Púrpura trombótica trombocitopénica versus síndrome de HELLP: un reto diagnóstico durante la gestación / Thrombotic thrombocytopenic purpura versus hellp syndrome: a diagnostic challenge during pregnancy

La trombocitopenia es una alteración relativamente frecuente durante la gestación. Varias entidades patológicas pueden presentarse con este dato de laboratorio. Entre ellas, destacamos la púrpura trombótica trombocitopénica (PTT) y el síndrome de HELLP (hemólisis, elevación de enzimas hepáticas y trombocitopenia). Ambas entidades, en ocasiones, pueden ser muy difíciles de diferenciar cuando se producen durante el embarazo, y su manejo y tratamiento difieren enormemente. Por ello es necesario conocerlas y realizar un correcto diagnóstico diferencial, ya que el diagnóstico erróneo de cualquiera de ellas puede tener consecuencias muy graves, incluso la muerte de la paciente y del producto de la concepción (AU)

Thrombocytopenia is relatively frequent during pregnancy and can occur in a range of syndromes. Among these, particular attention should be paid to thrombotic thrombocytopenic purpura (TTP) and HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count). It can be difficult to differentiate between these conditions during pregnancy, and their management and complications may differ widely. It is therefore essential to recognize their causes and perform a correct differential diagnosis, particularly in light of their possible serious consequences, which include maternal and/or fetal death (AU)

Medical therapy (methotrexate and mifepristone) alone or in combination with another type of therapy for the management of cervical or interstitial ectopic pregnancy.

OBJECTIVE: To describe cases of cervical or interstitial ectopic pregnancy managed conservatively with combined medical treatment (methotrexate and mifepristone) alone or in association with other minimally invasive strategies. STUDY DESIGN: We describe four cervical and two interstitial ectopic pregnancies at our hospital between 2006 and 2010. All received combined treatment with methotrexate and mifepristone. A search of MEDLINE is also described. RESULTS: The literature search identified only four previous cases of cervical ectopic pregnancies and no cases of interstitial ectopic pregnancy managed with combined therapy. In our study, all patients were successfully treated and had no adverse reactions with intramuscular methotrexate 50 mg/m² and oral mifepristone 600 mg, either alone or in association with minimally invasive treatment (uterine artery embolization and evacuation dilation and curettage). All patients remained asymptomatic with ß-HCG levels that decreased and became negative within 14-49 days: the median hospital stay was 5.5 days. We also describe the first patient with a cervical ectopic pregnancy treated with methotrexate and mifepristone, followed by vaginal misoprostol 800 mcg for cervical evacuation. CONCLUSION: Methotrexate-mifepristone, either alone or in combination with other minimally invasive strategies, could be considered an option for the treatment of both cervical and interstitial ectopic pregnancy. An individualized approach should be used in each patient, however, given the wide variety of possible clinical situations and the potential seriousness of ectopic pregnancy.