1. Investigation for recurrent miscarriage might have been
appropriate. It'd be more interesting to know the timing of the previous
miscarriages (i.e. within the first 8 weeks or early first trimester etc).
This information will give us some hints whether miscarriage was due to
chromosomal abnormalities versus placental vascular insufficiency .
2. The patient has (a) microangiopathic hemolytic anemia, (b)
thrombocytopenia, (c) renal failure, (d) CNS changes such as headaches and
She also has past history of recurrent miscarriage, history suggestive of
Raynaud's syndrome and hypertension. It'd have been worthwhile
investigating the cause of hypertension 1 year ago. Could it be
hypertension due to nephritis (with renal failure ) related to collagen
vascular disease ? Is current renal failure acute-on-chronic renal failure
? Is thrombotic thrombocytopenic purpura primary versus secondary. If
secondary, is it related to collagen vascular disease [1-4] ?
3. Chest radiograph also reveals pulmonary edema.
4. Having the above-mentioned thoughts in mind, I believe
we should do the following;
(a) admit the patient to intensive care unit.
(b) management of airways, breathing per ICU team.
(c) control of seizures.
(d) control of hypertension.
(e) several tubes and catheters - endotracheal tube and mechanical
ventilation if necessary, nasogastric tube, indwelling foley catheters, IV
(f) consult Hematology and Nephrology teams urgently.
(g) Investigations - Blood - vonWillebrand's factor protease (ADAMTS-
13 enzyme ) activity, type & crossmatch, ANA, RF, ds-DNA, complement
and vasculitic panels, etc, plasma protein immunofixation. Urine -
urinalysis, urine for microscopy, 24-hour urine for protein, urine for
(h)Place Vascath catheter.
(i) This patient will need urgent therapeutic plasma exchange
performed in tandem with hemodialysis (if feasible). The replacement
fluid for plasmapheresis will be fresh frozen plasma.
(j) systemic corticosteroids such as methylprednisone.
(k) ICU management including strict intake-output data etc.
(l) find out from GP if any investigations were done for miscarriage
and hypertension and urgent review of the patient's old hospital chart.
1.Yamada T, Handa Y, Kamikawa T, et al. A case of systemic lupus
erythematosus associated with thrombotic thrombocytopenic purpura and
hemophagocytic syndrome].Nihon Rinsho Meneki Gakkai Kaishi 2006
2.Majithia V, Harisdangkul V : Thrombotic thrombocytopenic purpura in
systemic lupus erythematosus: A frequent and severe consequence of active
Rheumatology (Oxford). 2006 Sep;45(9):1170-1.
3.Cheung WY: Thrombotic thrombocytopenic purpura and systemic lupus
erythematosus - distinct entities or overlapping syndromes?
Transfus Apher Sci. 2006 Jun;34(3):263-6
4. Aleem A, Al-Sugair S. Thrombotic thrombocytopenic purpura
associated with systemic lupus erythematosus.
Acta Haematol. 2006;115(1-2):68-73
5. Mahmood A, Sodano D, Dash A, Weinstein R:
Therapeutic plasma exchange performed in tandem with hemodialysis for
patients with M-protein disorders. J Clin Apher 2006; 21(2):100-4