Comment Regarding Prednisone Therapy for Recurrent Pregnancy Loss
I was happy to read your thoughts on the immune/thrombophilic connections to recurrent pregnancy loss. I have had 3 miscarriages and 1 ectopic pregnancy causing emergency laproscopy and the loss of my right fallopian tube. We have been trying to conceive for 2 years...I recently saw a specialist in NYC... who diagnosed me with high antinuclear antibody (ANA) 1:320, speckled. I am now trying o conceive for the first time since the diagnosis and am nervous about taking prednisone. Have you noticed any severe side effects from this? I was also advised to take one baby aspirin (81 mg), 40 mg of Lovenox twice per day (I have homozygous MTHFR, homozygous PAI-1, heterozygous factor XIII V34L), Vitamin E, Metanx(a Folgard-like drug), progesterone(always had low progesterone around 7 after ovulation). I will probably take Clomid because in the past, it has helped raise my postovulatory progesterone levels...I have high CD 19 and CD 19+ cell, CD5+ on the NK (natural killer) cell assay...
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 related to the prednisone therapy - how much are you taking each day? Many years ago, prednisone was the foundation of our therapy for women suspected of having an immunologic basis for their recurrent pregnancy loss. Over the years, the literature has shown no great benefit of that, and potentially some harm, over anticoagulation therapy with unfractionated and low-molecular weight heparin (Lovenox). I usually reserve the prednisone for women with diagnosed autoimmune conditions such as systemic lupus erythematosus (SLE), who need to be treated for acute flares in their disease, and for women who decline heparin therapy because of the need for daily injections. Incidentally, despite the "high ANA," you do NOT meet the criteria for SLE (from what you have told me so far) and, indeed, many individuals who have modestly elevated ANA have no identifiable autoimmune or pregnancy-related problems whatsoever!
Prednisone therapy during pregnancy is associated with increased risk for gestational diabetes, infectious complications, premature rupture of membranes, and early delivery. It also increases your appetite (and weight) and fluid retention at high enough doses. If you absolutely don't need prednisone, try to get off of it by 20 weeks gestation. It probably isn't going to help much beyond first trimester in your case anyway.
Incidentally, I have also 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!