Multidisciplinary management of concurrent postpartum eclampsia, HELLP syndrome, ruptured hepatic subcapsular hematoma, and atypical hemolytic uremic syndrome: a case report

The concurrent presentation of postpartum eclampsia, HELLP syndrome (hemolysis, elevated liver enzymes, low platelets), ruptured hepatic subcapsular hematoma, and pregnancy-associated atypical hemolytic uremic syndrome (P-aHUS) represents a life-threatening obstetric emergency. To the best of our knowledge, this represents a novel presentation, as the concurrent manifestation of these complications has rarely, if ever, been documented. This case highlights the paramount challenge of differentiating thrombotic microangiopathies (TMAs) in the context of postpartum multi-organ failure. A 39-year-old multiparous woman presented 1.5 h after an out-of-hospital vaginal delivery with postpartum eclampsia, HELLP syndrome, and hemorrhagic shock secondary to ruptured hepatic subcapsular hematoma (confirmed by 3,000 mL hemoperitoneum). Following emergency laparotomy and transfusion (52 units packed red blood cells, 8.25 L fresh frozen plasma), she developed P-aHUS (soluble C5b-9 1,079 ng/mL; C3 0.68 g/L) requiring 6 plasma exchanges and continuous renal replacement therapy. Platelet recovery began at postoperative day 12. The patient was discharged on postoperative day 40 with substantial clinical improvement. This case illustrates the importance of considering alternative etiologies, such as P-aHUS, in cases of persistent or new-onset thrombotic microangiopathy beyond 48–72 h postpartum. Early complement testing and multidisciplinary escalation (including plasma exchange) are vital for survival in such multi-organ failure situations. The clinical and laboratory features observed in this case underscore the diagnostic challenges and therapeutic strategies required for this rare constellation of postpartum complications.