Background
Whilst triple positivity of antiphospholipid antibodies confers annual first thrombosis rate of 2.3-5.3 %, pregnancy amplifies this risk substantially. Therefore, it is crucial to calculate the thromboembolic risk correctly in pregnant woman with triple positive antibodies and to manage proactively with anticoagulation during pregnancy and post-partum period.
Case Presentation
We would like to present a case of 30-year-old primigravid twin pregnancy with known triple positive antiphospholipid antibodies and asymptomatic severe aortic regurgitation. Past medical history includes stage 2 chronic kidney disease, hypertension and hypothyroidism. Before planning pregnancy, she was not anticoagulated due to absence of past or family history of thromboembolism or obstetric criteria. However, after thorough investigations, she was diagnosed with primary antiphospholipid syndrome (2 points for aortic valve thickening and regurgitation with diagnosis of Libman-Sacks endocarditis, 2 points for mild thrombocytopenia, 12 points for high-titre triple positive antibodies) based on 2023 ACR/EULAR diagnostic criteria. Current guidelines recommend prophylactic anticoagulation (NOT therapeutic) without family or personal history of thromboembolism despite limited evidence in this situation. However, after careful consideration, weighing benefits and risks of anticoagulation in MDT meetings, shared decision to commence therapeutic dose of enoxaparin from the start of pregnancy was made. Her pregnancy is uneventful to date (36 weeks' gestation today) with surprising echocardiographic improvements on serial assessments (lessened aortic valve thickening and regurgitation).
Conclusion
This case highlights the importance of careful APS diagnostic criteria review in pregnancy without prior history of thromboembolism and demonstrates echocardiographic improvement of Libman-Sacks endocarditis on therapeutic anticoagulation in pregnancy.