From uterine atony to aHUS: A case of postpartum thrombotic microangiopathy

We report the case of a 42-year-old primiparous woman who developed severe postpartum hemorrhage due to uterine atony after an instrumental delivery, requiring massive transfusion and Bakri balloon placement. Despite initial haemodynamic stabilization, she progressed to persistent anuria and acute kidney injury. Imaging revealed bilateral renal cortical necrosis. Atypical haemolytic uremic syndrome (aHUS) was suspected on the basis of tests showing anaemia, thrombocytopaenia, complement consumption, and ADAMTS13 activity >10%. Treatment with eculizumab and renal replacement therapy was initiated, achieving good haematologic response. This case highlights a rare postpartum complication in which early suspicion enables prompt targeted therapy. Ansesthesiologists play a key role in initial haemodynamic management and in identifying warning signs suggestive of thrombotic microangiopathies.