The diagnostic dilemma of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome in the obstetric triage and emergency department: lessons from 4 tertiary hospitals.

OBJECTIVE: We report a series of occurrences of thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS) in pregnancy that emphasizes early diagnosis. STUDY DESIGN: Fourteen pregnancies with TTP (n = 12) or HUS (n = 2) were studied. Analysis focused on clinical and laboratory findings on examination, initial diagnosis, and treatment. RESULTS: There were 14 pregnancies in 12 patients; 2 cases of TTP were diagnosed as recurrent. Five women were admitted to the emergency department (ED), and 7 patients were admitted to an obstetrics triage. Patients who were evaluated by an obstetrician were treated initially for hemolysis, elevated liver enzymes and low platelets syndrome/preeclampsia, whereas patients who were seen in the ED had a diagnosis that is commonplace in the ED (panic attack, domestic violence, gastroenteritis). Latency from the onset of symptoms to diagnosis ranged from 1-7 days. Plasmapheresis treatments in early gestation resulted in favorable maternal-neonatal outcome. Maternal and perinatal mortality rates were 25% each. CONCLUSION: TTP/HUS is a challenging diagnosis in obstetric triage and ED areas. We propose a management scheme that suggests how to triage patients for early diagnosis in pregnancy.

Cystic fibrosis screening at the Greenville Hospital System.

The cost effectiveness of prenatal screening for cystic fibrosis needs to be reexamined. This will require further study. At the time prenatal screening for CF carrier status was initiated, newborn screening for cystic fibrosis was not commonly available. The benefit of screening in our population was detection of 68 female carriers; however, this did not result in finding any fetuses affected with cystic fibrosis. The American College of Obstetrics and Gynecology has recommended CF screening for women of childbearing age but as yet no consensus has been reached concerning the cost effectiveness of this policy. Although over 2600 pregnancies were tested, the reproductive outcome was not altered in a single pregnancy.