Management of a high-risk pregnancy associating autoimmune diseases, chronic hypertension, prediabetes and inherited thrombophilia

We report the case of a 34 years old woman that came for preconceptional evaluation after 2 first trimester miscarriag­es. She was known with Graves’ disease, chronic anaemia, vitiligo, hypertension, PCOS and overweight, both her par­ents had hypertension and ischemic heart disease. She was on treatment with L-thyroxine and ACE-inhibitor. She was referred to a haematologist that diagnosed Biermer anae­mia and Factor V Leiden gene mutation; B12 therapy was started. Other preconceptional recommendations were diet, changing ACE-inhibitor to α metil-dopa, low dose aspirin, metformin, folic acid. Her pregnancy was followed-up by a multidisciplinary team. Vitamin D, Mg, Ca and low-molecu­lar-weight-heparin were added. She was twice admitted for threatened abortion thus natural micronized progesterone was started. At 35 weeks foetal growth restriction was diag­nosed, foetal wellbeing was monitored by Doppler velocim­etry until delivery at 39 weeks. The neonate, 2,570 g, needed no admission in the neonatal intensive care unit. Both were discharged after 4 days.
The pregnancy outcome was improved due to the compliance of the patient to all treatment options beginning with diet and ending with self-administered low-molecular-weight-hep­arin and due to the prenatal care offered by the multidisci­plinary team. This pregnancy didn’t complicate with abortion, preterm birth, acute foetal distress, preeclampsia, abruptio placentae or thromboembolic accidents. The only complica­tion that could not be avoided was foetal growth restriction.
In such complex associations of diseases there might be a risk of overtreatment in order to minimised maternal, foetal and neonatal risks.