Another Late Midtrimester Pregnancy Loss
Hi I lost my pregnancy at 24 weeks on July 17. Actually I didn't have any complications during pregnancy. When I didn't feel any movements for 5 days, I went to the hospital and they didn't find my baby's heartbeat. My doctor said that blood results are showing protien C and protien S deficiencies and an MTHFR abnormality. She told me that perhaps these abnormalities caused the blood to clot in the placenta and that I should see a high risk specialist before another pregnancy so that he can give me treatment to help overcome these problems. She also said that after delivery protein C and protein S generally will be reduced.... When I lost my baby I didnt have any other symptoms like bleeding or stomach pain except when the baby moved. There is no family history of blood clotting problems. Can you tell me what would be the reason and if so what will be the treatments for blood clotting? Should I start the medication before another pregnancy or only after getting pregnant?
Fri Aug 10, 11:14:00 PM 2007
Kenneth F. Trofatter, Jr., MD, PhD said...
To Soumya: I am sorry for your loss. The most common causes of late midtrimester fetal demise are fetal chromosomal abnormalities (and, less commonly, genetic abnormalities), infection, congenital birth defects, and abnormalities of placentation (that may be associated with "blood clots," sterile inflammatory changes, and fetal growth restriction). The latter are also often associated with maternal pregnancy-related hypertensive disorders and premature placental separation (abruption).
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 cannot be sure the results you describe above are actually 'abnormal' or simply related to the pregnancy itself. It would help me if I knew what tests were done to measure protein S and protein C, the actual test results, and the 'normal' range of test results in the laboratory that did the studies. It would also be helpful if you could give me more specific information regarding the MTHFR abnormality (the specific 'polymorphism(s)' and whether this is heterozygous (one dose), homozygous (two doses), or complex heterozygous (two different abnormal genes)).
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!) BEFORE you get pregnant again. Other studies that can be done to look for autoimmune or genetic thrombophilias (factors that increase your risk for either making blood clots or not breaking them down efficiently) include: antiphospholipid antibodies; lupus anticoagulant; antithrombin III levels; factor V Leiden mutation; factor II (prothrombin) G20210A mutation; 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.
Ask the doctor who delivered your baby if the placental pathology showed any specific evidence of infection or blood clot formation (either placental abruption or evidence of vascular abnormalities or inflammatory changes). Without abdominal pain or bleeding, it is unlikely that you had a placental abruption. Was the placenta normal size? Did the baby appear normal and was it a normal size for 23-24 weeks (i.e., what did the baby weigh)? Was there any evidence of the baby having a chromosomal abnormality (and were chromosomal studies sent) or an infection (bacterial, viral, or parasitic)? Did you have any evidence of infection when you were admitted to the hospital (high white blood cell count, fever, bladder infection)? Did you have cultures sent for Group B Streptococcus? Were you or the baby tested for cytomegalovirus or toxoplasmosis infections or other organisms that are known to cause problems in your country?
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 complications for both you and the baby. Sometimes this means simply having to take extra folic acid (2-4 mg per day) and/or a baby aspirin (81 mg). In other situations, it may be best to treat you with either prophylactic or even therapeutic levels of anticoagulation therapy (by self-injection of heparin or low-molecular weight heparin) for part or all of the pregnancy. Before you get pregnant again, you might also consider sitting down and talking with a genetic counselor who might help identify risks that may not be so obvious and help you to better understand some of your risks based on the findings of your doctors. 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
Fri Aug 17, 12:26:00 PM 2007