Recurrent cervical hemorrhages and thromboses associated to pulmonary thrombembolism in a hereditary thrombophilia with heterozygous mutants of MTHFR and PAI-1. Case Report and Pathophysiology Hypotheses

Abstract

Manuela Cristina Russu, A Bogza, Codruta Mirciulescu and Ilinca Gussi

A 30 years Caucazian nullipara, 1 blighted ovum, former Yasmin user (1 year), without antiphospholipid antibodies, prophylactic cervical cerclage at 19 weeks pregnancy, is readmitted in emergency at 21 weeks gestation for heavy pelvic pains, and abundant vaginal red blood loss, with cerclage suppression. Under tocolysis and vaginal progesterone, she presents 3 new episodes of intense pains and red, pulsatile blood loss from different cervical areas at 24- 36 hours after admittance, with mechanical hemostasis by nylon sutures at cervico- vaginal junction. The 4th episode is followed by severe anemia (Hb= 6.03mg/dL, Ht= 18.32%), haemodinamic instability, coagulation disorders- hematomas, generalized petaechia, and at 24 hours after last vaginal sutures she claims thoracic pains, dyspneea, cianosis. There are not registered fetal distress, placental abnormalities, cervical shortness below 2.5 cm (when cerclage), and maternal heart abnormalities at repeated ultrasound examinations. No thoracic computer tomography because maternal refuse. After a cardiologist consultation it is appreciated a mild/moderate pulmonary thrombembolism, without deep legs venous thrombosis, and it is started continuous intravenous anticoagulant therapy – heparine 25,000UI/day x 6 days, then fraxiparine in increased dosages continued to term, and 6 weeks postpartum. The laboratory test confirms intravascular disseminated coagulation with secondary fibrinolysis, and positivity for heterozygous mutants of MTHFR (methylene tetrahydrofolate reductase deficiency C677T and A1298C), and PAI (plasminogen activator inhibitor)-1 (4G). Cesarean delivery is performed at 37 weeks for fetal distress at labor onset, with extraction of a girl 3340g, Apgar=7/8, premature senescent placenta, thin umbilical cord. No maternal and neonate postpartum complications.

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