Early onset preeclampsia with placenta accreta in a multiparous woman post-renal transplant
Abstract Number: F2D-2
Abstract Type: Case Report/Case Series
A recent case series on pregnancy outcomes post-renal transplantation (RT) reported that preeclampsia (PEC) often occurs (38%) but is not associated with long-term renal dysfunction or graft loss.(1) We present the case of a complicated cesarean delivery (CD) in a patient with RT due to lupus nephritis, presenting with early onset PEC.
A 34 yo G4P1 with SLE/lupus nephritis since 2000, NSVD in 2005, TOP in 2nd trimester in 2006 after lupus flare, PRES, focal cerebral infarcts and severe vasculitis, a RT (brother donor) in 2012, presented with severe PEC at 26 weeks. Reversal of umbilical artery end-diastolic flow, headaches, severe HTN (SBP 170mmHg) at 22 weeks prompted labetalol and aspirin therapy. Proteinuria 7G/24h, serum Cr 1.8 mg/dL (baseline 1.4 mg/dL), GFR 39ml/min (baseline 56 ml/min), K+ 5.3 mEq/L raised concern for rejection vs. SLE-related changes, and prompted renal biopsy, which was negative for rejection.
A CD with was decided at 26 weeks; 6g IV MgSO4 for fetal neuroprotection was started. MgSO4+ was sub-therapeutic (4.4 mg/dL) and redosed; 4h later MgSO4+ was 7.8 mg/dL resulting in profound lethargy. Spinal anesthesia (bupivacaine 12mg, fentanyl 15mcg, duramorph 150mcg) was performed in right LDP. The neonate was delivered via classical uterine incision and transferred to the NICU. The placenta was morbidly adherent (accreta) and unplanned hysterectomy was performed. General anesthesia was induced, (propofol, rocuronium 40mg IV). EBL was 2L, nadir HCT was 24% (baseline 29.8%); 3 units PRBCs were transfused. Delayed NMB recovery was accelerated by use of sugammadex 240mg IV, and the patient was extubated uneventfully. She was discharged on POD 4 with a plan to continue immunosuppressants, labetalol, and for repeat renal biopsy.
Conclusion: This case highlights the pregnancy risks of RT, including PEC and challenging MgSO4+and NMB management. Despite a history of PRES and focal infarcts in 2006 following TOP, she had no neurological issues with this episode of early onset severe PEC. To our surprise, a placenta accreta was identified during CD; it has been hypothesized that sFLT-1 regulates placental cytotrophoblast invasion and that lower levels of sFLT-1 would be observed in invasive placentas (accreta/increta/percreta), while sFLT-1 levels are increased 2- to 3-fold in PEC.(2) Immunohistochemistry for sFLT-1 was performed on the hysterectomy specimen (results pending). In the future, we will consider measuring serum sFLT-1 levels in women diagnosed with both PEC and an invasive placenta, to further our understanding of the rare concomitant presentation of these two obstetric conditions. The role of immunosuppression in the context of RT may also be of interest; to our knowledge, the occurrence of placenta accreta in an organ recipient woman has not previously been reported.
1. Obstet Gynecol 2018;13:1-6.
2. Am J Obstet Gynecol 2014;210:68.e1-4.