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Postpartum Renal Failure: What’s the Diagnosis?
Abstract Number: RF2BB-87
Abstract Type: Case Report Case Series
34 y.o. G1P0 at 36 weeks gestation was admitted for planned cesarean delivery of twins for malpresentation. Her current obstetrical course was significant for cholestasis of pregnancy. Her platelets were noted to be 60,000 10*3/uL; other laboratory studies and vital signs were unremarkable. The decision was made to proceed with cesarean delivery under general anesthesia.
The case proceeded uneventfully, and the quantitative blood loss was 800 mL. Approximately 30 minutes after arrival in the PACU, the uterus was found to be atonic and when expressed, an additional 800 mL of blood loss was noted. The patient was returned to the OR for an exam under anesthesia. General anesthesia was induced, and a Bakri balloon was placed. Cumulative quantitative blood loss was 2200 mL. The patient remained hemodynamically stable throughout and received 1 unit of packed red blood cells, a thromboelastogram was sent which was within normal limits. She was extubated and brought to the PACU.
In the PACU her urine output decreased to <0.5mL/kg/hr. Lab tests were re-assessed 6 hours later and it was noted that creatinine had increased from 0.98 to 1.7 mg/dL. Other lab abnormalities were a decrease in platelets to 28,000 10*3/uL, AST/ALT 133/44 U/L, K 5.3 mmol/L, fibrinogen 121 mg/dL, total bilirubin of 2.3 mg/dL and LDH of 480 Units/L. The decision was made to transfer the patient to SICU for closer observation.
In SICU her signs and symptoms were attributed to atypical HELLP and she was treated with intravenous magnesium sulfate at 1g/hr. However, her creatinine continued to rise up to 7 mg/dl, and LDH increased to 1700 Units/L.
Schistocytes were seen on her peripheral blood smear, and a diagnosis of Thrombotic Thrombocytopenic Purpura and Hemolytic-Uremic Syndrome (TTP-HUS) was considered.
An ADAMTS13 level was sent STAT, and methylprednisolone plus plasmapheresis were started emergently. Her platelet count began to increase, and her creatinine slowly began to decrease. Seventy-two hours after the beginning of the plasmapheresis, the ADAMTS13 levels came back normal (38%). Decision was made to stop the plasmapheresis and to start eculizumab. Finally her laboratory tests gradually improved, and she was discharged home on POD 7 on eculizumab and steroids, with the presumed diagnosis of atypical HUS.
TTP-HUS is a rare complication of pregnancy. TTP-HUS may occur for the first time during the postpartum period for reasons that are unclear, presenting with microangiopathic hemolytic anemia, thrombocytopenia, central nervous system abnormalities, fever and renal impairment. All the above clinical presentations overlap with that of the more common HELLP syndrome. It is important to consider both diseases in the differential diagnosis for a woman presenting with the above features, as the management of the two syndromes differ.
Julius CM, Sandro V, Tadele B. TTP-HUS and Pregnancy. Pan Afr Med J. 2014; 17: 255.
D'Angelo A, Fattorini A, Crippa L. Thrombotic microangiopathy in pregnancy. Thromb Res. 2009;123(Suppl 2):S56–62.