Navigating complexities: differential diagnosis of thrombotic microangiopathies in pregnancy - a case report

Thrombotic microangiopathy (TMA) during pregnancy is most commonly due to hypertensive disorders such as the hemolysis, elevated liver, low platelet (HELLP) syndrome and preeclampsia (PE). In these cases, delivery is the primary therapeutic intervention. However, distinguishing these pregnancy-related TMAs from other etiologies is critical, as alternative or coexisting causes may necessitate additional diagnostic and therapeutic strategies.

We report a complex and unique case of a pregnant patient with prior bariatric surgery who developed a severe early-onset HELLP. The clinical course was further complicated by posterior reversible encephalopathy syndrome (PRES). Laboratory evaluation demonstrated severe vitamin B12 deficiency and glucose-6-phosphate dehydrogenase deficiency. Due to the rapid maternal deterioration, pregnancy termination was necessary to prevent further maternal morbidity.

This case highlights the complexity of diagnosing and managing TMA during pregnancy. It emphasizes the need for clinical vigilance and a multidisciplinary approach to identify coexisting metabolic or genetic conditions that may influence both maternal and fetal outcomes.