19 – Microangiopathic Haemolytic Anaemia (MAHA) in Pregnancy Presenting in A&E




19 Microangiopathic Haemolytic Anaemia (MAHA) in Pregnancy Presenting in A&E


Louise Simcox and Jo Gillham



Scenario in a Nutshell



Patient presents with hypertension, proteinuria, headache and confusion. MAHA on blood results. Has seizure. Probable thrombotic thrombocytopenic purpura (TTP).


Stage 1: Initial assessment and management by the emergency department team of a hypertensive, proteinuric, pregnant patient with history of abdominal pain, headache and confusion.


Stage 2: Assessment of patient by obstetrician and anaesthetist. Fetal death in utero (FDIU) diagnosed. MAHA on blood results. Patient becoming increasingly agitated.


Stage 3: Patient deteriorates and has tonic–clonic seizure on critical care. Further multidisciplinary input regarding likely diagnosis of TTP and management.



Target Learner Groups


A+E staff, obstetricians, anaesthetists, critical care doctors and nurses.

















Specific learning opportunities
Effective team management of obstetric emergency – MAHA
Exploration of differential diagnosis: TTP/atypical haemolytic uraemic syndrome (HUS)/acute fatty liver/HELLP
Demonstrate appropriate leadership and communication with other specialities
Appropriate use/interpretation of investigations








































Suggested learners (to represent their normal roles) In the room from the start Available when requested
Emergency department (ED) Registrar √
Emergency department (ED) Nurse √
Obstetric ST3+ √

Anaesthetic ST3+


Critical care ST3+


Critical care nurse

√


√


√

Suggested facilitators
Faculty to play role of patient’s partner √
Haematology ST7 √ in critical care at end of scenario


Details for Facilitators



Patient Demographics









Name: Clare


Age: 32


Gestation: 25+4


Booking weight: 81 kg


Parity: P0



Scenario Summary for Facilitators



32-year-old 25+4/40 gestation primigravida attended emergency department (ED) with headache, abdominal pain and reported confusion.


Seen by ED team in Majors – hypertension with proteinuria, confused and agitated. Transferred to Resuscitation bay.


Seen by Obstetric Team – identify FDIU.


Abnormal blood results – explore differential diag-nosis of MAHA.


CT head and liver USS.


Transfer to Critical Care Unit.


Seizure on critical care.


Confirm likely diagnosis of TTP – management plan for plasma exchange and delivery.



Set-up Overview for Facilitators

























  • Clinical setting


  • On a trolley in Emergency Department Majors




  • Patient position


  • Semi-recumbent




  • Initial monitoring in place


  • Pulse oximeter



  • NIBP cuff



  • ECG




  • Other equipment


  • Nil




  • Useful manikin functions


  • Seizures



Medical Equipment


For core equipment checklist, see Chapter 9 including advanced airway equipment.























Additional equipment specific to scenario
Doppler fetal monitor Ultrasound machine Magnesium Sulphate (MgSO4)
Labetalol PO/IV, hydralazine or other antihypertensives as per local severe pre-eclampsia protocol Pen torch Tendon hammer
Arterial line Benzodiazepines


Information Given to the Learners











Information given to ED nurse and ED registrar who are taking over care at start of their shift



  • Time: 08:00



  • This handover is given by a facilitator playing the role of the ED nurse from the night shift who is now going home.



  • The SBAR handover is as follows:



  • Situation: This is Clare. She has just come around from the waiting room with a bad headache, abdominal pain and a history of being confused a bit earlier.



  • Background: 32 years old, previously fit and well primip who is 25+4 weeks pregnant. She has no allergies and is on no regular medication. History from partner – unwell for 4–5 days with abdominal pain, headache for past 2 days and intermittently confused over last 24 hours. Noted blood in urine today. Referred following telephone consultation with GP.



  • Assessment: I have done her first set of observations.



  • Recommendation: Are you two OK to take over her care?

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Related posts:

  1. 6 – Introduction to Human Factors and Ergonomics in Obstetric Simulation
  2. 13 – Minimising Decision to Delivery Interval (DDI) in a Category 1 Caesarean Section – Pre-Theatre Phase
  3. 18 – HELLP Syndrome with Fetal Compromise Requiring an Emergency GA Caesarean Section
  4. 36 – Obstetric Trauma

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Oct 24, 2020 | Posted by in OBSTETRICS | Comments Off on 19 – Microangiopathic Haemolytic Anaemia (MAHA) in Pregnancy Presenting in A&E

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