When to Start Anticoagulation Therapy for Recurrent Early Pregnancy Loss
Saturday, January 26, 2008
Kenneth F. Trofatter, Jr., MD, PhD
Under these circumstances and, particularly, when used as ‘empiric therapy’, even when a successful pregnancy results, we cannot be entirely sure if our treatment was the deciding factor or it if was simply the result of chance. The original thinking was that somehow the anticoagulation properties of these agents prevented abnormal clotting of the placenta that was preventing the early pregnancy from developing normally. In recent years, we have discovered that other factors may be equally, if not more, important in early growth and development of the placenta as I allude to in my response to our reader’s questions below…
• At Sat Jan 19, 02:46:00 PM 2008, ONE OUT OF SIX said…
Dr. T - what are your thoughts on starting lovenox prior to implantation - either right before, or right after ovulation? And is your opinion the same in regard to a natural cycle as opposed to an ovulation induction cycle in which ovulation is then triggered with HCG? Also - does the patient already being on a daily baby aspirin have an impact one way or the other?
It has been suggested to me that being on both baby aspirin and lovenox (40mg/once a day) could actually inhibit implantation by causing a bleed at implantation site.
Others have said this is not the case at all - and in fact the opposite is true - healthier blood flow to uterus will assist with implantation (that may have been prevented in the past by diagnosed clotting disorders - homo MTHFR C677T and hetero Factor V.)
Last question - can you move to Pittsburgh, PA so I can become a patient? ;-)
Thanks for your insight.
• At Fri Jan 25, 10:53:00 AM 2008, Kenneth F. Trofatter, Jr., MD, PhD said…
To One out of Six: Flattery will get you an answer EVERY TIME! Personally, I rarely will start lovenox or heparin before midway through the luteal phase after spontaneous ovulation or ovulation induction (about day 20-21) unless you have documented antiphospholipid syndrome or another condition that requires chronic anticoagulation. The reasons for that are it may increase bleeding from the ovarian ovulatory site (and, personally, I have taken two young women, who were not even on lovenox or aspirin, to the operating room in the past month with bellies full of blood from that very thing) and I sincerely doubt it does much good until the embryo has reached the uterine cavity and attachment has actually taken place. With all that said and done, on prophylactic doses of lovenox such as you are taking, it probably would not hurt or put you at much risk.
With regard to recurrent early pregnancy loss, however, the anticoagulation properties of lovenox and aspirin may be LESS important than their roles in improving trophoblast invasion and migration! This may be especially true under those circumstances in which 'thrombophilic antibodies' such as lupus anticoagulants, antiphospholipid antibodies, and anti-β2-glycoprotein-1 antibodies are present. These antibodies can bind to the trophoblasts in association with β2-glycoprotein-1 and impair both trophoblast invasion and migration that are necessary for early pregnancy success. Interestingly, heparin and lovenox can reverse the effects of these antibodies by blocking their binding to β2-glycoprotein-1. Anyway, I will put your question and my answer into a brief post on this subject soon (and perhaps a larger series later on) so, thanks for reading, for the excellent questions, and best of luck!
Dr T
Labels: heparin, lovenox, recurrent pregnancy loss, thrombophilias
29 Comments:
At Mon Jan 28, 06:59:00 AM 2008,
shirly777 said…
Hello:
I would like to start letting you know that I have periods of 30-32 days, My periods last about 7 days with cramps the first 2 -3 days. I have never missed a period, my mother had 3 healthy babies as well as everybody in my family.
I just turn 25 years old and I got pregnant of my husband when I was 22, at that time we were only boyfriend and girlfriend, we didn't know how it happened but we were happy with the idea, I was only 4-5 weeks when I started bleeding, he took me to the hospital and they confirmed that I just miscarriage my first baby. I was very depressed but quickly recover because I was young not married yet and I could wait. My husband and I got married last year in July and on December 27,2007 I found out I was pregnant again, I was so happy I told my husband , we told our families etc. We had 2 ultrasound in the secons I was 6 weeks 4 days, the baby heartbeat was normal but I had a small rethro.. bleeding , the doctor said that it was ok because it didn't grow since the last visit, I was schedule for an other ultrasound in 1 week. When I went back the doctor told me that my baby's heart was not beating anymore, I felt devastated, i didn't know what to do , I was under prometrium all this time to prevent a miscarriage and even thought I lost my baby again, The doctor gave me some pill to introduce inside my cervix and some to take orally. He also says all my blood work came normal. I really want to have a baby, I 'm very scared of this happening again, I'm trying to buy books of how to prepare myself this time, because those two times were unexpected , now my husband is looking forward to have a baby, I'm trying to change my life around in a way that I don't have to deal with stress anymore, I'm also trying to move out to another house because I live in a 3 floor townhouse and I have to go up and down stairs 20 times a day ( my bedroom is in the 3rd floor and the kitchen in the 2nd floor) Please help me what should I do? I want to be pregnant in 3 months from now and I know I'm fertile but for some reason I lost my babies. what do you think is wrong with me?
At Mon Jan 28, 04:51:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Shirly777: Most likely, NOTHING is wrong with you and odds are you WILL have a baby without any special help. I wrote a whole series on recurrent prrgnancy loss back in March and April 2007, so if you want a lot of details, check that out. But, my suggestion is simply this...wait the two or three months, start taking a prenatal vitamin even now. Eat well, RELAX, and stop smoking if you are a smoker. The month you want to try to get pregnant, start taking a baby aspirin (81mg) each day. If your doctor wants to put you on prometrium, that's fine. I also recommend that neither one of you tell your families until you are at least 12 weeks and everything is going well. If you lose another pregnancy, you will probably warrant a more thorough evaluation as detailed in my posts, but think POSITIVELY for the time being, okay!?! Best regards, Dr T
At Wed Feb 06, 10:38:00 AM 2008,
Dan said…
Dr. T,
My wife is heterozygous for C677T, with no other mutations. Currently she takes a total 1.2 mg of folic acid daily as well as a prenatal vit. Her non-fasting homocystein is within normal ranges. I am azoospermic so we have done 4 attempts of donor insem and we are in the middle of of our 4th attempt waiting to see if it worked (should know is a couple days). My question is should she be taking baby aspirin and a higher dose of folic? Our specialist has not mentioned taking baby aspirin or a higher dose of folic. I also presume that she should not be doing blood thinning shots with just the single mutation. With so much at stake with each attempt b/c we have to use a donor we just want to make sure we are as proactive as possible.
Lastly, if I have read the other entries correctly it seems there is a controversial but possible risk of Down Syndrome even with the single c677t mutation. Will the 1.2 mg or higher of folic mitigate this or is this of not high concern given the mixed results in the studies?
Thanks much!
At Sun Feb 10, 06:52:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Dan Feb 6: That dose of folic acid is probably adequate under the circumstances. Her risk for coagulation problems is low with a single C677T mutation as well, so 'anticoagulation' is not necessary. If your wife has had recurrent miscarriages, there is a chance the baby aspirin might be a benefit, but that would be purely 'empiric therapy' at this point. Folic acid does not appear to influence the risk for Down syndrome since that is a chromosomal problem and not an 'inborn error', however, I have wondered if it might possibly affect the survival of babies with trisomy 21! Hope this cycle went well. Let us know how things turn out! Dr T
At Tue Feb 12, 12:50:00 PM 2008,
Mara F. said…
Dear Dr. Trofatter,
I experienced a tragic full-term pregnancy loss after many years of infertility. Extensive testing indicated fluctuating levels of antiphospholipid antibodies. I also have auto-immune (Hashimoto's Thyroiditis) I have since lost 40 pounds to improve my health and am taking selenium to reduce anti-thyroid peroxidase antibodies. I take levoxyl daily. I have been told I will need heparin in pregnancy. I want to become pregnant again but I am afraid of bleeding too much. Are there special considerations in my situation?
At Fri Feb 15, 10:32:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
Mara: I am so sorry for your loss. The risk of thromembolic complications from the antiphospholipid antibodies is far gretaer than the risk of bleeding complications from the heparin. You will need to be followed very carefullt during the next pregnancy for fetal growth and Dopplers. Your doctor can explain the significance of the latter. Even if you baby looked fine late in pregnancy, I would still probably offer you an amniocentsis to assess fetal lung maturity at 37-38 weeks and deliver you early if that was reassuring. Again, I am sorry for your loss. Hope things turn out better for you the next time. Dr T
At Sat Mar 08, 08:58:00 PM 2008,
nikki said…
Dear Dr. Trofatter,
I have found your blog while trying to Google anything about PAI-1 and antiphospholipid antibodies and am very happy to find all the useful information that you have posted. It was also interesting to read your fun account about the cruise, thank you for sharing and glad you’ve enjoyed the long-deserved break from work!
I would be very grateful if you could comment on my situation. I am nearly 35 y.o. and am 13-weeks pregnant. I have had two bleeding incidents at 8th and 10th weeks with a very small amount of dark brown blood and a slightly larger amount of bright red blood respectively. The second bleeding followed some incidental heavy lifting while traveling by air for a total of 15 hours (I am currently at a location with substandard medical facilities and limited doctor’s expertise, with no access to a better healthcare provider). Both times, the ultrasound had found small subchorionic hematomas, both of which have successfully dissolved now without any medication.
I have not had a history of miscarriages, strokes, heart attacks or thrombosis but, to help determine a possible cause of those hemmorages, the local doctor advised blood testing for antiphospoholipid antibodies and trombophilias, which came back with these two results:
IgM=15, 6 positive (IgG=5, 2 negative, Lupus test=negative)
PAI-1-675 4G/5G heterozygote carrier (negative for G20210A, MTHFR C677 T, Leiden Factor, Fibrinogen FGB 455G/A)
Predicting that I am otherwise risking a placental abruption after 20 weeks, she recommends injections of a blood thinner (Clexane) into the abdominal skin but I am hesitating because I am not sure it is really needed (after all, the hematomas have disappeared on their own) and that it will not harm the baby. I am also wondering if any of the two factors below could affect the heightened IgM level: my GSD-1 blood test came back positive (even though I have never felt any effects of it) and I have also been given a RhoGAM shot following the first bleeding b/c I am Rh- and my husband is Rh+.
So far, I have had no more bleeding and the my little girl has a heartbeat of 153 (down from 167 at eight weeks) and a CRL of 73 mm. What further testing or therapy would you recommend? Do I need to worry about those two test results and consider administering a blood thinner?
Many, many thanks in advance for any advice that you can spare. Sorry about the long posting.
Warmly,
Nikki
At Tue Mar 11, 06:20:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Nikki: Clexane is a low-molecular weight heparin (enoxaparin). I am not convinced by the blood tests you have had done that you need it. Clexane is also VERY expensive. I am not sure you need anything at this point (except to avoid "heavy lifting" and other strenuous activity), but you could consider as a compromise simply starting one baby aspirin (81 mg/day). Good luck to you for the rest of the pregnancy and let us know how things turn out! Dr T
At Fri Mar 28, 06:56:00 AM 2008,
betsy said…
Dr. T,
I am 29 and a half years old, and was diagnosed in May of 2007 with MTHFR a1298c homozygous, and FVL hetero. The testing took place after a complicated delivery with my now 12 month old son. I had placental clots and infarction at 37 weeks, and had an emergency c-section for fetal distress. He suffered from metabolic acidosis, congential pneumonia, a left pneumothorax, numerous electrolyte imbalances, and had very immature lungs, requiring 3 doses of surfactant. He spent a week on the vent. I am currently 19 weeks 3 days pregnant, and my MFM doc has me on Folgard, baby asa, prenatal and omega 3's this pregnancy. I will receive 6 week ultrasounds for growth scans until 32 weeks,then they will be every 4 weeks or sooner if determined. I will also have weekly non stress tests starting at 32 weeks, and will have a repeat c-section, if I have not gone into labor on my own, by 39 weeks to prevent placental degrading and aging (clots and infarction again). My question is, do you think baby asa is enough. I have been fighting for lovenox, and have not made any headway with my mfm or regular ob. They think that it is not warrented, because I have never had a dvt or pe myself, or a miscarriage to my knowledge (although I think I did the month prior to conceiving my son, I had a faintly positive test, follwed by heavy cramping and bleeding, and was told an lsh surge could have given me the false positive, my hcg levels were never tested). I am concerned because my 32 year old sister, who has never had any pregnancy complications (she has 2 children) was diagnosed with FVL only (no mthfr) and they are going to put her on lovenox in her hometown if she becomes pregnant again. (she has no hx. of dvt or pe, or mc either) Thank you so much for your opinion. The 19 week us for this baby was very normal, and he looks great. Thanks again, Betsy
At Sun Mar 30, 04:45:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Betsy: With your history, personally, I do not think the aspirin is enough. If they are concerned enogh to 'anticoagulate' for the reasons you have indicated, then a 'prophylactic' (not necessarily 'therapeutic') doese of either heparin or Lovenox would be a much more effective choice and relatively 'safe' to boot. You might still do just fine, but as I have said on numerous occaions in the past, "obstetrical history tends to repeat itself even if we are not smart enough to understand why!" Best of luck and let us know how things turn out. Dr T
At Tue Jul 08, 01:07:00 PM 2008,
Anonymous said…
Hello, It's so great that you offer your expertise on this blog. I have been trying to conceive for 3 years.
Six months ago through routine bloodwork I discovered I had very mild hyperthyoidism (graves' disease) and tested positive for antithyroid antibodies. I had normal bloodwork in 2006. I recently went forward with my first IVF choosing to do single embryo transfer. First blastocyst failed to implant. Second attempt I had a chemical pregnancy. I'm currently on a low dose of PTU to keep my thyroid high normal (50 mg once a day). I have a great Endo Dr. monitoring me who thinks I have a good chance of regaining normal thyroid function or that I may go hypo naturally -- preferable to RAI treatment.
My question is do you think antithyroid antibodies can contribute to IVF failure? My current RE believes this wont interfere but said if I wanted I could take a baby aspirin for my next attempt. Thanks for your input. Signed 34 year old.
At Tue Jul 08, 01:09:00 PM 2008,
Anonymous said…
Hello, It's so great that you offer your expertise on this blog. I have been trying to conceive for 3 years.
Six months ago through routine bloodwork I discovered I had very mild hyperthyoidism (graves' disease) and tested positive for antithyroid antibodies. I had normal bloodwork in 2006. I recently went forward with my first IVF choosing to do single embryo transfer. First blastocyst failed to implant. Second attempt I had a chemical pregnancy. I'm currently on a low dose of PTU to keep my thyroid high normal (50 mg once a day). I have a great Endo Dr. monitoring me who thinks I have a good chance of regaining normal thyroid function or that I may go hypo naturally -- preferable to RAI treatment.
My question is do you think antithyroid antibodies can contribute to IVF failure? My current RE believes this wont interfere but said if I wanted I could take a baby aspirin for my next attempt. Thanks for your input. Signed 34 year old.
At Sat Jul 12, 04:38:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July *: We are finding that thyroid conditions, especially when they are related to autoimmunity, can deleteriously affect early stages of embryonic growth, if not the implanataion process itself, and be a risk factor for early pregnancy loss. However, the mechanism for that is unclear. Is it related to the antithyroid antibodies or to some other immune imbalance that makes successful pregnancy less likely? We do not know. By the way, have you been tested for any other autoimmune conditions? Regardless, the aspirin (only 81 mg) is reasonable to try and if that is unsuccessful, the empiric addition of prophylactic doses heparin or lovenox can also be tried. Good luck and thanks for a great question. I will address the issue of thyroid diseases and pregnancy loss in the near future, so stay tuned. Dr T
At Tue Jul 15, 09:55:00 PM 2008,
gloria said…
Dr. T.
Wow. Thanks for all the information! I was wondering if you could offer an opinion on my situation. Two years ago I delivered by C-section my daughter at 29 weeks gestation due to the sudden onset of HELLPS. She spent two months in the NICU but thankfully did not suffer any complications and was and is fairly healthy despite her small size. My blood tests prior to delivery and post-delivery revealed APS. My husband and I would like to try to have another child. My haemotologist has prescribed lovenox which I am to begin administering as soon as I confirm that I am pregnant. She seems to think that it is very likely that I will have a normal pregnancy and deliver a health child. I have been reading that the probability of developing HELLPS during this second pregnancy is somewhere around 20%.
How much should I be worrying about this for my own health and a successful pregnancy given the recommended lovenox treatment?
Additionally, given the probable immune system interaction in HELLPS, could this have caused the unbelievable hives I experienced during around the 15th and 16th weeks of pregnancy (the second phase of implantation you discuss in your posting)?
Any comments you may have would be greatly appreciated. Thanks so much in advance!
At Wed Jul 16, 05:29:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Gloria: If you truly have antiphospholipid syndrome, the lovenox may reduce, but it will not eliminate your risks for pregnancy complications - repeat HELLP syndrome, thromboembolic complications, etc. Your chance of HELLP syndrome again is still at least 20%. I am very curious about the "hives" you had during your last pregnancy. I am not sure if it had anything to do with the outcome (or placentation for that matter), but did they persist, how long, and what other symptoms did you have? Thanks for reading. Dr T
At Wed Jul 16, 09:37:00 PM 2008,
gloria said…
Thanks for your reply. With respect to the hives--this strange condition lasted about two weeks during which time, I would have these localized outbreaks on some part of my body (mostly neck down) that were intensely itchy (even wake me up in the middle of the night). Hives would develop and worsen with scratching but then within a couple of hours the hives would disappear from that particular area.
With respect to whether or not I really have APS--are you referring to the fact that this may be a HELLPS induced condition that has still not subsided. 2 years after the fact blood tests still show strong APS. Could the APS still subside in time? APS was initially discovered after a false syphilis test result and I recall a similar experience after a pap some years ago (pre-pregnancy) where I had a false positive but was never tested for APS. I'm even more concerned now. How would you advise one of your patients in this situation as it relates to pursuing a second pregnancy?
Sincerely,
Gloria
At Fri Jul 18, 05:11:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
Gloria: As I said before, and as I tell any patient of mine in your situation, when you have APS, the lovenox can reduce, but cannot eliminate, your risks for preeclampsia, blood clotting complications (deep venous thrombosus, stroke, pulmonary emboli), early deliveries, small babies, cesarean section, etc during another pregnancy. If you understand those risks, and want to pursue another pregnancy, then we will do everything we can to help you get through it safely. By the way, I am still pondering the issue of the hives! If I get any bright ideas on that, I will let you know. It would be interesting to see if they recurred in another pregnancy!
Dr T
At Fri Jul 25, 02:56:00 PM 2008,
Anonymous said…
Hello.. I hope you will be able to provide me with some of your opinions on aspirin therapy. The past year I have suffered 2 miscarriages, all before 8 weeks. THere have been several blood tests done to test for thyroid, blood clotting disorders that have all come back negative. I am currently about 5 wks pregnant now and I am wondering if it would be "safe" to start empiric therapy with a baby aspirin. I really would like to see this pregnancy go to full term. Thank you.
At Sat Jul 26, 05:02:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous July 25: Safety and efficacy are two separate issues. In most instances, baby aspirin (81 mg per day) is 'safe'. It is a potent inhibitor of platelets and can lead to bleeding and gastric distress (so get the enteric coated form). There are some data to suggest that it may also be associated with premature separation of the placenta. Unfortunately, the data is also not very strong to support the efficacy of aspirin in preventing early pregnancy losses. So chances are it won't hurt, but I cannot promise you it will help either and the chance of getting through first trimester may be good for this pregnancy anyway in the absence of identifiable reasons for the two previous miscarraiges. By the way, if you do start the aspirin, please let your doctor know. Best of luck and please let us know how things turn out. Dr T
At Fri Aug 29, 03:20:00 PM 2008,
Kam said…
Hello: I am 24 years old and have 3 miscarriages in the past 2 years, all around 7 - 8 weeks. I don't actually find out about the loss until a while later due to spotting. i have been tested for lupus anticoagulant antibodies 3 times and i've had 2 positives and a negative. I am taking low dose aspirin. I was wondering what the next step is. I've been told that I'll have to do Heparin Injections, but I just need more information on that. Thank you.
At Tue Sep 02, 06:39:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Kam: From what you have told me, I am still not sure we have the answer for your miscarriages. However, if heparin is the next step (and I probably woould go there too with the understanding that it is entirely 'empiric therapy' at this point), I would start at 'prophylactic' (not therapeutic) dosage levels. Heparin is very safe under those circumstances and does not cross the placenta to the baby. It is simple to learn how to give the injections or to have a family member help you with that. Dr T
At Thu Sep 11, 09:10:00 AM 2008,
JBH said…
Dear Dr. T:
I have homo MTHFR (C677t) and for that I take baby aspirin daily and extra folic. I also have elevated anticardiolipins (2 tests show low-mod positives of 22 and 26). I took Lovenox during my last pregnancy which ended in miscarraige (chromosomal, not clotting-related).
I am currently doing an IVF cycle; the transfer is scheduled for Tuesday, Sept. 16, 2008. Should I start 40 mg Lovenox the day of the transfer? Also, would you say 40mg as a prophylactic dose is sufficient?
Many, many thanks!!!
JBH
At Fri Sep 12, 03:41:00 PM 2008,
Anonymous said…
Hi Dr. T,
I am hoping you can provide me with some guidance or reassurance.
I have had 2 very early miscarriages since my husband and I started trying to conceive 13 months ago, one at 5.5 weeks and one at 6.5 (and I think the second one might have happened sooner but for the fact that I was taking progesterone). My HCG was not doubling normally in either pregnancy from the get go.
I was just diagnosed with antiphospholipid syndrome. I found out about the APS early this week. I was in the middle of my cycle but hadn't ovulated yet and to my joy the doctor said it was ok to try this month, just to start taking baby aspirin right away and make an appointment with a high risk OB.
I have been taking 81mg aspirin for the past 4 nights. My husband and I had sex several times this week and I am fairly certain I ovulated yesterday (temping and fertility monitor say so).
Here's my question: my appt with the OB is for next Wednesday, which will be 6 or at most 7 days past ovulation. Is it ok that I am not currently on LMW heparin or with my history of such early miscarriages should I try to get on it BEFORE implantation could possibly occur.
I am very worried about this. Thanks so much!
- Mimi
At Mon Sep 15, 07:51:00 AM 2008,
Anonymous said…
I am 39 y.o. w/one child who is now 14 mos. old. I delivered via c-section at 40 weeks (had early labor around 31 weeks which they stopped). Immediately after delivery & for about a mos. or so post delivery I had problems w/very high blood pressure. After a miscarriage at 9 wks in March we had no luck conceiving and went to get tests. Tests revealed the following:
MTFHR: Two mutations -one copy of C677T and one copy of the A1298C.
[My homocisteine was normal]
PAI-1: Homozygous for the 4G deletion allelle (4G/4G genotype)
Low for Protein S & Low for Protein C [the hematologist ordered new tests b/c he said this is extremely unusual & wanted to confirm it wasn't an error]
My fertility dr. suggested b6, b12, and folic acid (in addition to my prenatal vitamin) and low dose aspirin after the hematologist finishes his testing. I did another round of tests last mon. And I started the low dose aspiring the next day. I probably ovulated the next day (wasn't keeping exact track b/c we were told to hold off trying until all my results were in). My question is I think I may be very, very early pregnant (same really early queasy feeling as last 2 times)- if i am is the low dose aspirin sufficient until I reach the point where I can do a preg. test?
At Tue Sep 23, 04:41:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To JBH: With both the homozygous MTHFR polymorphism an the antiphospholipid antibodies, I tend to be a little more aggressive with the Lovenox therapy. I would stay in the porphylactic range at this point but would increase the dose to 1 mg/kg per day. I usually start that in mid-luteal phase or as soon as the hCG turns positive. There is no "right way" to do this, but that has been my approach in recent years. Best wishes. Dr T
At Tue Sep 23, 04:47:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Mimi: I apologize for my delayed response, but the folks at Healthline had not sent comments to my mailbox since Sept 4 and I got hit with 180 of them all at once. First, I have a question for you - what were the results of the studies that led to the diagnosis of antiphospholipid syndrome. Secondly, I usually start therapy with heparin or Lovenox in mid-luteal phase or as soon as an hCG returns positive. If the diagnosis of APS is simply on the basis of the laboratory studies and your two miscarriages, I usually start Lovenox at 1 mg/kg daily. If you have a history of thromboembolic complications, I give that dose twice daily. Good luck and let us know how things turn out! Dr T
At Tue Sep 23, 04:55:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Sept 15: Those laboratory studies usually do not affect your ability to conceive, but may impair implantation and placentation. Your loss at 9 weeks may well have been a baby that was chromosomally abnormal - still the most common cause of miscarriages, and more likely because of your age. The aspirin and folic acid should go a long way to counter the affects of the MTHFR polymorphisms and the PAI-1 over-reactivity - so I would not add anything at this point. Do you have any other medical problems? Are you on any other medications at this time? Did you actually have preeclampsia with the last pregnancy? What did that baby weigh at delivery? Did you have any other complications with that pregnancy? Anyway, thanks for reading and I wish you the best! Dr T
At Mon Oct 27, 09:25:00 AM 2008,
Anonymous said…
Hello! First, I want to say thank you for all the information you provide here. It is wonderful to be able to access this info when you are desperately searching for some. I have a very long history of pregnancy issues. I am currently 8 weeks pregnant, for the 7th time. My husband and I had a stillborn at 26 weeks, in July of last year due to severe PE, HELLP, and placental abruption. The remaining 4 pregnancies have ended in miscarriage, two at 4/6 weeks and two at 12/13 weeks. This has all occurred in the last 8 years. With my current pregnancy, I am seeing a MFM who is going to test me for any anticoagulants and possibly start me on Heparin. I am currently taking 81 mg aspirin, vitamin D, and calcium daily. My husband is in the middle of changing jobs and we are without insurance for another 5 weeks. At the time I am able to be tested for anything and possibly started on Heparin, I will be 13-14 weeks. My question to you is, will that be too late? Do I lose any of the reducing properties for conditions(PE, HELLP, Abruption, by starting the medication after the placental development is complete? Will Heparin "undo" any clotting that has already begun to occur? I thank you so much for your answer and I truly look forward to it.
Sincerely,
Amanda
At Sun Nov 23, 12:48:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Amanda: Sorry for my delayed response but I just received your comment in my mailbox yesterday. If you pregnancy losses are indeed related to a "clotting problem" (thrombophilia), it really is to your advantage to start the heparin very early in pregnancy. In fact I will start it just as soon as and sometimes even before a pregnancy is confirmed. Heparin may improve the way the placental tissues invade your blood vessels and if you do not start it early, and if that occurs abnormally, there is no way to reverse that process and make it better. That's not to say that it might hel;p you later in pregnancy as well, but the way I think about things, it is especially important early. Best of luck and please let us know how things turn out. Dr T
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