Introduction
Antiphospholipid syndrome (APS) presents several obstetric challenges through all stages of pregnancy and postpartum with catastrophic APS (CAPS) a rare but life-threatening subset. CAPS involves rapidly progressive and widespread small vessel thrombosis with high rates of feto-maternal morbidity. Triggers for CAPS have been suggested to include pregnancy itself being a pro-coagulable state and related events such as infection, trauma, surgery and anticoagulation withdrawal. 1,2 Close maternal followup is essential to monitor for rapid transformation of CAPS.
Case Report
We present the case of a 26 year old whose previous pregnancy ended with termination at 21 weeks due to severe HELLP syndrome and then was subsequently diagnosed with APS. Aspirin and prophylactic enoxaparin was commenced early in this pregnancy. At 33 weeks she was symptomatic with headache and routine monthly pre-eclampsia toxemia (PET) screen was deranged. She was admitted, steroid covered and enoxaparin ceased with immediate delivery by Caesarean section of live baby. Mother was discharged day 5 postoperative then readmitted the day after with abdominal pain, vomiting and fevers; initially treated for sepsis. She was transferred to ICU, subsequently developing digital ischemia, acute kidney and liver injury and severe cardiogenic shock requiring intra-aortic balloon pump. She underwent plasma exchange, intravenous immunoglobulin, heparin infusion, and high dose steroids. She discharged day 81 post delivery with close outpatient followup.
Discussion
Patients with APS who develop HELLP should have stringent postpartum followup. This case highlights the need for a high index of suspicion for CAPS as the early stages can often mimic other pathologies such as sepsis.1,2 Microangiopathic coagulopathy may lead to multi-organ failure including postpartum cardiopulmonary syndrome, hepatic and renal failure.1 Multidisciplinary management considerations of CAPS are vital with input from obstetric medicine, renal, vascular and intensive care teams. Counselling for future pregnancies with pre-conceptual advice is essential.