Post-traumatic thrombotic microangiopathy: What trauma surgeons need to know?

Plasma Exchange in Postpartum Hemorrhage (PPH)-Associated Thrombotic Microangiopathy (TMA): A Case Report

Thrombotic microangiopathy (TMA) is a rare yet potentially life-threatening condition. The diagnosis is difficult as there are other conditions presenting with features akin to TMA during the peripartum period such as eclampsia, preeclampsia, hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome, and antiphospholipid syndrome. A 28-year-old woman with no significant past medical history developed TMA following a massive hemorrhage after an emergency cesarean section at 41 weeks of gestation. This case was finally diagnosed as postpartum hemorrhage (PPH)-associated TMA. The patient fully recovered after plasma exchange therapy. We posit the value of accumulating case reports, given that the documentation on the efficacy of plasma exchange in PPH-associated TMA is limited.

Therapeutic plasma exchange is feasible and tolerable in severely injured patients with trauma-induced coagulopathy

Objectives

Trauma-induced coagulopathy (TIC) occurs in a subset of severely injured trauma patients. Despite having achieved surgical hemostasis, these individuals can have persistent bleeding, clotting, or both in conjunction with deranged coagulation parameters and typically require transfusion support with plasma, platelets, and/or cryoprecipitate. Due to the multifactorial nature of TIC, targeted interventions usually do not have significant clinical benefits. Therapeutic plasma exchange (TPE) is a non-specific modality of removing and replacing a patient's plasma in a euvolemic manner that can temporarily normalize coagulation parameters and remove deleterious substances, and may be beneficial in such patients with TIC.

Methods

In a prospective case series, TPE was performed in severely injured trauma patients diagnosed with TIC and transfusion requirement. These individuals all underwent a series of at least 3 TPE procedures performed once daily with plasma as the exclusive replacement fluid. Demographic, injury, laboratory, TPE, and outcome data were collected and analyzed.

Results

In total, 7 patients received 23 TPE procedures. All patients had marked improvements in routine coagulation parameters, platelet counts, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activities, inflammatory markers including interleukin-6 concentrations, and organ system injuries after completion of their TPE treatments. All-cause mortality rates at 1 day, 7 days, and 30 days were 0%, 0%, and 43%, respectively, and all patients for whom TPE was initiated within 24 hours after injury survived to the 30-day timepoint. Surgical, critical care, and apheresis nursing personnel who were surveyed were universally positive about the utilization of TPE in this patient population. These procedures were tolerated well with the most common adverse event being laboratory-diagnosed hypocalcemia.

Conclusion

TPE is feasible and tolerable in severely injured trauma patients with TIC. However, many questions remain regarding the application of TPE for these critically ill patients including identification of the optimal injured population, ideal time of treatment initiation, appropriate treatment intensity, and concurrent use of adjunctive treatments.

Level of evidence

Level V.

Thrombotic microangiopathy after traumatic brain injury: A case report and review of the literature

Key Clinical Message

This case report supports that trauma can rarely cause thrombotic microangiopathy (TMA). Early recognition is important due to a high mortality of untreated TMA, but diagnosis can be delayed by attributing lab abnormalities as due to blood loss.

Abstract

Major trauma can provoke coagulopathy, ranging from hypo- to hypercoagulation. Thrombotic microangiopathy (TMA), characterized by hemolytic anemia, renal failure, thrombocytopenia, and intravascular hemolysis, results in bleeding tendency but also microvascular thrombosis. We report a rare case of isolated traumatic brain injury leading to TMA treated with plasmapheresis.

Isolated quadrilateral plate fracture with central hip dislocation after epileptic seizure in a postpartum patient: A case report

Isolated quadrilateral plate fractures are extremely rare and their treatment is complex. The postpartum period and recent caesarean section additionally increase already significant risks of surgical treatment. Modified Stoppa approach and the use of infrapectineal plate represent the optimal surgical treatment method. One case of central hip dislocation and isolated quadrilateral plate fracture was reported during an epileptic seizure 1 day postpartum, which was treated with open reduction and internal fixation. A 25-year-old female patient had given birth via cesarean section. One day postpartum, she had multiple generalized tonic clonic seizures. Arteriovenous malformation was identified as the cause of seizures by MRI. The patient complained of left hip pain and inability to move the left leg which prompted clinical and radiological examination. A pelvic CT scan verified multifragmentary fracture of the quadrilateral plate without fracture of the acetabular columns. The central hip dislocation was verified. Due to the rarity of the fracture, the clinical decision-making process was difficult. The patient, being in the postpartum period, was also at a greater risk of infection. The patient was treated surgically, and osteosynthesis was performed with an infrapectineal plate for the acetabulum using the modified Stoppa approach. The initial incision was done through the same Pfannenstiel incision from caesarean section. The patient's postoperative recovery was good at 1 year follow-up.