{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,4]],"date-time":"2025-12-04T11:25:49Z","timestamp":1764847549156,"version":"3.46.0"},"reference-count":27,"publisher":"BMJ","issue":"12","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2025,10,25]]},"published-print":{"date-parts":[[2025,12]]},"abstract":"<jats:p>Hypertensive disorders of pregnancy (HDP) including haemolysis, elevated liver enzymes and low platelet count (HELLP) and pre-eclampsia are one of the leading causes of maternal mortality. There is significant overlap between the acute clinical presentation of such HDP and other medical conditions with thrombotic microangiopathy such as acute fatty liver of pregnancy, catastrophic antiphospholipid antibody syndrome, acute systemic lupus erythematosus, atypical haemolytic uraemic syndrome and thrombocytopenic thrombotic purpura. This can make timely clinical diagnosis and treatment challenging. Here, we present a complex case of severe pre-eclampsia and HELLP with concerns for a thrombotic microangiopathy, where accurate clinical diagnosis of overlapping pathologies posed a clinical challenge, and share our key reflections and learning points in the context of current evidence. We discuss diagnostic tests to aid diagnosis and review the cardinal presenting features and pathophysiology of possible causes of thrombotic microangiopathy in pregnancy.<\/jats:p>","DOI":"10.1136\/bcr-2025-266376","type":"journal-article","created":{"date-parts":[[2025,12,4]],"date-time":"2025-12-04T11:20:59Z","timestamp":1764847259000},"page":"e266376","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["The conundrum of thrombotic microangiopathy in pregnancy"],"prefix":"10.1136","volume":"18","author":[{"given":"Akanksha","family":"Garg","sequence":"first","affiliation":[{"name":"Obstetrics and Gynecology, Yale University, New Haven, Connecticut, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Layla","family":"Van Doren","sequence":"additional","affiliation":[{"name":"Hematology, Yale University, New Haven, Connecticut, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Eesha","family":"Dave","sequence":"additional","affiliation":[{"name":"Obstetrics and Gynecology, Yale University, New Haven, Connecticut, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Katherine","family":"Kohari","sequence":"additional","affiliation":[{"name":"Obstetrics and Gynecology, Yale University, New Haven, Connecticut, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,12,4]]},"reference":[{"key":"2025120403205183000_18.12.e266376.1","doi-asserted-by":"publisher","DOI":"10.1097\/AOG.0000000000003891"},{"key":"2025120403205183000_18.12.e266376.2","doi-asserted-by":"publisher","DOI":"10.1097\/01.AOG.0000258281.22296.de"},{"key":"2025120403205183000_18.12.e266376.3","doi-asserted-by":"crossref","first-page":"2103","DOI":"10.1182\/blood.2020005221","article-title":"Management of thrombotic microangiopathy in pregnancy and postpartum: report from an international working group","volume":"136","author":"Fakhouri","year":"2020","journal-title":"Blood"},{"key":"2025120403205183000_18.12.e266376.4","first-page":"1594","article-title":"16th International Congress on Antiphospholipid Antibodies Task Force Report on Catastrophic Antiphospholipid Syndrome","volume":"29","author":"Cervera","year":"2020","journal-title":"Lupus (Los Angel)"},{"key":"2025120403205183000_18.12.e266376.5","doi-asserted-by":"crossref","first-page":"e125","DOI":"10.1055\/s-0036-1579539","article-title":"Pregnancy-Associated Atypical Hemolytic-Uremic Syndrome","volume":"6","author":"Saad","year":"2016","journal-title":"AJP Rep"},{"key":"2025120403205183000_18.12.e266376.6","doi-asserted-by":"publisher","DOI":"10.3748\/wjg.15.897"},{"key":"2025120403205183000_18.12.e266376.7","doi-asserted-by":"publisher","DOI":"10.1038\/ajg.2017.54"},{"key":"2025120403205183000_18.12.e266376.8","doi-asserted-by":"publisher","DOI":"10.1016\/0002-9378(92)91735-S"},{"key":"2025120403205183000_18.12.e266376.9","article-title":"Acute Fatty Liver of Pregnancy: A Diagnostic Challenge","volume":"15","author":"Yemde","year":"2023","journal-title":"Cureus"},{"key":"2025120403205183000_18.12.e266376.10","doi-asserted-by":"crossref","DOI":"10.1136\/bcr-2019-230863","article-title":"Catastrophic antiphospholipid syndrome in pregnancy: a life-threatening condition","volume":"12","author":"Collict","year":"2019","journal-title":"BMJ Case Rep"},{"key":"2025120403205183000_18.12.e266376.11","first-page":"1731","article-title":"Studies on the methods of diagnosing pancreatic cancer with the use of tumor markers by discriminant analysis","volume":"82","author":"Kawanishi","year":"1985","journal-title":"Nihon Shokakibyo Gakkai Zasshi"},{"key":"2025120403205183000_18.12.e266376.12","doi-asserted-by":"publisher","DOI":"10.1007\/s10067-004-1017-1"},{"key":"2025120403205183000_18.12.e266376.13","doi-asserted-by":"publisher","DOI":"10.1136\/ard-2023-224609"},{"key":"2025120403205183000_18.12.e266376.14","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1016\/j.semarthrit.2018.11.005","article-title":"Secondary thrombotic microangiopathy in systemic lupus erythematosus and antiphospholipid syndrome, the role of complement and use of eculizumab: Case series and review of literature","volume":"49","author":"Kello","year":"2019","journal-title":"Semin Arthritis Rheum"},{"key":"2025120403205183000_18.12.e266376.15","doi-asserted-by":"publisher","DOI":"10.1016\/j.autrev.2022.103055"},{"key":"2025120403205183000_18.12.e266376.16","doi-asserted-by":"publisher","DOI":"10.1182\/blood.2020007499"},{"key":"2025120403205183000_18.12.e266376.17","doi-asserted-by":"crossref","DOI":"10.1136\/bcr-2023-256022","article-title":"Atypical haemolytic uraemic syndrome in a postpartum patient","volume":"16","author":"Hierholzer","year":"2023","journal-title":"BMJ Case Rep"},{"key":"2025120403205183000_18.12.e266376.18","unstructured":"Mancini A , Ardissino G , Angelini P , et al . HELLP syndrome and hemolytic uremic syndrome during pregnancy: two disease entities, same causation. Case report and literature review. G Ital Nefrol 2019;36."},{"key":"2025120403205183000_18.12.e266376.19","doi-asserted-by":"crossref","DOI":"10.1186\/s12884-020-03185-3","article-title":"Diagnostic dilemma in postpartum associated hemolytic uremic syndrome in a 38th week pregnant 31-year-old Congolese: a case report","volume":"20","author":"Tshilanda","year":"2020","journal-title":"BMC Pregnancy Childbirth"},{"key":"2025120403205183000_18.12.e266376.20","doi-asserted-by":"crossref","DOI":"10.1177\/20543581231209009","article-title":"Complement-Mediated Thrombotic Microangiopathy in Pregnancy: An Educational Case Report","volume":"10","author":"Bruno","year":"2023","journal-title":"Can J Kidney Health Dis"},{"key":"2025120403205183000_18.12.e266376.21","doi-asserted-by":"crossref","DOI":"10.3389\/fimmu.2020.00548","article-title":"Eculizumab Treatment for Postpartum HELLP Syndrome and aHUS-Case Report","volume":"11","author":"Lokki","year":"2020","journal-title":"Front Immunol"},{"key":"2025120403205183000_18.12.e266376.22","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1007\/s40620-016-0357-7","article-title":"Atypical hemolytic uremic syndrome in the setting of complement-amplifying conditions: case reports and a review of the evidence for treatment with eculizumab","volume":"30","author":"Asif","year":"2017","journal-title":"J Nephrol"},{"key":"2025120403205183000_18.12.e266376.23","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1111\/nep.12935","article-title":"Suspected atypical haemolytic uraemic syndrome in two post-partum patients with foetal-death in utero responding to eculizumab","volume":"22 Suppl 1","author":"Chua","year":"2017","journal-title":"Nephrology (Carlton)"},{"key":"2025120403205183000_18.12.e266376.24","article-title":"Efficacy of eculizumab in a case of pregnancy-associated aHUS","volume":"33","author":"Cravero","year":"2016","journal-title":"G Ital Nefrol"},{"key":"2025120403205183000_18.12.e266376.25","doi-asserted-by":"crossref","first-page":"e96","DOI":"10.1055\/a-2164-8438","article-title":"Pregnancy-Associated Atypical Hemolytic Uremic Syndrome: A Case Report with MCP Gene Mutation and Successful Eculizumab Treatment","volume":"14","author":"Dom\u00ednguez-Vargas","year":"2024","journal-title":"AJP Rep"},{"key":"2025120403205183000_18.12.e266376.26","doi-asserted-by":"publisher","DOI":"10.15585\/mmwr.mm6627e1"},{"key":"2025120403205183000_18.12.e266376.27","first-page":"530","article-title":"Catastrophic antiphospholipid syndrome: international consensus statement on classification criteria and treatment guidelines","volume":"12","author":"Asherson","year":"2003","journal-title":"Lupus (Los Angel)"}],"container-title":["BMJ Case Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bcr-2025-266376","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,4]],"date-time":"2025-12-04T11:21:02Z","timestamp":1764847262000},"score":1,"resource":{"primary":{"URL":"https:\/\/casereports.bmj.com\/lookup\/doi\/10.1136\/bcr-2025-266376"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12]]},"references-count":27,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2025,12,4]]},"published-print":{"date-parts":[[2025,12]]}},"alternative-id":["10.1136\/bcr-2025-266376"],"URL":"https:\/\/doi.org\/10.1136\/bcr-2025-266376","relation":{},"ISSN":["1757-790X"],"issn-type":[{"value":"1757-790X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12]]}}}