Postpartum Hemolytic-Uremic Syndrome

A.C.Chester, MD, Department of Pathology, 153 Basic Science Building, 4000 Reservoir Road, N.W., Washington, DC 20007 (USA) Sir. Dr. Per Brandt et al. [1] report the administration of antithrombin-IΠ to be useful in the treatment of postpartum hemolytic-uremic syndrome. The conclusion of its efficacy is based on a favorable outcome and a quick return of the renal function in a condition they state has a poor prognosis. We consider the projected mortality to be overstated, which would make the contribution of antithrombin-IΠ unclear. Accordingly, we report a case similar to theirs in which no specific therapy was employed and a favorable outcome resulted within a short time frame. A healthy 39-years-old white woman, gravida IV, para III, with a pregnancy of 35 weeks was admitted for abdominal pain approximately 6 h prior to a normal spontaneous vaginal delivery. The pregnancy had been uncomplicated; however, the fetus was small for dates. She developed hypertension with blood pressure as high as 200/120 mmHg. Magnesium sulfate infusions were instituted and continued after delivery. Oliguria was noted shortly after delivery with a urinary excretion of approximately 10 ml/h. On physical examination 2 h postpartum, the blood pressure was 200/110 mm Hg, the pulse was 80 beats/min, and the respirations were 16/min. Erythema of the face and chest was evident. Positive physical findings were limited to a laterally displaced point of maximal impulse on cardiac examination with a grade 2/6 systolic ejection murmur, atrial diastolic gallop, and systolic click. The liver was 18 cm in span, 3 cm below the right costal margin. The spleen was palpable. Pigmented and granular casts with numerous red blood cells were noted on urinalysis. A urine osmolality of 303 mosm/kg was recorded, and 4+ blood and 3+ protein noted on dipstick. The peripheral blood smear, which was normal on admission, had schistocytes, fragments, and microspherocytes 4 h later. The platelet count was 42,000/ml. Methylprednisolone, 75 mg/day, was started for possible vascular stabilization. Within 1 day, she developed right-sided focal seizures and was started on diphenylhydantoin. Indications of intravascular coagulation were apparent; latex test 40 μg/ml (normal 0–8 μg/ml), staphylococcal clumping time 16 μg Fe/ml (normal 0–4 μg Fe/ml), and a thrombin time of 29.8 s (control 20.7 s). The fibrinogen was 265 mg/dl; and the haptoglobin 0. The urine output increased to greater than 50 ml/h by the 2nd day, however, the serum creatinine continued to rise, peaking on the 6th day at 9.2 mg/dl. The platelet count reached a low of 7,000, remaining at approximately 50,000 the 1st week before returning to normal.