Background
Antiphospholipid syndrome (APS) is associated with significant obstetric morbidity, with an increased risk of miscarriage, premature birth, intrauterine growth restriction and pre-eclampsia. Plasmapheresis can improve pregnancy outcomes for those with APS at high risk of pregnancy loss (1), but is infrequently performed.
Aim
We describe a 28-year old with APS and recurrent miscarriages successfully managed in her fifth pregnancy with regular plasmapheresis and anticoagulation.
Case Presentation
A 28 year old female presented in her fifth pregnancy. Her first four pregnancies were managed overseas. Her first two pregnancies resulted in foetal death in utero at 20 and 24 weeks respectively. She received aspirin prophylaxis throughout her third pregnancy but suffered a spontaneous miscarriage at six weeks. Her fourth pregnancy was managed with prophylactic heparin and aspirin, but complicated by severe pre-eclampsia at 24 weeks, with premature delivery at 32 weeks with the infant surviving for two days only.
Her medical history includes systemic lupus erythrematosus with skin and joint involvement, treated with hydroxychloroquine, and hypothyroidism on thyroxine. Moderate titre antiphospholipid antibodies were detected with IgG anticardiolipin antibody (ACA) 38 GPL and anti-B2-glycoprotein-1 antibody (B2GP1) 105 G units. She was lupus anticoagulant positive and protein S deficient.
The patient was commenced on aspirin, therapeutic enoxaparin, and calcium supplementation prior to successful conception in early 2015. Plasmapheresis was commenced at 15 weeks and initially given thrice weekly, with the frequency reduced to maintain ACA titre < 15 GPL. Serial ultrasounds showed the uterine artery pulsatility index (PI) was high with bilateral notching from 13 weeks. She presented to the antenatal unit at 35 weeks with headaches and epigastric pain. Her blood pressure, urinalysis and CTG were normal. She was delivered by emergent caesarean section. Her baby has thrived.
This case describes the successful management of a high-risk pregnancy secondary to APS with anticoagulation and regular plasmapheresis. Plasmapheresis would appear to be a relatively safe and effective intervention in such high-risk patients.