Long-term Memory of Sensory Experiences from the First Pregnancy, its Peri-partum and Post-partum in Women with Autism Spectrum Disorders without Intellectual Disabilities: A Retrospective Study.

PURPOSE: To explore the recalled experience of pregnancy and motherhood in women diagnosed with Autism Spectrum Disorders (ASD) without intellectual disabilities, focusing on sensory perceptions and mood. METHODS: We retrospectively evaluated, through an ad-hoc structured interview, the sensory sensitivity during the pre-partum, the peri-partum, and the post-partum of thirty-three mothers with ASD and thirty-two neurotypical mothers. Participants also underwent a psychometric assessment about autistic traits, general sensory sensitivity, and post-partum depressive symptomatology. RESULTS: Mothers with ASD recalled a higher sensitivity than the comparison group across the three time-points; however, during the peri-partum their recalled hypersensitivity decreases, and in the post-partum it returned as high as before childbirth. The difference in the length of recall between groups did not statistically influence our results. Higher levels of autistic traits correlated with higher depressive post-partum symptomatology. CONCLUSIONS: Mothers with ASD seem to recall their experience of pregnancy, childbirth, and post-partum period differently from neurotypical mothers, particularly in terms of hypersensitivity. The correlation with depressive symptoms and the potential role of oxytocin and of long-term memory (encoding and recollection) are discussed. Further exploring these aspects might give fundamental hints to provide tailored support to mothers with ASD during pregnancy and motherhood.

Clinical considerations during spontaneous coronary artery dissection in the post-partum period: a case report.

Background: Spontaneous coronary artery dissection (SCAD) is a common and under-recognized cause of myocardial infarction during the post-partum period. Case summary: We report a case of a young women presenting with chest pain in the post-partum period. Her clinical appearance was that of a myocardial infarction, and angiography was indicative of a Type 2 SCAD. The patients had persistent chest pain, reduced left ventricular function, and critical left anterior descending artery stenosis. Percutaneous coronary intervention was done with caution. Shared decision-making with the patient helped guide the medical treatment plan and follow-up. Discussion: We discuss the clinical considerations surrounding the management of this patient.

Peri-operative anaesthetic management of women with obesity.

Obesity in women is prevalent and growing at an alarming pace worldwide, resulting in significant healthcare and socioeconomic consequences. Obesity is a multisystemic disease that is associated with numerous comorbidities, particularly sleep-disordered breathing, hypertension, coronary artery disease, pulmonary hypertension, thromboembolism, and diabetes mellitus. Additionally, obesity poses several peri-operative challenges including difficulty with airway management and mechanical ventilation, challenges with intravenous access or regional blocks, the need for modified anaesthetic drug dosing, the requirement for correctly sized and rated equipment, and appropriate post-operative monitoring. Therefore, early multidisciplinary planning is crucial to identify and address important peri-operative and clinical issues. Parturients with obesity are especially at high risk due to the additional physiological changes and obstetric comorbidities associated with obesity. Antenatal anaesthetic consultation along with close communication and collaboration within the multidisciplinary team are important to improve maternal and neonatal safety.

The effect of clinician education on blood transfusion practice in obstetrics: completing the audit cycle.

BACKGROUND: With blood products being a limited and expensive resource within the healthcare system, there is an ever-increasing emphasis on judicial and appropriate use. AIMS: To evaluate whether implementing contemporary society recommendations on restrictive transfusion policies would reduce inappropriate use of red blood cell transfusions, by evaluating the effect of a staff educational campaign. METHODS: An audit of peri-partum red cell concentrate (RCC) transfusion practice within a tertiary obstetric unit was undertaken, covering a 1-year period (2015), examining data related to transfusion prescribing practices. Subsequently, an educational programme was held for clinical and laboratory staff which aimed to bring practice in line with society guidelines. A repeat audit covering another 1-year period (2018) was undertaken. RESULTS: The number of RCC units of transfused reduced by 49% between 2015 and 2018 (426 to 218). The number of patients receiving transfusion dropped from 166 in 2018 (1.8% of births) to 119 in 2015 (1.5% of births). Among stable patients who were transfused, the proportion receiving a single unit increased from 6.9 to 53.9%. (p < 0.001). Haematological reassessment between units rose from 13.8 to 80.4% (p < 0.001). Written consent documentation improved (68% in 2018 vs. 38% in 2015) (p < 0.001). CONCLUSIONS: The implementation of guidelines has resulted in substantial reduction in RCC transfusions between 2015 and 2018. Fewer women received a blood transfusion, and those who did received fewer units. There is a higher proportion of patients being reassessed between units and receiving single unit transfusions. Recording of consent has improved.

Reactivated disseminated tuberculosis in pregnancy: Case report and review of the literature.

This case report describes the evaluation and management of a 32-year-old woman who presented shortly after a fetal demise at 23 weeks of gestation with multiple symptoms, including bloody vaginal discharge. Although the initial diagnostic concern was for metastatic malignancy, the patient was ultimately determined to have disseminated tuberculosis. Genital tuberculosis is common worldwide, yet guidelines for evaluation are limited. This report highlights the relationship between pregnancy-reactivated tuberculosis, and guides clinicians on diagnostic and management considerations in the peripartum period.

Echocardiographic assessment and critical care management of peri-partum women with unexpected left ventricular failure.

Introduction: Cardiac disease remains the largest single cause of maternal death. Whilst uncommon, left ventricular failure during pregnancy and delivery can be devastating to both mother and child. Echocardiography can play a significant role in rapidly establishing a diagnosis, guiding initial therapy and then monitoring response. Clinical vignettes: The history, presentation and management of three cases of peri-partum left ventricular failure is examined: stress cardiomyopathy in a 34 year old with twins, left ventricular dysfunction secondary to pre-eclampsia in a 22 year old with a singleton pregnancy and a true peri-partum cardiomyopathy in a 42 year old with IVF twins. The defining risk factors, presenting characteristics and echocardiographical findings for each pathology are highlighted. Conclusion: Echocardiography is playing an increasingly important role in the immediate assessment and management of left ventricular failure. This is especially true in the peri-partum woman, where establishing the correct therapy is both challenging and crucial due to the significant cardiovascular changes that occur around the time of delivery. To this end we believe that echocardiography should be rapidly available to guide the management of these patients by a multidisciplinary team made up of obstetricians, cardiologists, anaesthetists and intensive care physicians.

Early Uterine Necrosis due to Modified B-Lynch Suture.

B-lynch compression sutures, applied as a life-saving procedure in cases of atonic postpartum haemorrhage can sometimes lead to life-threatening complications. We report a case of early uterine necrosis following B-lynch compression suture application for PPH at the time of LSCS, resulting in peripartum hysterectomy.

Maternal mental health during COVID-19 pandemic outbreak: A cross-sectional comparative study.

Background: As COVID-19 spread in several countries, social distancing measures was implemented around the world, affecting the quality of lives for millions of people. The impact was more pronounced on vulnerable populations such as pregnant women, who are at even more risk due to their suppressed immune system. Moreover, mental health disorders are more common among pregnant women compared to non-pregnant. This study aims to assess the influence of social isolation measures due to the COVID-19 pandemic on the mental health of women in their third trimester and postpartum. Material and methods: This is a cross-sectional survey-based study conducted in Khalid University Hospital, Riyadh, Saudi Arabia, between the months of April to May 2021, to explore depression and anxiety levels in females who gave birth during the COVID-19 pandemic. In addition to background demographic data, the survey included Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder Scale-7 (GAD-7) were utilized to detect symptoms of depression and anxiety, respectively. Results: A total of 283 women were included in this study, almost half of them were ante-natal (n-141) and the rest were post-natal (n = 124). 62.3% were in the age groups of 25-35 years. Based on the PHQ-9 scoring, 65% of the study sample had depression (ranging from mild to severe). Moreover, based on GAD-7 scoring, 49.1% had anxiety (ranging from mild to severe). No association was found between PHQ-9 and GAD-7 scores and different sociodemographic and obstetric factors. Additionally, the mean scores of women infected with COVID-19 vs. women who has never been diagnosed with COVID-19 were closely comparable. Conclusions: We reported a high prevalence of depression and anxiety among pregnant women during COVID-19 pandemic. Policymakers and health care providers are advised to implement targeted preventive measures for pregnant women to improve mental health in times of epidemics.

Peripartum Management of Congenital Fiber Type Disproportion Myopathy With Severe Restrictive Lung Disease.

Congenital myopathies raise unique challenges for anesthesiologists during labor and delivery. Apart from having a risk for malignant hyperthermia, this patient population can present with severe restrictive lung disease in the third trimester. Scoliosis and weak pelvic muscles could make regional anesthesia difficult. The common complications in pregnancy include premature labor, preterm delivery, spontaneous abortion, a prolonged first stage of labor, and uterine atony. We report a case of 28-year-old primigravida of 37 weeks gestation diagnosed with congenital fiber type disproportion successfully managed by a team of high-risk obstetricians, anesthesiologists, and pulmonologists. The patient was closely monitored with serial arterial blood gas to determine carbon dioxide retention in a high-risk labor floor with a backup operating room for cesarean delivery. We reserved a malignant hyperthermia cart and a postpartum hemorrhage cart for emergencies. Our patient was able to deliver vaginally with the help of ultrasound-guided regional anesthesia despite having severe restrictive lung disease and scoliosis. We emphasize a multi-disciplinary team approach for a successful outcome for this patient population.

Mapping services at two Nairobi County primary health facilities: identifying challenges and opportunities in integrated mental health care as a Universal Health Coverage (UHC) priority.

INTRODUCTION: There is a need to scale-up mental health service provision in primary health care. The current extent of integration of mental health in primary care is pertinent to promoting and augmenting mental health at this level. We describe a facility mapping exercise conducted in two low-income/primary health facilities in Kenya to identify existing barriers and facilitators in the delivery of mental health services in general and specifically for peripartum adolescents in primary health care as well as available service resources, cadres, and developmental partners on the ground. METHOD AND MEASURES: This study utilized a qualitative evidence synthesis through mapping facility-level services and key-stakeholder interviews. Services-related data were collected from two facility in-charges using the Nairobi City County Human Resource Health Strategy record forms. Additionally, we conducted 10 key informant interviews (KIIs) with clinical officers (Clinicians at diploma level), Nurses, Community Health Assistants (CHAs), Prevention of Mother-to-child Transmission of HIV Mentor Mothers (PMTCTMs), around both general and adolescent mental health as well as psychosocial services they offered. Using the World Health Organization Assessments Instrument for Mental Health Systems (WHO-AIMS) as a guideline for the interview, all KII questions were structured to identify the extent of mental health integration in primary health care services. Interview transcripts were then systematically analyzed for common themes and discussed by the first three authors to eliminate discrepancies. RESULTS: Our findings show that health care services centered around physical health were offered daily while the mental health services were still vertical, offered weekly through specialist services by the Ministry of Health directly or non-governmental partners. Despite health care workers being aware of the urgent need to integrate mental health services into routine care, they expressed limited knowledge about mental disorders and reported paucity of trained mental health personnel in these sites. Significantly, more funding and resources are needed to provide mental health services, as well as the need for training of general health care providers in the identification and treatment of mental disorders. Our stakeholders underscored the urgency of integrating mental health treatment, prevention, and well-being promotive activities targeting adolescents especially peripartum adolescent girls. CONCLUSION: There is a need for further refining of the integrated care model in mental health services and targeted capacity-building for health care providers to deliver quality services.

Severity of shock, rate of physiological stabilization and organ failure in healthy women admitted to the intensive care unit following major peripartum hemorrhage: A retrospective, descriptive study.

PURPOSE: To describe shock severity, physiological stabilization and organ failure in healthy women admitted to the intensive care unit (ICU) after major peripartum hemorrhage (PPH). MATERIALS AND METHODS: Retrospective, descriptive, single center study. RESULTS: Twenty-nine women median age 33 years (interquartile range [IQR] 30-36) and gravidity 5 pregnancies (IQR 3-9) were studied. One woman died. The median maternal admission hematocrit was 28.8 (IQR 25.7-32.4). Median transfusion rates were nine units of packed red blood cells (IQR 7-12.25), eight fresh frozen plasma (IQR 6-12), 17 platelets (IQR 10-22) and 15 cryoprecipitate (IQR 9.75-20). Blood pressure dropped significantly in the six hours following ICU admission. Nonetheless, lactate decreased from 3.23 mmol/L to 1.54 mmol/L within 24 h of ICU admission, renal and pulmonary function were unaffected and coagulopathy was never observed. Two-thirds of the women underwent hysterectomy. One-third underwent repeated surgery. The median length of ICU stay was <48 h and that of mechanical ventilation was <24 h. Increased transfusion rates correlated with lengthier ICU admission (p ≤ 0.01 regardless of blood product). CONCLUSIONS: Ongoing hemorrhage in women with severe PPH manifests subtly and often requires active intervention. Hemorrhage control is required to achieve physiological stabilization and minimize organ damage.

Patient satisfaction with peri-partum care at Bertha Gxowa district hospital, South Africa.

BACKGROUND: Patient satisfaction is one of the key outcome measures of healthcare services.Aim and Setting: To explore factors that influence women's satisfaction with peri-partum care at Bertha Gxowa district hospital, South African primary care. METHODS: A cross-sectional study involving 260 women was conducted. A structured questionnaire collected information from participants on pain relief, health education provided by healthcare providers, privacy, cleanliness of the ward and their participation in decision-making about care received in the peri-partum period. RESULTS: Most respondents were co-habiting with their partners (100, 38%) and had completed only secondary school education (119, 46%). The average participant age was 27 years, with an average parity of two children. Most participants were satisfied with the privacy (218, 84%) and the general cleanliness of the wards (233, 90%). However, large proportions of women were dissatisfied with the information given to them by doctors (104, 55%) and nurses (89, 37%), and the rest were unsure. About 189 (73%) participants were dissatisfied with the extent of their participation in decision-making about their own care. The study had a caesarean rate of 53 (20%). Compared to normal vaginal delivery, participants who had caesarean section were significantly more likely to report being satisfied with pain relief during labour (p 0.001). CONCLUSION: The study findings showed varying levels of satisfaction with different aspects of peri-partum care and suggested the need for better pain relief during vaginal delivery, information sharing by doctors and patient emancipation for decision-making about their own care.

The Spectrum of Pregnancy-Associated Heart Failure Phenotypes: An Echocardiographic Study.

Compare echocardiographic phenotypes of women presenting with peripartum heart failure. A retrospective case-control study of pregnant women (n = 86) presenting with PP-HF symptoms (i.e., dyspnea, PND, orthopnea) and objective examination and laboratory findings (lung congestion, elevated JVP and/or HJR, elevated brain natriuretic peptide [BNP] and pulmonary edema on chest X-ray). Three distinct phenotypes based on echocardiographically-defined LVEF were identified: (a) PP-HF with preserved ejection fraction (PP HFpEF, LVEF: > 50%); (b) PP-HF with midrange ejection fraction (PP HFmrEF, LVEF: 40-50%); c) PP-HF with reduced ejection fraction (PP HFrEF, LVEF: < 40%); these were compared with 17 pregnant subjects without PP-HF symptoms/findings. Most patients were African American (n = 63; 73%), with low prevalence of hypertension (n = 15, 17%) or diabetes mellitus (n = 5, 5%); pre-eclampsia was highly prevalent (n = 52, 60%). Echocardiographically-defined phenotypes (HFpEF, n = 37; HFmrEF, n = 18; HFrEF, n = 31) showed progressively worse abnormalities in LV remodeling (LV enlargement, LV hypertrophy), LV diastolic function, and right ventricular function; the three PP-HF groups had comparable abnormalities in increased left atrial size and estimated peak tricuspid valve regurgitation velocity. Compared to controls, all three groups had significantly increased filling pressures, LV mass index and left atrial volume index. Peripartum women presenting with the clinical syndrome of heart failure exhibit a spectrum of echocardiographic phenotypes. Significant abnormalities in LV structure, diastolic function, LA size, peak TR velocity and RV function were identified in women with preserved and mid-range EFs, suggesting pregnancy-related cardiac pathophysiologic derangements.

Irish Maternal Early Warning Score.

Early Warning Systems (EWS) track the physiological parameters of individual patients and trigger a response when the parameter threshold has been reached. The use of early warning scores in adult hospital medicine has been shown to be beneficial in facilitating the early recognition of the deteriorating patient, thereby enabling prompt treatment. In 2012, a standardised National Early Warning Score was introduced in Ireland for all non-pregnant patients. The 2007 Confidential Enquiry into Maternal and Child Health recommended that EWS be introduced into maternity practice. However, the unique physiological changes of pregnancy even in health means that any scoring system must be specially adapted. The Obstetric Early Warning Score (OEWS) aims to promote early recognition of the pregnant patient at risk of deterioration. In 2013, a standardised Irish Maternity Early Warning System (IMEWS) was introduced nationally. However, the scoring system is only part of the package, once triggered it needs to be effectively communicated and acted upon promptly by appropriately trained clinicians. Despite undoubted shortcomings, the international evidence to date is supportive of the beneficial role of the OEWS in preventing maternal morbidity. Further research is needed to improve the sensitivity and specificity of the OEWS and how to better integrate it into every-day clinical practice.

Long-term effects of motherfit group therapy in pre-(MOTHERFIT1) and post-partum women (MOTHERFIT2) with stress urinary incontinence compared to care-as-usual: study protocol of two multi-centred, randomised controlled trials.

BACKGROUND: Stress urinary incontinence (SUI) is highly prevalent during pregnancy and after delivery. It is often associated with a failing pelvic floor, sphincteric and/or supportive system. Pelvic-floor-muscle training (PFMT) peri-partum has been proven effective for up to 1 year post-partum; however, its long-term effects are unknown. Group PFMT, given by a physiotherapist, has been proven to be as equally effective as individual therapy. Motherfit is a group-PFMT therapy with an emphasis on pelvic floor exercises, adherence and general fitness. Care-as-usual (CAU), if guideline driven, should, as first treatment option, consist of PFMT. Cost-effective strategies are of relevance, given the rise of health care costs. Motherfit group therapy has the potential to be cost-effective in women with urinary incontinence. Therefore, the objectives of the two current studies are: (1) to investigate whether intensive, supervised, pre-partum (MOTHERFIT1) or post-partum (MOTHERFIT2) pelvic-floor-muscle group therapy reduces 18-month post-partum severity of SUI compared to CAU and (2) whether MOTHERFIT1 OR MOTHERFIT 2 is more (cost-)effective compared to CAU. METHODS: Two multi-centred, randomised controlled trials (MOTHERFIT1, n = 150, MOTHERFIT2, n = 90) will be performed. Participants will be recruited by their midwife or gynaecologist during their routine check. Participants with SUI will receive either motherfit group therapy or CAU. Motherfit group therapy consists of eight group sessions of 60 min each, instructed and supervised by a registered pelvic physiotherapist. Motherfit group therapy includes instructions on pelvic floor anatomy and how to contract, relax and train the pelvic-floor muscles correctly and is combined with general physical exercises. Adherence during and after motherfit will be stimulated by reinforcement techniques and a mobile app. The primary outcome measure is the absence of self-reported SUI based on the severity sum score of the International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI-SF) at 18 months post-partum. Secondary outcomes evaluate quality of life, subjective improvement and health care costs. DISCUSSION: The motherfit studies are, to our knowledge, the first studies that evaluate both long-term results and health care costs compared to CAU in pregnant and post-partum women with SUI. If motherfit is shown to be (cost-)effective, implementation in peri-partum care should be considered. TRIAL REGISTRATION: Netherlands Trial Register, ID: NL5816 . Registered on 18 July 2016.

Peripartum Care for Mothers Diagnosed with Hepatitis B During Pregnancy: A Survey of Provider Practices.

Objectives Hepatitis B (HBV) remains a significant public health burden, despite effective therapy. Routine HBV screening is recommended during pregnancy to reduce the risk of vertical transmission, but the rates of follow-up care peri-partum are low. The aim of this study was to evaluate physician practices and knowledge regarding HBV in women diagnosed perinatally. Methods A survey was distributed to obstetricians and midwives within the Partners HealthCare system at Brigham and Women's Hospital and Massachusetts General Hospital. Results Of 118 survey respondents (response rate 56%), 97% reported that they always tested for hepatitis B, and 77% referred new diagnoses of HBV during pregnancy to a HBV specialist for further care. Only 10% of respondents reported that there was formal referral mechanism in place to facilitate follow-up care for mothers diagnosed with hepatitis B infection. 91% of survey respondents selected hepatitis B surface antigen as the correct screening test, and 76% selected hepatitis B immune globulin with vaccination for the newborn as the correct prophylaxis regimen. Only 40 and 51% of respondents accurately identified serologies that were consistent with acute and chronic infection, respectively. Conclusions for Practice Routine screening for HBV in this population presents an important opportunity to identify cases and to reduce the public health burden of this disease. Providers were somewhat knowledgeable about HBV, but the lack of formal referral mechanism may explain why HBV follow-up is suboptimal in this healthcare system. Supplemental provider education and formal linkage to care programs may increase rates of follow-up HBV care.

Predictors of postoperative hospitalisation in women who underwent the Triple-P Procedure for abnormal invasion of the placenta.

The 'Triple-P Procedure' is a conservative surgical alternative to peri-partum hysterectomy; it involves Peri-operative placental localisation and delivery of the foetus above the placenta, Pelvic devascularisation, and Placental non-separation with myometrial excision and uterine wall reconstruction. Our aim was to determine the factors influencing the duration of post-operative hospitalisation in women undergoing the procedure. A retrospective analysis of 24 patients was performed. The results were; 4 had additional measures (compression sutures and intrauterine balloon tamponade), 2 had co-morbidities, 3 undergoing intra and post-operative complications. We concluded that in those who had the procedure alone, the mean of hospitalisation was 4.2 days, compared to 5.5 days for those who had the complications mentioned above (p < .001). Regarding placental position, 19 had anterior, 4 had posterior and 1 had cornual placenta. The resulting blood loss mean was 3, 1.3 and 1.1 L, respectively, which explains that the blood loss is greater with anterior placenta compared to posterior and cornual invasion. Impact statement What we already know: Abnormal invasion of the placenta is associated with a maternal mortality rate of 7-10% worldwide. The conventional management options are surgical peri-partum hysterectomy and conservative intentional retention of placenta, which are associated with post-operative morbidity and mortality. Therefore, the need for a new approach is mandatory. What the results of this study add: The Triple-P Procedure is a conservative surgical technique associated with a low incidence of complications, as reflected by the short period of post-operative hospitalization. The implications of the findings for practice and/or further research: This research emphasis that more attention needs to be paid to pregnant women with co-morbidities and anterior abnormal invasion of placenta: as they are at great risk for bleeding. post-operative complications and prolonged hospital stay.

Morbidly Adherent Placenta: Its Management and Maternal and Perinatal Outcome.

OBJECTIVES: The aim of the study was to identify the risk factors predisposing to morbidly adherent placenta and to study the different modes of management and the obstetric and neonatal outcome of these patients. METHODS: This was a retrospective cum prospective observational study conducted in the Department of Obstetrics and Gynaecology in a tertiary care referral hospital in Mumbai from January 2012 to November 2014. RESULTS: The incidence of morbidly adherent placenta was 1.32 per 1000 pregnancies with patient profile comprising second gravida in the age group 26-28 years; 90 % of the patients in this study had previous Caesarean section and co-existing placenta praevia was diagnosed in 63 %. Fifty-three per cent of the women delivered between 35 and 38 weeks and 40 % had elective deliveries. Caesarean section was the mode of delivery in 90 % of the patients. Prophylactic balloon placement in the internal iliac artery followed by classical Caesarean section, uterine artery embolization and post-operative methotrexate was done in 27 % which preserved the uterus and was associated the blood loss of 1000-2000 mL. CONCLUSION: Antenatal diagnosis of morbidly adherent placenta allows for multidisciplinary planning in an attempt to minimize potential maternal or neonatal morbidity and mortality.

Suspected atypical haemolytic uraemic syndrome in two post-partum patients with foetal-death in utero responding to eculizumab.

BACKGROUND: Atypical haemolytic uraemic syndrome (aHUS) is a rare condition with the triad of microangiopathic haemolytic anaemia, thrombocytopenia and acute kidney injury. Other conditions that present in a similar manner peri-partum include thrombotic thrombocytopaenic purpura, and pregnancy associated conditions including HELLP syndrome (haemolysis, elevated liver enzymes and low platelets), severe pre-eclampsia and less commonly acute fatty liver of pregnancy. CASE REPORTS: We describe two cases of suspected aHUS, who presented post-partum with foetal death-in-utero at 33 and 37 weeks respectively. Both presented with the triad features of aHUS but had considerably different clinical courses. The first case required a prolonged ICU admission, needed intubation for neurological deterioration and dialysis for acute kidney injury, and developed complications including acute liver failure, septic shock, pancreatitis, and ischaemic colitis. Initial ADAMSTS13 activity was borderline-low (10.3%) and normal on repeat testing (42.6%), and there was no peri-partum pre-eclampsia. The other case remained clinically stable throughout her admission with creatinine peaking at 495, not requiring dialysis, minor liver transaminases derangement and was discharged after a week. Her ADAMSTS13 activity was normal (62%), and her pregnancy was complicated by peri-partum pre-eclampsia. Both eventually had a reduction in haemolysis with rapid and sustained reduction in LDH and normalised platelet counts, and complete recovery of renal function whilst receiving eculizumab therapy. CONCLUSIONS: It can be difficult to distinguish aHUS from other causes in peri-partum patients presenting with features of microangiopathic haemolytic anaemia, thrombocytopenia and acute kidney injury, and often, aHUS can be precipitated by pregnancy. In the setting of the clinical urgency to treat aHUS early with eculizumab, this presents a diagnostic challenge, as confirmatory tests for aHUS are not immediately available.