotic thrombocytopenic purpura.•Lactate dehydrogenase and serum creatinine help to differentiate aHUS and HELLP.•Caution is warranted when microangiopathic hemolysis persists after delivery.•Implement multidisciplinary care for complex cases of thrombotic microangiopathy.
Thrombotic microangiopathy (TMA) disorders are characterized by microangiopathic hemolytic anemia, thrombocytopenia and end-organ injury. In pregnancy and postpartum, TMA is most commonly encountered with HELLP (hemolysis, elevated liver enzymes, low platelet count syndrome) or preeclampsia with severe features, but rarely TMA is due to thrombotic thrombocytopenic purpura (TTP) or atypical hemolytic uremic syndrome (aHUS). Due to overlapping clinical and laboratory features, TTP and aHUS are often mistaken for preeclampsia or HELLP. Unfortunately, delays in appropriate diagnosis and treatment may be life-threatening. Our objective is to alert obstetrician-gynecologists, certified nurse midwives, family medicine providers, and subspecialty consultants, to the range of TMA disorders that may occur in and around pregnancy. To do this, we have provided a review of individual disorders that comprise the differential diagnosis of pregnancy TMA, and we have proposed a systematic approach to make an accurate diagnosis with readily available clinical and laboratory data. In complex or critical cases, we recommend a multidisciplinary team approach (e.g., Critical Care, Hematology, Maternal Fetal Medicine, Nephrology) to expedite diagnosis and treatment, which may be life-saving.