CR recurrent miscarriage

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					       CASE REPORT

Triple therapy in recurrent aborter
      thrombophilic patient



     Dr. Mohammed Abdalla
    Egypt, Domiat G. Hospital
    10 Abortions ,10 DVTs
the 11th,12th Pregnancies Were
           Full Term
Mrs. S. aged 29 years married 6 years ago
 with no living children .

When I examined her for the first time she had
 been experienced recurrent 10 abortions
 non exceeded 20 wk. gestation .BUT all of
 them were associated with femoral or iliac
 vein thrombosis .

the symptoms of DVT appear as early as 4 wk.
Gestation, they looked like a diagnostic
symptom of pregnancy.
The case was diagnosed as primary anti phospholipid
syndrome

 ( had a positive lupus anticoagulant test,
 positive for anticardiolipin and prolonged
 activated partial thromboplastin time (APTT) ).



APTT is an adequate screening test for lupus-
like anticoagulant antibodies (prolonged)

Protein c and protein s were not investigated.
The family history was highly suggestive of
 thrombophilia as her father had recurrent
 episodes of DVT, and an episode of
 pulmonary embolism . till now he is on long
 term oral anticoagulant.



her sister at that time was not married yet
( but later when she conceived she
developed DVT. ) …she is also my patient.
Low dose aspirin and 5000u /12 h sc.
  Unfractionated heparin was the
  prophylactic regimen once she got
  pregnant in most of previous pregnancies.




but unfortunately it did not guard
against the occurrence of DVT and
fetal death .
According to that frightening
 history she was advised never
 to get pregnant again. But
 she visited my clinic insisting
 to try another pregnancy risk.

(by her own words :I want to be
mother even for one day).
After proper counseling I advised …..
 TRIPLE daily THERAPY once serum HCG
       get +ve at 25 th . day cycle.
1. low dose aspirin +
2. 20,000 u unfractionated heparin on three
   doses sc +
3. 30mg Prednisone on three doses/ calcium
   and iron preparations Rx were provided..

NB. LMWH was excluded for financial causes.
             Follow up

APTT
was done weekly for the first month
 and monthly for the rest of
 pregnancy. To be kept within the
 lower limit of the target therapeutic
 range
                 Follow up

Platelet count

was assessed at the first week
 of therapy then every two
 months
          Follow up

Glucose tolerance test
was done at 10 wk. And 28 wk
            Follow up
Routine antenatal visits

Every two weeks assessing BP,
 HB, urine testing, wt. Gain.
 AND dose adjustment which
 was not needed.
             Follow up

Ultrasonographic assessment


At 10 wk –20 – 32wk revealed normal
 progressive growth, no congenital
    Anomalies , and good biophysical
    Profile
           Follow up
Superficial phlebothrombosis was
 marked all over the lower
 abdomen, flanks and lower
 limbs.
            Labour
At 37 wk. PROM occurred, so I stopped heparin
  and aspirin and CS was done after 12 hours.

The fetus weighed 2,500 grams with good
 apgar scoor at 1 and 5 minutes .the placenta
 was of average wt. With multiple infarcts.
            Labour
12 hours post partum heparinisation was
  resumed in a prophylactic dose
  (5000u/12h) sc. With warfarin , after 5
  days heparin was stopped and
  warfarin(5 mg/day ) continued .
  corticosteroid had been gradually
  withdrown over three weeks.
         After 2 Years
In spit of strict instructions of injectable
  contraceptive use ,she got pregnant again
  because she stopped contraception .

The same protocol was applied again and an
  elective CS was done at 38 wk on a single
  viable fetus.
She refused tubal ligation.
         comment
The immune system works by
 identifying proteins as normal or
 foreign
Autoimmune response represents the
 immunologic response of the mother
 to a pregnancy (woman is rejecting
 her own proteins)
           comment
There are four different autoimmune
problems that can cause recurrent
abortion:
1. Antiphospholipid antibodies
2. antithyroid antibodies
3. Antinuclear antibodies
4. Lupus-like anticoagulant
            comment
The antibodies themselves do not cause
  miscarriage, but their presence indicates
  that an abnormal autoimmune process will
  likely interrupt the ability of the
  phospholipids to do their job, putting the
  woman at risk for miscarriage, second
  trimester loss, intrauterine growth
  retardation (IUGR) and pre-eclampsia.
              comment
Heparin is administered to combat possible clotting
  problems.
Prednisone is given to decrease autoantibody
  levels, provide blood-thinning and anti-
  inflammatory reactions, and reduce the risk of
  clotting.
low dose Aspirin is a prostaglandin inhibitor which
  decreases agglutination of the platelets (clotting),
  and has some anti-inflammatory action.
Thank you
    Dr. Mohammed Abdalla
 Egypt, Domiat general hospital

				
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