Microangiopathy during pregnancy HELLP/aHUS/TTP taking COVID-19 in pregnancy into account

ABSTRACT

The fact that leading laboratory symptoms of thrombocytopenia in combination with other signs of hemolysis and a resulting microangiopathy, which may be associated with further clinical and, in particular additional acute symptoms, also concerns obstetricians in terms of differential diagnostics during pregnancy and around birth. The complexity of the diseases and also the different forms of treatment, make it necessary for gynecologists to have a basic knowledge of internal diseases that can lead to hemolysis. The differential diagnoses must therefore be known as these lead to different treatment needs and long-term damage to the kidneys, for example, must be avoided. The differential diagnoses of thrombocytopenia are the starting point for further diagnostics. In combination with signs of hemolysis and changes in erythrocyte morphology (fragmentocytes), there are different causes for microangiopathy. Thrombotic thrombocytopenic purpura (TTP) can be the cause of such changes throughout pregnancy, but especially in the last trimester. In this case, additional gastrointestinal or neurological symptoms are often present. Pre-eclampsia, especially in HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome, can also lead to microangiopathy, usually with a corresponding increase in blood pressure and especially with a significant increase in liver transaminases, also typically combined in the last trimester. If corresponding changes occur after birth and these are associated with renal failure in addition to hemolysis, this can be an atypical hemolytic uremic syndrome (aHUS), which should be specifically treated with antibodies. In addition to the typical coagulation activation in the sense of thrombosis, the entire picture of a corresponding microangiopathy is also found in coronavirus disease 2019 (COVID-19), partly through corresponding activation of the coagulation system and partly through an intensification of the other microangiopathies. The differential diagnoses and possible treatment for all areas are outlined in the article.