Recurrent Early Pregnancy Loss - 6 - A Special Patient
Tuesday, April 03, 2007
Kenneth F. Trofatter, Jr., MD, PhD
I remember being fascinated with patients who had recurrent pregnancy loss from early on in my training. The prototype patients for this problem were those with known autoimmune disorders, specifically, systemic lupus erythematosus (SLE). The curious thing about that was not all patients who had SLE had difficulty with pregnancies. The ones who seemed to be at the greatest risk were those who had lupus nephritis (kidney damage) or a history of blood clotting complications (deep venous thrombosis, arterial thrombosis, strokes, and pulmonary emboli). Many of these patients were also found to have false-positive RPRs (a test for syphilis) and later, as laboratory evaluation evolved, positive ‘lupus anticoagulants’ (in some ways a misnomer, because these actually increased the risk for persistence of blood clots).
In the early 1980’s, I took care of a woman who had history of recurrent early pregnancy losses who also happened to be the wife of the director of our Coagulation Laboratory. She was a ‘healthy’ woman who had no known medical problems. I first saw her on referral early in another pregnancy and during the routine evaluation, found that she too had a false-positive RPR. Out of curiosity (and with her husband’s blessing) we also screened for and found that she had a ‘lupus anticoagulant.’ She had no physical, symptomatic, or laboratory evidence of SLE, so by definition, she did not have this condition. She lost that pregnancy shortly after her first visit with me before any medical intervention could be tried. When I saw her back between pregnancies, her ‘lupus anticoagulant’ was no longer detectable! Regardless, I told her to start taking a baby aspirin (80 mg) daily (because of its known benefits in preventing clotting initiated by platelets on one side of the coagulation cascade) and to contact me the “minute you think you’re pregnant again.”
About 3 months later, she presented at about 5-6 weeks, still taking her baby aspirin. The RPR came back ‘false-positive’ again, and the ‘lupus anticoagulant’ had returned! At this point, I added high-dose prednisone to her treatment regimen ('immunosuppression' was one empiric approach to management of patients with lupus anticoagulants at that time). Her pregnancy survived the first trimester, so rather than arguing with success, we continued her on this regimen. Indeed, at many institutions back then, she would not have even been started on the prednisone until the pregnancy had gotten through the first trimester. At about 26 weeks, she was found to have developed ‘gestational diabetes’ probably as much the result of the prednisone therapy as any predisposition for this she might have brought to the pregnancy. We admitted her to the hospital to begin insulin therapy for the diabetes and during the course of her routine evaluation, an ultrasound was performed and the baby was found to be severely growth restricted. Within two weeks, she developed severe preeclampsia (HELLP syndrome) and needed to be delivered by cesarean section. Although small, that baby did just fine, but did require a long stay in the neonatal intensive care unit, and my friends had their first baby. When she returned for her postpartum examination, the lupus anticoagulant was gone again!
A year or so later, she again began taking the aspirin and conceived shortly thereafter. This time her RPR returned ‘negative’ and no lupus anticoagulant was detected either. Not knowing what to do with this information, but also with the history of her previous complicated obstetrical history fresh in our minds, we compromised on a plan. We started the prednisone again in early pregnancy, decided to follow the growth of the baby, and if that was normal, planned to begin tapering the prednisone at 24 weeks and to discontinue it completely by about 26 weeks, just before we ordinarily did our diabetes screening. The growth of the baby was normal, the lupus anticoagulant was never detected, and so we followed through on the plan. Stopping the prednisone when we did prevented the onset of gestational diabetes. The fetal growth continued to be normal, the patient never developed preeclampsia, and she was delivered close to term by repeat cesarean section, having a bouncing 8 pound+ baby. She subsequently conceived one more time, never redeveloped a lupus anticoagulant, and again carried to term with no therapy other than the baby aspirin (and who knows if that was even necessary at this point!).
This patient taught me several things: 1) ‘Healthy’ people can have abnormalities of their coagulation system that either are associated with early pregnancy loss, or are ‘markers’ for an abnormal immune response for pregnancy; 2) These ‘markers’ may only be apparent during a pregnancy in some cases; 3) Treatment may help, but it might not completely prevent an ‘abnormality of placentation’ that can still result in severe fetal growth restriction and maternal preeclampsia; 4) Resolution of a ‘marker’ (in this case a ‘lupus anticoagulant’) might also reflect having overcome an abnormal immune response to pregnancy (finally successfully immunized???) and should remind us to be flexible in designing empiric management strategies for these difficult patients.
Keeping this patient in mind, let’s now look at specific abnormalities of the immune and clotting systems that may be associated with recurrent early pregnancy losses….
55 Comments:
At Sat Jun 02, 10:40:00 AM 2007,
Anonymous said…
I have only one question to put to you. How do you go about getting the OBG/YN to test you for this disorder? All of the women in my family, my fathers side, have been diagnosed with lupus. I have had three prenancies and only one full term. In the other two, I miscarried at about 12 weeks. Could I too be suffering from this disorder and what should I do? htherchrsmdy@yahoo.com
At Tue Jun 05, 04:52:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
It's hard to say in your circumstances. Did you have the miscarriages and then the baby or did you have the baby first, or the baby in between? Did you change partners along the way and when? Autoimmune disorders do run in families, so you are at greater risk for developing one. However, these disorders are very complex and have 'variable penetrance'. That means you could have the genes that increase your risk but you don't go on to develop full-blown disease, whereas someone else in the family carrying the same genes may be very sick. People can also have the 'abnormal antibodies’ often found in lupus patients that increase their risk for pregnancy complications, just like the patient described in the post, but never become sick themselves. So yes, it is possible you have a problem and your doctors could easily screen you with tests like an ANA, lupus anticoagulant, and anticardiolipin antibodies if you asked. Let me know how things turn out and thanks for reading!
At Wed Jun 27, 06:49:00 AM 2007,
Anonymous said…
having had 3 children first i have since had 3 missed miscarriages.on investigation after the first 2 misscarriages i was dignosed with antiphospholipid antibodies - lupus anticoagulant. having been taking baby asprin until the most recent pregnancy i was put on inohep injections daily. unfortunately this pregnancy also failed after 9 weeks. any suggegestions
At Wed Jun 27, 04:33:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous June 27: Is the father of the first 3 children the same as the father of the pregnancies you have miscarried? Did you get chromosome studies on any of the babies you lost? How much heparin were you taking? Have they identified any other problems? Any weight changes? Do you know what type and what titer of antiphospholipid antibodies you have? Have they screened you for any other evidence of an autoimmune condition? Did you have any trouble getting pregnant? Have you developed any medical problems since the birth of your first 3 children? Get back to me with the answer to as many of the questions as you can and I will offer some thoughts! Thanks for reading.
At Wed Jul 04, 11:19:00 AM 2007,
Anonymous said…
I just found your article and wau was it informative for me. I do seem to have the same problem or similar. Maybe you have any suggestions on my situation. I already have two boys ( age 12 and 8 years) no problem during pregnancy both full term ( except the last one was breach and a c-section), in 2006 my new husband ( my boys are not from my current husband) and I had a pregnancy loss at 10 weeks( we found out that the heart stopped at our 12 week checkup and the actual mc started about 10 more days later) at my 12 week checkup I was also informed that I had a "false" positive for RPR, my doc also had me tested for Lupus which he said was positive and told me not to worry if I take a baby aspirin every day, well needless to say an hr later we found out the pregnancy had been terminated. I have been seeing a rumotalegist since then who keeps telling me I do not have lupus and she keeps checking my blood work, but the levels are still high, she informed me that this should not cause a problem for a new pregnancy, now I found out 3 weeks ago that we are pregnant again (I'm 5 weeks 4 days), i started taking baby aspirin right away, my first doc appt ( this time with a brand new OBGYN) will be July 16, well that was a lot inside so now my questions what can I do or should I do to keep the pregnancy going, what should I tell/ ask my OBGYN I'm worried and confused since I have no health problems at all, I'm healthy about 110 pounds etc.. any advise or suggestions would be appreciated. Thank you
Melanie
melanie_nicholson@msn.com
At Thu Jul 05, 05:49:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Melanie, your rheumatologist is correct. By definition, you do not have lupus, although, like the patient I discussed in the post, you may well have a "lupus anticoagulant" or perhaps even antiphospholipid antibodies. These may be found in lupus patients, women who have recurrent poor pregnancy outcomes,andeven in some people who have no problems with them whatsoever. Fot the tiem being, I would simply continue the baby aspirin and your prenatal vitamins alone. If you lose this pregnancy, then you should have a more thorough workup of you and your partner. Your doctor might give some thought to using heparin or low molecular weight heparin empirically, at that point based on your history of pregnancy losses and the presence of the lupus anticoagulant alone. That is certainly safe enough to do. Hope you don't need to go that route. Thanks for reading and best of luck with this pregnancy!
At Wed Jul 18, 01:23:00 PM 2007,
Anonymous said…
Hello Dr. Trofatter - I am 29 years old, 17 weeks pregnant, everything is so far so good on the pregnancy (ultrasounds, bloodwork, etc.) I did have a miscarriage last year, very early term, but this second pregnancy seems to be going well so that may have just been a chromosomal/typical miscarriage (both pregnancies with the same husband). Today the doctor called to report a false positive RDR test. She suggests that I see a rhumatologist for follow-up testing just in case of lupus although I understand other autoimmune discorders could cause a false positive RDR (correct?). I have to admit that I haven't experienced any of the lupus symptoms I've read about. However, at age 9, I was diagnosed with ITP (low platelets). My platelets were severely low (10,000-50,000) until about age 14. When they got really low I was treated with immune gobulin (probably did that 8 times). The platelet counts eventually started coming up to the 100,000's by the time I was in high school and college and my platelets have been 250,000-350,000 for the past year or two. The platelet count that came with the false positive RDR was 285,000. So here is my hypothesis but I wanted to see if this is possibly true-- could my ITP have been caused initially by an auto-immune problem in childhood, and perhaps those antibodies are still in my system thus causing a false positive RDR? My second question is if there's any way to know if the baby's platelets are okay or if those antibodies are crossing the placenta causing baby problems? Would my platelets definitely drop or could baby's be under attack and mine are fine? I'm just wondering if there are any special delivery precautions we should consider. My doc thinks we should not be concerned unless my platelet count drops. Any ideas or advice you have is welcome!
-Jill in Denver (jillshelton@hotmail.com)
At Fri Jul 20, 03:51:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Hi Jill. Autoimmune problems can be very dynamic. By that I mean they can affect different things at different times in your life. But, the bottomline is that you may be a person whose immune system just does not behave the way it is supposed to in response to both foreign antigens and self. This imbalance in your immune response may have led to the ITP of your childhood and other problems in the futurew. At this point, by definition (if what you have told me is accurate), you do not currently have lupus. However, some day you might or you might develop another autoimmune disease. I think it is a good idea for you to find a rheumatologist who will become familiar with your history and perhaps recommend some additional diagnostic studies. The least they need to do at this point is to screen for lupus anticoagulant and anticardiolipin antibodies since these may be the source of your false-positive RPR and may (or may not) affect pregnancy outcome. I would also suggest they screen for two other antibodies, anti-Ro (SS-A) and anti-La (SS-B). These are antibodies that can affect the structure and conducting system of a babys heart and lead to 'complete heart block'. If they are present, the baby should be followed more closely during the pregnancy for evidence of this. With regard to the history of ITP and its impact on your current pregnancy, I would lean toward agreeing with you doctor. As long as your platelet count is normal, chances are the baby's is as well. You may have just 'outgrown' the ITP phase of your autoimmune tendencies! Good luck, and let me know how things turn out, okay? Thanks for reading and for sharing your story and great questions!
At Mon Jul 30, 02:56:00 PM 2007,
Sarah said…
Hi Dr. Trofatter! I stumbled across this whilst looking for info on lupus-anticoagulant during pregnancy, and I'm hoping you may have some advice for me! :)
After 3 miscarriages (all around 5 weeks) I was diagnosed as having lupus anticoagulant (they couldn't find anything else wrong with me). My doctor said that any level over 10 was abnormal, and mine was 40. I started taking Lovenox (enoxaparin) as soon as i found out i was pregnant again, and I'm now nearly 15 weeks (this the first time I've made it this far into a pregnancy). I stopped taking Lovenox at 13 weeks as my doctor told me there was no point in taking it beyond the first trimester, as that's when the placenta takes over and the lupus anticoagulant isn't a danger after that. I've done some research and found that many women take Lovenox into their 2nd or 3rd trimester, so I'm not sure whether to trust my doctor's advice about stopping taking it. I'm fairly certain the reason this pregnancy has been successful so far is that i was taking the Lovenox, and I'm worried that now that i've stopped taking it i'm going to have another miscarriage. Also, i asked my doctor if i could have another blood-test to see what my lupus anticoagulant levels are now, but he didn't see any point in doing that either.
So, here are my questions: is it typical to stop taking Lovenox at 13 weeks? Do you think there would be any benefit in me taking it for longer? Should i take baby aspirin instead? Do you think it is worth me going to another doctor for a second opinion?
I'm sorry for all the questions and I hope this isn't too confusing! After 3 miscarriages i just can't help but worry, so any advice would be very greatly appreciated!! :)
-Sarah
At Mon Jul 30, 04:43:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
Sarah: Different folks ascribe to different approaches (religions?!?) on this, so I am not going to second guess your doctor. Much of it is simply empiric therapy (witchcraft) and we don't really know why it works. I generally place patients I am worried about on BOTH aspirin and Lovenox and if things are going well (normally grown baby and normal Doppler flow studies) at 26-28 weeks, then stop the Lovenox unless you have another risk factor such as a history of deep venous thrombosis, arterial thrombosis, or pulmonary embolism, or an active autoimmune disorder such as systemic lupus erythematosus. If things are going well so far, there is a very good chance they will continue to do so. If your baby doesn't grow well, if it has abnormal Doppler studies, or if you develop preeclampsia with this pregnancy, next time around, take it a little longer! Anyway, good luck and thanks for reading.
At Thu Aug 02, 09:31:00 AM 2007,
Anonymous said…
HI, I have a 7 year old daughter, and my husband and I have been trying to have more babies. After 2 miscarriages 1 year apart we are still trying. My doctor took a lupus test last year and came back neg. I went to see my doctor again and he seemed kind of worried and wanted to take another lupus test...... I have not been able to get pregnant for 1 year now, and both of my miscarriages we at 3 months on the date. Any advise?
At Thu Aug 02, 11:15:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous August 2: If you have not gotten pregnant in a year of trying, your best bet is to schedule an appointment with a specialist in Reproductive Endocrinology and Infertility(REI), especially if you are older than 30. Good luck and thanks for reading. Dr T
At Fri Aug 10, 11:14:00 PM 2007,
soumya said…
Hai
i lost my pregnancy at 24 weeks on july17.actualy i dont have any complications during pregnancy.i didnt feel any movements for 5 days then i went to hospital they didnt find my baby heartbeat(stillbirth).my doctor said that blood results r showing protien c &protien S deficiency and MTHFR is less.may be blood clotted in placenta.so she said to go near highrisk operator before next pregnancy so that he can give me treatment.she also said that after delivery protien C and protien S generally will be reduced .now we cant decide that due to bloodclot i lost my pregnancy. after 2 months i will be normal so that blood result will be shown perfect.when i lost my baby i dont have any other symptoms like bleeding,stomachpain except movements.can u tell me what would be the reason and if so what will be the treatments for bloodclotting , we should take it before pregnancy or during pregnancy. (my parents dont have any bloodclotting problems).
At Fri Aug 17, 12:26:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Soumya: I am sorry for your loss. Usually during pregnancy, protein S levels decrease and protein C levels remain the same or are only slightly lower, so from what you have told me, I am not sure these actually caused you to lose your baby. Now that you are no longer pregnant, you should go to the specialist BEFORE you get pregnant again to be tested for these and other factors that are associated with pregnancy losses and increased risk for blood clots. The best way to test for protein C and protein S deficiencies is to have a test for "functional protein C and S activity." (Don't ask me to explain that here!). Other studies that can be done are: antiphospholipid antibodies; lupus anticoagulant; antithrombin III levels; factor V Leiden mutation; factor II (prothrombin) G20210A mutation; MTHFR polymorphisms; and homocysteine levels.On rare occasions, mutations in the plasminogen activator inhibitor-1 (4G/4G) are also associated with increased risk for blood clot formation and pregnancy losses. Also, ask the doctor who delivered your baby if the placental pathology showed any specific evidence of infection or blood clot formation. Did the baby appear normal and was it a normal size for 23-24 weeks? Was there any evidence of the baby having a chromosomal abnormality? If any blood clotting problems are found, a specialist in high risk obstetrics or hematology can counsel you regarding the best ways to reduce the risk for a pregnancy complication for both you and the baby. I do hope things turn out better for you the next time. Let me know, okay? Thanks for reading and for the good question. Dr T
At Sun Aug 19, 01:53:00 PM 2007,
RJ said…
I am so confused by things that I am reading. I had a miscarriage at 12 weeks 6 days at 42 yrs old. Pathology tests showed on the remains came back as "normal female". Since I'm a normal female, my RE thinks it could have been my cells growing in the lab. I tested positive for homozygous MTHFR C677T, homocysteine at 5.1 (normal), Antithrobin (III) Activity 128% (High), and Phos Serine AB (IGM) 43 u/ml (high), everything else was came back within normal range.
My RE put me on FABB tablets (2.2 mg of Folic acid, B6, B12). I am trying to get pregnant again, and wonder if the extra supplments are enough. Do I need to see another specialist or am I good with the extra folic acid and vitamins?
At Tue Aug 21, 06:57:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Aug 19: Normally, I would not recommend more than what your daoctor is trying, but at your age, I am afraid you are running out of time and I would, personally, consider being even more aggressive about therapy: luteal phase and early pregnancy support with progesterone; 4 mg folic acid per day; 81 mg aspirin per day; and even consider daily injections with prophylactic doses of either heparin or lovenox (low-molecular weight heparin). You can alawys discontinue the latter at 20 weeks if things are going well at that time. Like I said, if you weren't 42 years old, I would be a little more conservative, but you are, and that's why I wouldn't be! Good luck with things the next time around and thanks for reading! Dr T
At Fri Aug 24, 03:24:00 PM 2007,
Jill said…
I am glad to have found your article. I read the comment from "Jill in Denver" and I have a similar question. I have had two miscarriages and one healthy pregnancy in between. I took baby aspiring during the beginning of the second pregnancy but not for either of the other two (both of which ended in miscarriage). Now that we are trying for another pregnancy, I have resumed taking baby aspirin, figuring that it can't hurt and might help. I have had no diagnostic tests to try to determine the cause(s) of the miscarriages, and I am told that most healthcare professionals will not do the tests until there have been 3 losses. Recently I have wondered if there could be a link between childhood ITP and my miscarriages. I came across your article in trying to investigate a possible link. Do you think it is likely (or even possible) that these incidences could be related? I was quite young when I had ITP (maybe 4), and it resolved on its own not long after it was diagnosed. What, if any, blood tests would you recommend I have done? Thank you very much for your time and thoughts.
Jill in Pennsylvania
At Mon Aug 27, 06:26:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Jill in Pennsylvania: The best thing you have going for you is that you HAVE had a successful pregnancy in between your two miscarriages. If that was uncomplicated, odds are in your favor that you will pull it off again. Most 'immunologic problems' and/or 'genetic thrombophilias' of significance result in consecutive miscarriages or pregnancies that are complicated by hypertensive disorders, early deliveries, fetal growth restriction, or intrauterine demise. With regard to your childhood ITP, I cannot rule out the possibility that this is a contributing factor, but I tend to doubt it. If you want anything else diagnostic done at this point, I would suggest only a ANA, lupus anticoagulant, and anticardiolipin antibodies. If you do lose another baby, I would strongly recommend an attempt be made to do chromosomal studies on the products of conception. Your doctor can explain why. Thanks for reading and for a very good question! Dr T
At Tue Sep 18, 08:37:00 AM 2007,
Anonymous said…
Hello. I was just diagnosed with lupus anticoagulant last night (my OB said 40 is considered high and mine was 52). I am 32 and have a 3 year old son with whom there were not really any complications during pregnancy (extreme "morning" sickness for the entire pregnancy and more ammniotic fluid than most, but that was it). We have been trying to get pregnant for over a year now and I have had two early miscarriages (around 6 weeks). I have a few issues at play here - I have mild hypothyroidism but am on meds for that and my numbers seem ok, I tested somewhat low on day 21 for progesterone (10.5), and now ALC. My OB put me on 50mg of Clomid to help with the progesterone but said she needs to get advice from a high-risk OB about the ALC because she has not dealt with it before. My questions are: 1) How do we determine which issue, or if all of them, are causing the miscarriages? 2) If I am put on baby asprin or heparin, etc. will this be something I need to take all my life? 3) Since my OB seems to know very little about ALC, should I just go to a high-risk OB now rather than wait? 4) How do we know if baby asprin is enough or if it needs to be treated with something more? 5) What are the chances of ALC turning into Lupus? I have a ton more questions but will start with these. Thank you for any information you can provide.
Lori
At Thu Sep 20, 08:50:00 AM 2007,
Anonymous said…
Hello,
I was happy to read your thoughts on the immune/thrombophilic connections to RPL. I have had 3 miscarriages and 1 ectopic causing emergency laproscopy and teh loss of my right fallopian tube. We have been TTC for 2 years. My first two miscarriages needed methotrexate to make my hcg drop, my 3rd was more of a chemical with a positive at 11dpo and a hcg of 25 followed by bleeding and sharp drop in hcg(to 7 I think)
I recently saw a specialist at the Rosalind Franklin Lab(Dr. Kwak-Kim) who diagnosed me with high ANA(1:320, speckled) I also saqw a specialist in NYC who diagnosed my husband and i with Chlamydia. We have been treated for the chlamydia with IV antibiotics, uterine clindamyacin washes and prostate injections for my husband. I am now TTC for the first time since all the diagnoses and am nervous about taking prednisone. Have you noticed any severe side effects from this? I was also advised to take 1 baby asprin, 40 mg of Lovenox 2X per day(I have homozygous MTHFR,homozygous PAI-1, hetero factor XIII V34L) Vitamin E, Metanx(a Folgard-like drug) progesterone(always had low progesterone around 7 after Ovulation) I will probably take Clomid as, in the past, it has raised my post-O progesterone levels. In addition iwth my one tube it may help me to ovulate from both ovaries. I have high CD 19 and CD 19+ cell, CD5+ on the NK Assay. My eosinophils were very elevated--I am not sure of thh signifigance of that-perhaps the Chlamydia?
At Mon Sep 24, 06:50:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Lori September 18: I probably have more questions than you have! What studies other than the lupus anticoagulant have you had done? Antiphospholipid antibodies? Evaluation for genetic thombophilias? Is the father of your 3 year old the same as that of your miscarriages? Your thyroid disease and your possible "luteal phase deficiency" appear to be in good hands at this point. With regrad to your specific questions: 1) We may never know which factor is contributing the most to your miscarriages. It may be a combination of the problems already found ot it may be something else that has not yet been identified. 2) I am not even sure of the significance of the "lupus anticoagulant" at this point. We don't know if this is something you have had for awhile or if it is something new. You obviously have not had any of the risk factors that would warrant long-term anticoagulation at this point, but a baby aspirin each day probably wouldn't hurt either! 3) I suggest getting a preconceptional counseling visit with a Maternal-Fetal Medicine specialist. He/She will be in the best position to review your records, assess the necessity of any additional laboratory evaluation, discuss pregnancy risks and formulate a 'game plan' for before, during and AFTER the pregnancy. 4) Personally, I would start with the baby aspirin and extra folic acid alone, unless some other risk factor is identified. If you felt like you needed to be 'doing more', at the most, I would add a 'prophylactic dose' of heparin or Lovenox and would probably discontinue this once you got past 20 weeks if all was going well. There are no strict guidelines for treatment women in whom there have been no medical complications related to 'thrombophilias.' The only assessment of the value of therapy in your case is a successful pregnancy. There is no other 'test' that tells us we are on the right path and even a successful pregnancy may have been more in the cards than the result of medical treatment under these circumstances! 5) At this point, from what you have told me, you do NOT have lupus and probably are at low risk for actually getting it. Thanks for reading and let me know how things turn out! Dr T
At Tue Sep 25, 11:47:00 AM 2007,
Anonymous said…
I was put on baby aspirin and progesterone as soon as I found out I was pregnant with my third child... (2 previous m/cs, two healthy babies in between.. same father). From my 11th week until my 18th, I had heavy bleeding. I stopped the meds at about 13 weeks. In the middle of the bleeding they found a blood clot between my placenta and uterus and said I had likely had a small abruption early on. They are monintoring my baby's growth now. I am 29 weeks and found out I have gestational diabetes. I have two questions: 1) Since the blood clot is still there (though it does not appear to have hurt the baby) should I start the baby aspirin again? 2) Since g/d makes babies grow bigger than usual, can this mask the fact that my baby may not be growing at a normal rate because of the blood clot?
Much thanks.
At Thu Sep 27, 05:42:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Sept 20: You are a mess, Girl! Just kidding. I have seen much worse! It sounds like you are in pretty good hands. did your doctors find any specific autoimmune antibodies known to be a problem in pregnancy, ie, anticardiolipin antibodies, lupus anticoagulant, anti-Ro(SS-A), or anti-La(SS-B)? Not that any of those would change your therapy at this point very much. Your primary question seems to be realted to the prednisone - how much are you taking each day? Many years ago, prednisone was the foundation of my therapy for women I suspected of having an immunologic basis for their recurrent pregnancy loss. I think the literature shows no great benefit of that, and potentially some harm, over unfractionated and low-moleculkar weight heparin (Lovenox). I usually reserve the prednisone for women with diagnosed autoimmune conditions such as systemic lupus erythematosus, to treat acute flares in tehir disease. Prednisone therapy during pregnancy is associated with increased risk for gestational diabetes, premature rupture of membranes, and early delivery. It also increases your eweight and fluid retention at high enough doses. If you absoluetely don't need it, try to get off of it by 20 weeks gestation. It probably isn't going to help much beyond first trimester anyway. Incidentally, I have found that women in your situation with homozygous PAI-1 are insulin resistant and often benefit from therapy with glucophage (metformin) prior to and during their pregnancies. Anyway, thanks for reading and writing and I wish you the best of luck! Dr T
At Fri Sep 28, 11:22:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous sept 25: Great questions. The aspirin has probably served its purpose now that you are this far along and it can increase your risk further of placental abruption. My suggestion would be to stop it. Keep your gestational diabetes under tight control and you will minimize your risk of the baby 'outgrowing' its placenta. But you raise and excellent concern. I think one of the reasons diabetics are at increased risk for losing babies 'unexpectedly' is because that actually happens - the baby grows like crazy and one day surpasses the reserve of the placenta to supply its demands. This is in contrast to the more typical situation of 'placental insufficiency' that is seen with intrauterine growth restriction. Thank you so much for reading and for the great comments. Good luck with the rest of your pregnancy! Dr T
At Wed Oct 03, 09:24:00 AM 2007,
Lori said…
Hi again. Thank you so much for your response. I thought I would write back to you and answer some of your questions, as well as provide more information that has come up since I last posted. No, I have not been tested for any other thombophilias, Antiphospholipid antibodies, etc. Is this something I should ask for? If yes, and it was found that I had some of these, would that dramatically change the treatment (baby asprin and folic acid)? And yes, the father of my 3 year old is the same as that of the miscarriages. Considering it seems I don't have much trouble GETTING pregnant, is it worth him getting tested? On top of the issues I mentioned in my last post, I have since been diagnosed with hetero C667T MTHFR mutation, a "small uterus" found during an HSG (whatever that means), and a possible fibroid. I feel like I have so many cards stacked against me that maybe it is not 'healthy' for me to try and have another child. At what point do docs tell their patients to stop? Anyway, I see two specialists next week (RE and high-risk OB) so hopefully someone will come up with a gameplan. I feel as though my OB is a little out of her realm right now, which leaves me a little uneasy. I truly appreciate the service you are providing on this site! I will let you know how things go with the specialists.
Thanks, Lori
At Fri Oct 05, 06:30:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Lori Oct 3: It will be interesting to see what the REI and MFM docs tell you. Many women carry the MTHFR C677T polymorphism as heterozygotes, so I am not real worried about that as a major cause of problems, The folic acid and aspirin should be adeqaute coverage in that regard. Probablt=y the only other thrombophilia evaluation I would suggest would be to have the antiphospholipid antibodies because if those were present, I would be more serious about the Lovenox or heparin. The "small uterus" doesn't make a lot of sense to me in a woman who has already had a baby, so I am writing that off as a big convern as well. The fibroid , on the other hand, depending on the location, could be a problem, especially if it is submucosal (right beneath the endometrium), but the REI will be in the best position to evaluate that and recommend therapy. Quite frankly, unless something else is going on we don't know about yet, you are NOT at the point where I would tell you not to get pregnant, but that will ultimately be your decision. I will be curious to know what the other specialists tell you, so stay in touch and, again, good luck! Dr T
At Tue Oct 23, 08:16:00 PM 2007,
Jennifer said…
Hi doc-- just in case you are still taking questions...(trying to keep it short) 38 y old, 3 misscarriages around 6 weeks. Diagnosed w/ Lupus SLE 1998, NO symptoms since 2000!!! Originally, anticardiolipid antibody, antiphospholipid, TIA. The last misscarriage, they tested hgc @ 5w 4 days 380, progesterone 1. I had always complained of possible luteal phase defect- spotting early 7-9 PO. Now using progest. cream during luteal phase, have prometrium on hand if I do get a positive home test, taking baby asprin and preg vitamins. My questions: Is there a link between low progesterone and Lupus? If so is it throughout or only trimester specific? My OB says I would be meeting with High Risk Dr. later on in pregnancy- should it be sooner? Any suggestion? Thank you for taking time to listen. Jennifer
At Fri Oct 26, 04:34:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Jennifer Oct 23: Do you have any living children? With your history, and at your age, you need very aggressive management if you are serious about having a baby. If things don't work out this time, find a good Reproductive Endocrinologist BEFORE you try to get pregnant again.You are running out of time from the standpoint of your 'biological clock'. You have very low progesterone levels and that could be a sign of pending ovarian failure. I have found that many women with autoimmune conditions develop ovulatory dysfunction and have to wonder if it isn't the result of autoimmunity against the ovarian tissues, but I do not know for sure. I will look into it and if I find out anything interesting, maybe will write a whole post on the subject. Thanks for reading. Dr T
At Mon Oct 29, 12:29:00 PM 2007,
Anonymous said…
Hi Dr. T. I'm 28 yrs old, don't have any children, had one miscarriage around 6 weeks in July of this year. I've been diagnosed with Reynaud's syndrome, positive ANA titer of 1:1280, positive SSA and SSB and also positive rheumatoid factor of 55. No other positives were found. Neither lupus anticoagulant nor antiphospolid syndrome was not found. My husband and I are now trying to get pregnant again, my obgyn suggested that I start taking baby aspirin daily and also once i get pregnant to start having Lovenox injections daily. I have also seen an MFM dr who had suggested just taking aspirin by itself without any additional injections. Your advice would be highly appreciated. Thank you.
At Mon Nov 05, 04:50:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Oct 29: If the recent loss was your first miscarriage, and if you don't have any evidence or medical/family history of thrombophilia,I would have to agree with your MFM at this point. A baby aspirin (and supplemental folic acid) are where you should start. Now, we aren't completely knowledgeable with regard to other 'risk factors' your autoantibofies might portend, so I don'rt claim to be clairvoyant in this regard either, and you may come down to requiring more aggressive anticoagulation. But if you choose to do that, I would suggest simply using prophylactic doses of heparin rather than the Lovenox. The latter is VERY expensive and would be hard to justify in your case based on what you have told me so far. Incidentally, the reasan I suggested the folic acid is because you have the anti-Ro and -La antibodies. These are associated with complete congenital heart block and various cardiac malformations. Your baby will have to be evaluated carefully for this during a successful pregnancy. I am not sure the folic acid will help, but I doubt very much that it would hurt. Good luck to you and thanks for reading! Dr T
At Tue Nov 20, 08:39:00 AM 2007,
Anonymous said…
I have had two miscarriages this year (Jan and Aug) both after normal heartbeats (8 and 10 wks). These are the only pregnancies. My doctor recently did a "miscarriage profile" and the only abnormal labs was the Lupus Anticoagulant. It was a 50. They only told me to take the aspirin and see him as soon as I get a positive test. Does this value mean that I have the Lupus anticoagulant?
At Mon Nov 26, 06:48:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Nov 20: Sorry it has been so long in responding to your question, but I just got your comment in my mailbox today. You MIGHT have a lupus anticoagulant. I have found that it is sometimes worth repeating that test alone to make sure or sending off a screen for anti-beta2glycoprotein-1. I would be very curious to know what other tests were in that "miscarriage profile" you had done. Let me know, please? Thanks for reading! Dr T
At Tue Dec 11, 07:59:00 PM 2007,
Anonymous said…
I am 42 years old, blood tests just back with elevated ANA and Anti SS-A @ 866.Adrenal adenoma (unilateral)with elevated DHEA/DHEAS.Could this cause the antibodies to be present?? Six weeks 4 days with a heartbeat :) Taking baby asprin on my own and seeing Rheum tomorrow for first time. Should I continue asprin? For how long? HELP...
At Fri Dec 14, 03:47:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Dec 11: Interesting! Why did you have the antibody studies done. Do you have or do your doctors suspect you have an autoimmune disorder? Wht other studies have you had done? Anyway, I doubt the antibodies are the result of the adrenal adenoma, but the adenoma could be the result of an autoimmune condition that either affects the adrenal gland or is in response of the adrenal gland to the autoimmune disorder. I would talk to the rheumatologist. I would also suggest remaining on the baby aspirin throughout the pregnancy. If you do have an autoimmune condition and that flares, appropriate therapy to control that would also be warranted. SS-A antibodies (anti-Ro) are associated with congenital heart block and cardiac malformations, so you should have a fetal echocardiogram done when you get to 18-20 weeks in the pregnancy. There are ways for us to assess if the baby appears to be at risk for developing heart block and perhaps some benefit to immunosuppressive therapy if that is the case. Thank you for your questions and please let me know what happens along the way! Dr T
At Sun Feb 10, 01:21:00 PM 2008,
Anonymous said…
I just had my second miscarriage at about 9 - 10 weeks(this has been in the last year). I have two year old who I had no problems with. After I had her I began to have elevated liver enzymes and have been seeing a GI. I have a positive ANA of 1:160. Possible AIH but are reluctant to diagnose since my symptoms have not gotten worse and my liver biopsy was not conclusive. It showed only mild inflammation. I also have hypothyroid. I am wondering if prednisone and aspirin therapy would help me go full term? Should I see a fertility specialist? Does prednisone cause birth defects?
At Tue Feb 26, 05:24:00 PM 2008,
Anonymous said…
I just read your article about the recurrent pregnancy loss and am hoping that you can give me some insight on my situation. I was diagnosed with ITP in 1995 and still do regular bloodtests to make sure my platelets are not too low. My first pregnancy in 2000, resulted in delivering a stillborn baby boy around 28 weeks. The autopsy showed a placental infarction had occurred. Then I had a miscarriage in 2001 about a week after I found out I was pregnant. In 2002, I found out I was pregnant and delivered a full term baby girl in 2003. I did not have any complications with this pregnancy. But I did have to take heprin shots twice a day. In 2004, I got pregnant again and this time the doctor put me on Lovenox shots once a day. At roughly around 25 weeks, I developed pre-eclampsia, my blood pressure was really high, and I had a lot of pain in my chest area. I was told to go to the hospital at that point. After being examined, the doctors diagnosed me with severe HELLP syndrome. While being examined, the chest pain went away and that is when the doctors said my liver had ruptured. I had to have an emergency C-section. My baby boy was premature but a strong fighter. However, a couple of weeks later, he developed necrotizing intercolitis and passed away. My husband and I want my daughter to have a sibling but my hematologist and high risk OB recommend not to get pregnant again because it is too risky. My OB doctor said I tested positive for the lupus anitcoagulant during my pregnancy and that is one of the reasons to not get pregnant. She said the only treatment is using heprin or lovenox but the lovenox obviously did not help with the last pregnancy. I tested negative recently for the lupus anticoagulant so I thought I was in the clear. But I got a second opinion from another OB doctor and she said it was possible that the issue has to do with the genes when my husband and I conceive. All of my pregnancies have been with my husband. I did not have chromosome studies done on the babies that I lost. After reading your article, it gave me hope that I could get pregnant again and carry a baby to full term. So this is where I need your advice. Do you think a successful pregnancy can happen if I start treatments like the predisone and baby aspirin? Or what do you recommend I look into regarding some kind of treatment? I am scheduled to see a new hematologist this week and want to discuss some of these treatment options that maybe my old hematologist overlooked. Also, I don't know if my issue is carrying a boy pregnancy since the 2 that failed were boys and the successful one was a girl. I want to thank you in advance for ANY suggestions/answers that you can give me.
At Fri Feb 29, 05:08:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Feb 26: You have an underlying 'defect' in your immune response to certain antigens. That is manifest by your ITP and other findings and is THE most likely cause of all of the pregnancy complications you have had to date (even if we aren't smart enough to figure out exactly why!). I doubt this related to fetal gender. Pregnancy will always place you at greater risk, but so is gping out in traffic every day. I don't know what dose of heparin and lovenox you used, but I would try placing you on "therapeutic" levels rather than "prophylactic" levels if that was not done previously. Since heparin seemed to work with your successful pregnancy, I would probably also suggest going back to that as well. The use of Prednisom=ne in your case could probably be justified by your known autoimmune disease. I won't go into details here about how I sometimes make that decision, but in your case, I would probably be fairly aggressive with the dose (40-60 mg per day) starting as soon as pregnancy is confirmed. There is a slightly increased risk for certain birth defects with corticosteroids, but I used that for many years very successsfully. I learned that once you get many women in your situation to about 20 weeks, you can often begin to reduce the dose of prednisone or get you off it completely by 24-26 weeks. That helps to prevent gestational diabetes as well which almost always occurs at high doses of prednisone. One other option that has had variable benefit in women with autoimmune conditions is high dose IV Ig. Perhaps youir doctor can explain that one to you in person. I hope this helped and please let us know what happens. Dr T
At Tue Apr 01, 08:54:00 PM 2008,
Anonymous said…
Hello again..I am the anonymous one that posted a comment on Feb 26, 2008. I went to see my new hematologist. He diagnosed me with having the antiphospholipid antibody syndrome which didn't surprise me. He did a more in depth blood screening. My Beta-2 Glycoprotein,IgG was at 123, a high positive. The Antiphosphatidylserine (APTS) IgG was at 29, the high end of moderate positive. These are the 2 results that stood out the most. The hematologist said he doesn't recommend me getting pregnant again but if I do decide to go forward, then to do therapeutic levels of lovenox and try the IVig treatment. Would the IVig treatment greatly reduce the chances of me developing preeclampsia and/or HELLP syndrome again? I have read articles regarding HELLP syndrome. Some state that once it happens with a pregnancy, the HELLP syndrome will be less severe. I am not sure if this is true or not but it probably differs from case to case. One of my concerns regarding going forward with another pregnancy is the fact that my liver ruptured. It is scary to think that it may happen again. Have you dealt with any patients that have had their liver rupture and then go on to have successful pregnancies? I will be seeing a new high risk OB next week and am still hanging on to hope that I can have a successful pregnancy.
At Thu Apr 03, 01:40:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Apr 1: I thought there was more going on with you than met the eye, so thanks for letting us know. You are at high risk for recurrence of HELLP syndrome, even with aggressive therapy. It can be just as severe in subsequent pregnancies. The treatment might give you a better chnace at a good outcome, but you would have to be followed VERY carefully for evidence of HELLP recurrence. You would be a "HIGH RISK" pregnancy from start to finish so get to know the "new high risk OB" very well. Yes, I have taken care of women after liver rupture and so far have not had/let anyone get to the point where that recurred - so it is possible. Thank you so much for reading and best of luck to you in the future! Dr T
At Mon Apr 14, 09:31:00 PM 2008,
Anonymous said…
My wife and I had a healthy little girl 2 years ago next month. Last year was terribly difficult as we had two losses. The first was developing on the small side and was lost in week 10 or 11. The second measured fine at the 12 week u/s but when we went back at 14 weeks there was no heart beat and it was later determined that the baby died shortly after the u/s. There were no chromosomal abn. with the fetus and we were told to try again. My wife just took a pregnancy test on the the day she expected her period and it was positive. Should she be taking baby aspirin? She has not had any of the antibody testing that we knew of during the previous pregnancies and I am worried that we will not be able to see her doctor until next week. Her sister has 3 healthy children but has gotten rhumatoid arthritis during and after each pregnancy. Thanks! Martin
At Tue Apr 15, 01:39:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Martin: With your wife's pattern of 'unexplained' pregnancy losses following a normal pregnancy, and the family history of autoimmune disease, she probably needs to be evaluated for a subclinical autoimmune condition. I wish she had done that BEFORE she got pregnant again. The types of studies I am thinking about include: thyroid studies, antiphospholipid antibodies, lupus anticoagulant, and perhaps a screen for more common thrombophilias such as factor V Leiden, prothrombin mutation, and MTHFR polymorphisms. The aspirin and a prenatal vitamin with some extra folic acid probably would not hurt right now, but it would be best if you asked your doctor about that first. Good luck to you and let us know how things turn out. Dr T
At Fri May 16, 01:12:00 PM 2008,
Anonymous said…
I have a healthy son from my first pregnancy and 4 miscarriages after. I have been diagnosed with hashimoto. My tsh was 3,2 and ft4 was 52% of normal range and anyway I take euthyrox 75 (but i miscarried again) and baby aspirin and folic acid 5mg (i am also MTHFR homozygous).
What kind of treatment would you prescribe to me BEFORE and in my next pregnancy?
My antibodies level is now 56 after the last miscarriage (before pregnancy was 263 - I think, that pregnancy reduced inflammation in my thyroid gland) and I've got my first menstrual period after d&c 12days ago. I've started prednisolone therapy (I don't know, if not too soon after d&c - but regarding low level of aTPO - to stop them growing).
I take also baby aspirin from almost a year (3 miscarriage in 2007/2008) and folic acid 5mg.
What I could do more? I think of heparin very seriously.
At Fri May 16, 05:54:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 16: Hasimoto's is an autoimmune disease. Have you been screened for any other autoantibodies such as antiphospholipid antibodies or lupus anticoagulant? The aspirin and the folic acid is fine, but I would probably offer you heparin or low molecular weight heparin empirically the next go-around. It certainly is safe enough! Best of luck and thanks for reading! Dr T
At Fri May 23, 07:07:00 AM 2008,
Anonymous said…
I was just diagnosed with lupus anticoagulent after two previous miscarriages at 11 and 8 weeks (both with heartbeats present). I was diagnosed after a comprehensive thrombophilia scan: APA, TEG, Factor V Leiden, Activated Protein C resistance etc. at St Mary's in London which I have read is among the world's best clinics in recurrent miscarriage and autoimmune issues. My question is I just started the stimulation phase of IVF and I have received conflicting advice. St. Mary's told me to start heparin injections 6 hours after egg colleciton and then take baby aspirin only after a positive pregnancy test. They say that baby aspirin even in LA patients can potentially get in the way of implantation (makign the blood too thin at that stage) But my RE at the IVF clinic is telling me to take baby aspirin during the entire course of ivf and any subsequent pregnancy (starting heparin the day after egg collection).
Both doctors are top in their field so I have no idea when to start the aspirin. Please help!thanks very much
Please advise g Ivf treatment
At Fri May 30, 08:05:00 AM 2008,
Anonymous said…
I have just had another miscarriage since my last post(see below). I am seeing a fertility spec. now. Everything has come back normal. The only thing they have found is written below. How would you treat this?
""""I just had my second miscarriage at about 9 - 10 weeks(this has been in the last year). I have two year old who I had no problems with. After I had her I began to have elevated liver enzymes and have been seeing a GI. I have a positive ANA of 1:160. Possible AIH but are reluctant to diagnose since my symptoms have not gotten worse and my liver biopsy was not conclusive. It showed only mild inflammation. I also have hypothyroid. I am wondering if prednisone and aspirin therapy would help me go full term? Should I see a fertility specialist? Does prednisone cause birth defects?"""
At Mon Jun 02, 12:21:00 PM 2008,
Elaine said…
I am 35 and I have one healthy 3 y.o. son from my first pregnancy and have since had 2 confirmed miscarriages (and a suspected 3rd prior to the 2 confirmed ones). The first was missed m/c at 11.5wks (baby only 9wks) and resulted in incomplete m/c and subsequent D&C (Nov 07). I had two normal periods then got pregnant again which resulted in a very early loss at 5 wks 2 days and no D&C required (March 08). I have been to see an excellent RE and he did a full work-up which all came back ok. I do have a mild b12 deficiency (no anemia, just neuro sympyoms)that was discovered after the first m/c and treated prior to the second. My Folic acid levels were normal. My questions are:
1) can the b12 have anything to do with recurrent pregnancy loss and if so, now that my levels are normal, would my chances of having a successful pregnancy be improved
2) even though my non-pregnancy lupus anticoagulant levels were negative, should they be tested during pregnancy to make sure they aren't positive
3) my RE said I could be treated empirically with daily baby aspirin (already started taking) and once pregnant, with progesterone and lovenox or heparin if I want. What are your thoughts?
Any input is appreciated, Elaine
At Wed Jun 04, 06:30:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 23: Just saw that this had been posted awhile back. Sorry I had not seen it. Actually just got to my mailbox. Either approach is reasonable. I lean more toward that of your RE doctor. the heparin is probably more important than the aspirin in helping to overcome the affects of the LAC. Good luck with the pregnancy and let us know how things turn out! Dr T
At Wed Jun 04, 06:41:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 30: Thyroid disease and the hepatitis might be evidence of an imbalance in your immune system that may eventually be diagnosed as a recognizable "autoimmune disease" such as systemic lupus. However, autoimmune diseases are a variable mess with which to deal and not all are balck and white with regard to definitve diagnosis. We do know that wmen who develop autoimmune conditions are at greater risk for recurrent pregnancy loss, but not all are. For years we used prednisone and it is fairly safe although at higher doses it puts you at increased risk for diabets and premature rupture of membranes duuring pregnancy. It has a low level associiation with midline facial defects, but these are not seen very often and the risk may not be significant. Our preference when we suspect autoimmunity as a controbutor to early pregnancy loss is to treat with heparin or low-molecular weight heparin starting shortly after conception. Good luck! Dr T
At Wed Jun 04, 06:45:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Elaine: Some B12 deficiencies are the result of an autoimmune condition called pernicious anemia where one develops antiparietal cell antibodies and cannot absorb B12. So, the simple answer is yes, correction of the B!@ might help, but if you have an autoimmune condition of any sort, that might mean your immune system is also not responding normally to pregnancy. That's a long story and for a separate post. The bottomline is that you MIGHT benefit by empiric theray with low-dose aspirin and heparin or low molecuklar weight heparin since these are the foundation of empiric therapy and therapy in individuals with known thrombophilias. Best wishes! Dr T
At Thu Jun 05, 11:58:00 AM 2008,
Anonymous said…
Dear Doctor, I am Anonymous May16.
First of all - thank you for your advice! And I am sorry for my english - I'm from Poland.
After second and third miscarriage I had checked antiphospholipid antibodies, lupus anticoagulant, trombophilia screening and karyotypes. And of course thyroid gland and aTPO. The only not correct results I achieved: TSH - 3,2 (now 0,5 after euthyrox 75), aTPO - 263 (now 56 only on euthyrox) and also homozygous mutation MTHFR C667T.
Some doctors think the reason of my loses is hashimoto - i'm taking now 10mg of prednisolone for aTPO_ and some of them think it could be MTHFR...
My present doctor said, that aTPO was to low to couse miscarraige and he sees the reason in my homozygous mutation. His opinion this mutation cause blood clotting.
I wonder...I have a son from my first pregnancy - why later all these miscarriages happend to me?
My doctor thinks to prescibe me following treatment:
-10mg prednisolon until pregnancy test and later 20 mg to mid of pregnancy
- aspirin and folic acid 2 monthes before pregnancy and by all pregnancy later
- heparin from pregnancy test until 34 weeks of pregnancy.
What do you think about it? Is Prednisolon neccessary in my treatment?
I will so appreciate your any advice... Best regards - Dorota
At Sat Jun 07, 08:14:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Dorota: I do not know your entire situation, but from what you have told me, the thyroid replacement, folic acid, baby aspirin and at most a prophylactic (not therapeutic) dose of heparin is all I would use. The predniso,one is probably not necessary and may cause more harm than good. It's use is associated with an increased risk for gestational diabetes, premature rupture of membranes and preterm delivery. Good luck and thank you for reading. Dr T
At Thu Jun 26, 09:10:00 AM 2008,
Anonymous said…
I have a quick question: after two chemical pregnancies my physician found that I had a single mutated copy of the MTHFR gene -- the "A" one, no the "C" one. as a result, she put me on folguard and baby aspirin. I am pregnant again (within 2 monhts of starting the regimen) and she has reccomended doubling my dose of folguard to 5 mg. Is this necessary? I am 36 with a healthy 2 year old son. Also, how long should I stay on the baby aspirin. I am currently 6 weeks pregnant.
At Sat Jun 28, 08:57:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous June 26: Short and sweet. The extra folic acid won't hurt and should overcome any minor concerns related to the single MTHFR mutation; and, the aspirin is probably not necessary and can be stopped any time. Dr T
At Tue Jul 01, 08:30:00 AM 2008,
Dana said…
I have had 3 early miscarriages. I was taking clomid for all three. I have elevated ANA and positive for lupus anticoagulant. I exhausted the amount of times I could take clomid and am now on my 3rd round of IUI. Upon insemintaion the doctor recommends I take 10mg prednisone 2x a day, prometrium 2x a day, one 40 mg shot of lovenox, 1 baby aspirin and a prenatal vitamin. In your opinion is this too much medication?
At Tue Jul 01, 06:43:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Dana: There is no really "righyt way" to do this. that certainly is a reasonable approach. If you do take the prednisone, you probably will not need that beyond 20 weeks unless you have other evidence of an autoimmune disorder. Personally, I have leaned to using higher doses of lovenox instead of prednisone over the years. Good luck! Dr T
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