Thrombotic Thrombocytopenic Purpura in First Trimester Pregnancy

Pathophysiologic Mechanisms

Increased levels of fibrinogen, factor VIII, and von Willebrand factor create additional substrate for thrombosis, suppressed fibrinolysis and reduced protein S activity further shift the hemostatic balance, and hemodilution and increased platelet activation/clearance stress the ADAMTS13 system in pregnant women, according to the American Society of Hematology 1

Gestational thrombocytopenia, preeclampsia, HELLP syndrome, and acute fatty liver are predominantly third-trimester complications, whereas thrombocytopenia with microangiopathic hemolytic anemia in the first trimester should raise a high index of suspicion for TTP, as stated by the American College of Obstetricians and Gynecologists 2
The presence of thrombocytopenia with microangiopathic hemolytic anemia in the first trimester is a critical diagnostic distinction, with a high index of suspicion for TTP being essential, and ADAMTS13 activity testing should be obtained immediately, as recommended by the National Institutes of Health [1, 2, 3 is ignored as per instruction]