Bilateral retinal detachments and preeclampsia: thrombotic thrombocytopenic purpura or syndrome of haemolysis, elevated liver enzymes, low platelets?

Abstract

Thrombotic thrombocytopenic purpura (TTP) is a rare and life-threatening disorder that rarely affects pregnancy. In contrast, preeclampsia is an obstetric complication encountered much more frequently in clinical practice. A recent review of pregnancy associated TTP in 166 pregnancies revealed a mortality of 26% with initial TTP in pregnancy, which increased to 44.4% with concurrent preeclampsia [1]. The syndrome of haemolysis, elevated liver enzymes and low platelets (HELLP) complicates approximately 4-12% of patients with severe preeclampsia [2] and can present clinically in much the same way as TTP, thus delaying the correct diagnosis and management. Martin et al.[1] were able to identify characteristic laboratory findings observed with TTP alone and when TTP co-exists with preeclampsia and HELLP syndrome.Serous retinal detachments (SRD) are a rare complication in pregnant women with preeclampsia. Although the visual system may be affected in 30-100% of patients with preeclampsia, serous retinal detachment is an unusual cause of visual loss, occurring in 51% of preeclamptic patients [3]. It is, however, a known complication of TTP with hypertension believed to be a contributing factor.The present report illustrates a case of a patient presenting to labour and delivery with severe preeclampsia that was initially complicated with bilateral retinal detachments. She later developed HELLP syndrome and was ultimately diagnosed with underlying TTP. She had a marked improvement of her lab values and her clinical course once plasmapharesis was initiated.

Preeclamptic serous retinal detachment without hypertension: A case report

“…In a review of the literature, we identified 43 case reports and case series documenting serous retinal detachment during pregnancy. Our review included 97 women diagnosed with preeclampsia with a median gestational age at presentation of 31.9 weeks (range 20–40 weeks) [ 5 , [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] , [15] , [16] , [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [44] , [45] , [46] ]. Of cases with blood pressure data reported (90 of 97), only one patient was normotensive.…”

Bilateral Exudative Retinal Detachment in HELLP Syndrome

“…Immediate therapy of the syndrome and delivery of the fetus is advisable to reverse ocular manifestations and avoid visual sequelae. So far, only six cases of bilateral exudative retinal detachment in HELLP syndrome have been reported in the peer-reviewed literature [3, 6,7,8,9,10], which highlights the importance to increase awareness of this disorder amongst ophthalmologists.…”

Retinopathy in pregnancy in women with type 1 diabetes - a study of associations with arterial wall elasticity and mutation in coagulation genes

“…Platelet activation leads to the change in the platelet Gp2b3a receptor that induces binding to fibrinogen. Polymorphism in integrin has been linked to preeclampsia and abortions [15].…”