CASE REPORT article
Front. Immunol.
Sec. Immunological Tolerance and Regulation
Immune profiling-informed immunomodulation associated with gestational extension in early-onset preeclampsia with monochorionic twins: a case report
Denqin Ma 1
Li-Na Zhang 2
Xiangyuan Liu 2
Sheng-Guang Li 2
Qun Li 1
1. The First People’s Hospital of Tianshui, Tianshui, China
2. Peking University International Hospital, Beijing, China
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Abstract
Background: Early-onset preeclampsia (EOPE) is linked to placental malperfusion and systemic endothelial dysfunction. Maternal immune dysregulation has been implicated, but immune abnormalities measured during severe disease are descriptive and do not define a validated EOPE subtype. Case presentation: A 22-year-old woman (G2P0) with a monochorionic diamniotic twin pregnancy developed gestational hypertension at 25+5 weeks and met criteria for EOPE at 30–31 weeks. With refractory progression under standard management, immune testing at 31+1 weeks showed elevated TNF-α, low complement C4, weak ANA positivity, and T/B-cell imbalance (descriptive findings in this single case). After multidisciplinary discussion and informed consent for off-label therapy in pregnancy, an immunomodulatory regimen was initiated at 31+1 weeks (prednisone 10 mg/day, hydroxychloroquine 200 mg bid, and a single 200 mg SC dose of certolizumab pegol). Over the following week, proteinuria decreased by >50% (10.78 to 4.99 g/24 h), blood pressure improved to 100–120/60–80 mmHg, and edema regressed. Gestation continued to 35+0 weeks, when cesarean delivery was performed for fetal compromise (Type II sFGR with umbilical-artery AEDF). Placental pathology showed multifocal infarctions and basal-plate fibrinoid deposition. Discussion: EOPE likely reflects heterogeneous pathways in which inflammatory mediators, complement dysregulation, and cytokine excess have been reported. This case is hypothesis-generating and underscores the need for validated immune/angiogenic stratification and prospective evaluation of adjunctive immunomodulation in severe EOPE. Conclusion: In this MCDA twin pregnancy with severe EOPE and concurrent immune-activation markers, initiation of a pregnancy-compatible immunomodulatory regimen was temporally associated with maternal stabilization and a 3–4-week interval to delivery for fetal indications. Controlled studies with validated phenotyping, serial biomarkers (including sFlt-1/PlGF), standardized endpoints, and detailed safety follow-up are required before attributing benefit or recommending this approach.
Summary
Keywords
Certolizumab pegol, Early-onset preeclampsia, Hydroxychloroquine, Immunomodulation, Maternal–fetal tolerance, TNF-α, Twin pregnancy
Received
13 December 2025
Accepted
17 February 2026
Copyright
© 2026 Ma, Zhang, Liu, Li and Li. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Denqin Ma; Qun Li
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