A Case Report of Successful Management of Thrombotic Thrombocytopenic Purpura Syndrome (TTP) in a Pregnant Woman with Plasmapheresis

Document Type : Case Report

Author

Department of Operating Room, Faculty of Nursing and Midwifery, Kurdistan University of Medical Sciences, Sanandaj, Iran

Abstract

Background and Aim: Thrombotic thrombocytopenic purpura is a rare and life-threatening disease with a relatively high prevalence of 5% in pregnancy that causes thrombocytopenia. Due to the high prevalence and mortality of fetal and maternal mortality, which resolves rapidly with the onset of plasmapheresis, the diagnosis of this disease is clinically important. The aim of this study was to successfully manage thrombotic thrombocytopenic purpura syndrome (TTP) with plasmapheresis in pregnant women.
Case Report: The patient was a 29-year-old woman who was admitted at 21 weeks’ gestation and second pregnancy with fever, muscle aches, increased liver enzymes, headache, decreased consciousness and hallucinations. Due to the low pH and high lactic acid dehydrogenase and neurological symptoms and fever, TTP was diagnosed for the patient and started with 15 units of freshly frozen plasma daily plasma milling until normalization of lactic acid dehydrogenase and platelets. He was discharged in good general condition.
Discussion and Conclusion: TTP should be considered in the differential diagnosis of missed pregnancies in the second trimester of pregnancy and pregnancies with thrombotic microangiopathy and reduced ADAMTS13 activity should be considered. Although TTP is a deadly disease without treatment, most patients recover with plasmapheresis, so it is recommended to start plasmapheresis as soon as there is clinical doubt based on the patient's tests and symptoms.

Keywords


1. Mohseni M, Asgarlou Z, Azami-Aghdash S, Sheyklo S, Tavananezhad N, Moosavi A. The global prevalence of thrombocytopenia among pregnant women: A systematic review and meta-analysis. Nursing and Midwifery Studies. 2019;8(2):57-63. 2. Kovács EM, Molvarec A, Rigó Jr J, Szabó A. Bilateral serous retinal detachment as a complication of acquired peripartum thrombotic thrombocytopenic purpura bout. Journal of Obstetrics and Gynaecology Research. 2011;37(10):1506-9. 3. Forat Yazdi M, Nazmieh H, Dehghani A, Pordehmobad A. Effect of Plasmapheresis on Thrombotic Thrombocytopenic Purpura. medical journal of mashhad university of medical sciences. 2009;52(1):13-8. 4. Ilter E, Haliloglu B, Temelli F, Ozden S. Thrombotic thrombocytopenic purpura and pregnancy treated with fresh-frozen plasma infusions after plasmapheresis: a case report. Blood coagulation & fibrinolysis. 2007;18(7):689-90. 5. Gasparri ML, Bellati F, Brunelli R, Perrone G, Pecorini F, Papadia A, et al. Thrombotic thrombocytopenic purpura during pregnancy versus imitator of preeclampsia. Transfusion. 2015;55(10):2516-8. 6. Bayraktaroğlu Z, Demirci F, Balat O, Kutlar I, Okan V, Uğur G. Plasma exchange therapy in HELLP syndrome: a single-center experience. The Turkish journal of gastroenterology: the official journal of Turkish Society of Gastroenterology. 2006;17(2):99-102. 7. Scully M, Thomas M, Underwood M, Watson H, Langley K, Camilleri RS, et al. Thrombotic thrombocytopenic purpura and pregnancy: presentation, management, and subsequent pregnancy outcomes. Blood, The Journal of the American Society of Hematology. 2014;124(2):211-9. 8. Howard MA, Williams LA, Terrell DR, Duvall D, Vesely SK, George JN. Complications of plasma exchange in patients treated for clinically suspected thrombotic thrombocytopenic purpura‐hemolytic uremic syndrome. Transfusion. 2006;46(1):154-6. 9. Yang C-W, Chen Y-C, Dunn P, Chang M-Y, Fang J-T, Huang C-C. Thrombotic thrombocytopenic purpura (TTP): initial treatment with plasma exchange plus steroids and immunosuppressive agents for relapsing cases. Renal failure. 2003;25(1):21-30. 10. Delmas Y, Helou S, Chabanier P, Ryman A, Pelluard F, Carles D, et al. Incidence of obstetrical thrombotic thrombocytopenic purpura in a retrospective study within thrombocytopenic pregnant women. A difficult diagnosis and a treatable disease. BMC pregnancy and childbirth. 2015;15(1):137. 11. Mwita JC, Vento S, Benti T. Thrombotic thrombocytopenic purpura-haemolytic uremic syndrome and pregnancy. The Pan African medical journal. 2014;17. 12. von Krogh A-S, Hovinga JAK, Tjønnfjord GE, Ringen IM, Lämmle B, Waage A, et al. The impact of congenital thrombotic thrombocytopenic purpura on pregnancy complications. Thrombosis and haemostasis. 2014;111(6):1180-3. 13. Ferrari B, Maino A, Lotta LA, Artoni A, Pontiggia S, Trisolini SM, et al. Pregnancy complications in acquired thrombotic thrombocytopenic purpura: a case–control study. Orphanet journal of rare diseases. 2014;9(1):193. 14. Moatti-Cohen M, Garrec C, Wolf M, Boisseau P, Galicier L, Azoulay E, et al. Unexpected frequency of Upshaw-Schulman syndrome in pregnancy-onset thrombotic thrombocytopenic purpura. Blood, The Journal of the American Society of Hematology. 2012;119(24):5888-97. 15. George JN. Thrombotic thrombocytopenic purpura. New England Journal of Medicine. 2006;354(18):1927-35. 16. Rehberg JF, Briery CM, Hudson WT, Bofill JA, Martin JN. Thrombotic thrombocytopenic purpura masquerading as hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome in late pregnancy. Obstetrics & Gynecology. 2006;108(3):817-20. 17. Gallwas J, Ackermann H, Friedmann W. Thrombotic thrombocytopenic purpura--a rare and difficult differential diagnosis to HELLP syndrome in late pregnancy. Zeitschrift fur Geburtshilfe und Neonatologie. 2008;212(2):64-6.