COVID-19 triggers difficult-to-treat TTP in pregnancy for woman, 41
Case shows need for personalized treatment to improve patient prognosis
COVID-19 may trigger or worsen refractory, or difficult-to-treat, thrombotic thrombocytopenic purpura (TTP) during the first months of pregnancy, requiring early diagnosis and aggressive treatment to protect both mother and baby.
That’s according to a new report from Iran that detailed the case of a pregnant woman in her 40s who developed refractory TTP in her first trimester after unknowingly contracting COVID-19. While treatment at first appeared successful, the woman again started showing signs of disease activity and was given therapy weekly throughout the pregnancy.
The woman ultimately delivered her baby and recovered well, but the researchers stressed that diagnosing the rare blood disorder early and providing personalized care are crucial for treating TTP during pregnancy.
“This case highlights the need for individualized treatment plans, careful monitoring, and multidisciplinary collaboration to improve prognosis in pregnant patients affected by TTP,” the researchers wrote.
The report, “Can COVID-19 Lead to Refractory Thrombotic Thrombocytopenic Purpura (TTP) During Pregnancy and Postpartum? A Case Report and a Review of the Literature,” was published in the journal Clinical Case Reports.
TTP occurs when clots form in small blood vessels and block blood flow to organs. As blood is forced through these narrowed vessels, red blood cells break down prematurely, causing anemia — when a person does not have enough healthy red blood cells or sufficient hemoglobin protein to carry oxygen to the body’s tissues.
The formation of clots also consumes platelets — the small cell fragments that normally help blood clot — leading to thrombocytopenia, or low platelet counts.
Pregnancy can make blood more likely to clot, which can complicate the diagnosis and treatment of TTP. While TTP usually appears in the third trimester of pregnancy, it can, though rarely, occur earlier, posing serious risks for both the mother and her baby.
Woman developed TTP early in pregnancy, after testing positive for COVID-19
In this report, doctors from Shahid Beheshti University of Medical Sciences described the case of a 41-year-old pregnant woman who developed refractory TTP. She was in her third pregnancy, with two past cesarean deliveries. At just six weeks into her pregnancy, she developed sudden hematuria, or blood in her urine, and a fever.
When she was admitted to the hospital, the woman tested positive for the virus that causes COVID-19.
“Emerging data suggest that COVID-19, similar to other viral infections, can trigger TTP through direct or immune-mediated mechanisms,” the researchers wrote.
Blood tests showed the presence of schistocytes — red blood cell fragments — and thrombocytopenia, with about 12,000 platelets per microliter of blood (normal range is 160,000-450,000). These findings “strongly supported the diagnosis of TTP,” the researchers wrote.
This case study underscores the vital importance of early diagnosis and timely intervention in managing TTP during pregnancy, particularly in the rare situation of refractory [hard-to-treat] TTP occurring in the first trimester.
Doctors began treatment with the corticosteroid methylprednisolone and plasma exchange, which removes and replaces plasma, the liquid portion of blood. Fresh, healthy plasma contains functional ADAMTS13, the enzyme missing or underactive in TTP. This enzyme normally prevents clots from forming when they aren’t needed.
The woman underwent four sessions of plasma exchange. After three days of treatment, her platelet counts increased to 152,000 per microliter of blood and she was discharged from the hospital.
However, at 11 weeks of pregnancy, still in the first trimester, she again developed thrombocytopenia, showing the disease was still active. The patient underwent additional sessions of plasma exchange and was given oral prednisolone.
After improving, she was discharged from the hospital, with physicians providing close follow-up. During her pregnancy, she had weekly sessions of plasma exchange to maintain platelets within the normal range. However, at 36 weeks, she developed labor pain, headache, nausea, vomiting, and suicidal thoughts.
She underwent an emergency cesarean section to deliver her baby. After surgery, the woman required more sessions of plasma exchange and ongoing treatment with oral prednisolone to control her TTP. She recovered well after delivery and was discharged two weeks later, without further complications.
“This case study underscores the vital importance of early diagnosis and timely intervention in managing TTP during pregnancy, particularly in the rare situation of refractory TTP occurring in the first trimester,” the researchers wrote, adding that it also “highlights the complexities involved in managing refractory TTP during pregnancy and the postpartum period.”
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