RCOG World Congress 2023

Postpartum Microangiopathy-Thinking of Differentials

Dr Harkiran Narang,(ST7 OBGYN) Dr Ellie Jarvie (Consultant OBGYN)

University hospital Wishaw, Lanarkshire, Scotland UK

Antepartum

33yrs, BMI 20.6

Para 0, 40+6 weeks

Low risk , no significant past history

Spontaneous labour

Intrapartum pyrexia

Sepsis 6 commenced - IV Augmentin

Pathological trace- fetal tachycardia @ 180/min, reduced variability- no response to fluids

Straight forward LSCS for failure to progress at 4 cm, pathological trace and maternal sepsis

Birth Weight- 3160 gms

Blood Loss - 1060 ml

Cord pH- 7.1

Postpartum

Blood culture- E coli

Placental culture- no growth

HVS- anaerobic growth

MSSU- no growth

Differential diagnosis-

AKI with multisystem involvement

? Sepsis driven presentation of vasculitis

? HUS

? HELLP

? DIC, severe sepsis

Investigations

Blood film- occasional red cell fragments

PCR - 74 , Repeat - 26

ADAMTS 13- 47.1 ( low)

ANA- neg , RF- neg

Anti GBM- neg

Myeloperoxidase ab – neg

Vit 12, FA- normal

Haptoglobin- 3.2

C3, C4 levels- normal

Interpretation

•Uncontrolled terminal complement activation leads to systemic thrombotic microangiopathy (TMA)

•Pregnancy can trigger aHUS

•May progress to end-stage renal disease

Conclusion

•Laboratory parameters in HELLP syndrome begin to resolve spontaneously within 3 to 4 days postpartum

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•They continue to worsen after delivery in the setting of aHUS, often progressing to renal failure and requiring dialysis (65%) or complement inhibition (35%)

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•In the postpartum period, marked elevation of both serum creatinine and LDH is highly specific for aHUS and is uncommon in HELLP syndrome

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•Hemolysis and renal failure may occur transiently after delivery, their persistence for >72-hour postpartum should raise suspicion for aHUS provoked by pregnancy.

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• Useful to keep in mind the differential diagnosis so that timely referral can be done if required

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•Importance of multidisciplinary care and team work

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•Complement genetic testing may be considered

RCOG World Congress 2023

Postpartum microangiopathy -thinking of differentials

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