When Autoimmunity Meets Pregnancy: Investigating Antiphospholipid Syndrome and Preeclampsia

This is a case report of a 23 year old primiparous female with past medical history of antiphospholipid syndrome, unprovoked deep venous thromboses and venous thromboembolisms, chronic hypertension and class III obesity. She presented to us at 20 weeks and 1 day gestation with known left sided pulmonary embolism who was being managed on the antepartum service. She was taking therapeutic anticoagulation; however, her clinical picture worsened when she then had worsening bilateral pulmonary embolisms and was subsequently diagnosed with superimposed preeclampsia with severe features at 23 weeks and 1 day gestation. She had acutely worsening proteinuria and difficult to control hypertension despite multiple medications. Management included a multidisciplinary approach including maternal fetal medicine, hematology, neonatology, anesthesia and interventional radiology in addition to routine obstetrical care inpatient. As she desired full neonatal resuscitation, she received betamethasone for fetal lung maturity and magnesium sulfate for fetal neuroprotection (in addition to maternal seizure prophylaxis). Fetus was diagnosed with fetal growth restriction at 23 weeks and 5 days gestation, with elevated umbilical artery Dopplers. Patient was ultimately delivered at 24 weeks gestation for worsening preeclampsia via an uncomplicated primary classical cesarean section utilizing perioperative heparin drip, with no excessive bleeding noted intraoperatively or thrombotic events. Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by circulating antiphospholipid antibodies Lupus Anticoagulant, Anticardiolipin Antibody (IgG/IgM), or Anti-B2 Glycoprotein I (IgG/IgM). Diagnostic criteria include one laboratory finding with positive antiphospholipid antibodies on two occasions at least 12 weeks apart as well as one clinical finding (2). Clinical findings include vascular thrombosis, unexplained death of a morphologically normal fetus > 10 weeks gestation, premature birth of a morphologically normal neonate <34 weeks gestation due to preeclampsia, eclampsia or placental insufficiency, or > 3 unexplained pregnancy losses < 10 weeks gestation (with maternal hormonal, anatomic, chromosomal and paternal chromosomal causes excluded) (2). Pregnancy complications can include venous and arterial thrombosis, fetal loss, fetal growth restriction, preeclampsia and preterm delivery. Pregnancy management of APS can include daily low dose aspirin and prophylactic anticoagulation in addition to treating any complications in pregnancy. The APS complications seen in our patient included pulmonary embolism, fetal growth restriction, preterm preeclampsia with severe features, preterm delivery, placental insufficiency, livedo reticularis, autoimmune hemolytic anemia, and a false positive RPR. Multidisciplinary approach to this patient including played a crucial role to the success of this delivery and should be considered in delivery planning in all high-risk obstetric patients with multi-system compromise and high risk for maternal and fetal morbidity and mortality from medical condition.