Martee Olenich, MD; Elaine Schattner, MD
Olenich M, Schattner E. Postpartum Thrombotic Thrombocytopenic Purpura (TTP) Complicating Pregnancy-Associated Immune Thrombocytopenic Purpura (ITP). Ann Intern Med. 1994;120:845-847. doi: 10.7326/0003-4819-120-10-199405150-00005
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Published: Ann Intern Med. 1994;120(10):845-847.
Although immune thrombocytopenic purpura in pregnancy is common, thrombotic thrombocytopenic purpura is rare and requires aggressive therapy. We report the case of a young pregnant woman with refractory immune thrombocytopenic purpura who developed postpartum thrombotic thrombocytopenic purpura and was successfully treated with plasmapheresis. The case emphasizes the importance of reviewing peripheral blood smears for evaluation of thrombocytopenia even when the diagnosis is felt to be clear. The coexistence of these two disorders has not been previously reported in the English-language literature.
A 15-year-old girl, gravida 1, para 0, presented at 11 weeks of pregnancy with hyperemesis gravidarum. A manual platelet count was 56 × 109/L. The patient had had no previous blood counts and no history of bleeding or bruising. She was normotensive and had no petechiae, bruises, or organomegaly. The hemoglobin was 107 g/L; hematocrit, 0.33; mean corpuscular volume, 83 fL; and leukocyte count, 11.5 × 109/L. The peripheral blood smear showed normal red cell structure, with some platelet clumping and an overall decreased platelet count. The prothrombin time was 12.1 s (normal range, 9 to 13 s), and the activated partial thromboplastin time was 31.8 s (normal range, 23 to 38 s). Circulating antiplatelet antibody assays were negative, and renal and liver functions were normal. Idiopathic thrombocytopenic purpura was diagnosed, based on persistent thrombocytopenia during an otherwise normal pregnancy. The patient was followed until week 36 without pharmacologic intervention. Her platelet count ranged from 40 × 109/L to 68 × 109/L, and she had no clinical evidence of bleeding. At 36 weeks the patient was hospitalized with early labor, cervical dilatation, and a platelet count of 20 × 109/L. Peripheral blood smears still showed normal red cell structure and thrombocytopenia (Figure 1, top). The patient was treated with intravenous methylprednisolone, 20 mg every 8 hours, and gammaglobulin, 0.5 g/kg body weight daily for 4 days. Because she did not respond to therapy, bone marrow aspiration and biopsy were done to confirm the diagnosis of immune thrombocytopenic purpura. The aspirate showed fully maturing granulocytic and erythroid elements, with abundant megakaryocytes and decreased iron stores. She refused administration of vincristine, and a second course of methylprednisolone, 1 g/d for 2 days, and gammaglobulin, 2 g/kg for 3 days was given.
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Hematology/Oncology, Platelet Disorders, Coagulopathies.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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