Triple therapy in recurrent aborter
Dr. Mohammed Abdalla
Egypt, Domiat G. Hospital
10 Abortions ,10 DVTs
the 11th,12th Pregnancies Were
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
( 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.
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
was assessed at the first week
of therapy then every two
Glucose tolerance test
was done at 10 wk. And 28 wk
Routine antenatal visits
Every two weeks assessing BP,
HB, urine testing, wt. Gain.
AND dose adjustment which
was not needed.
At 10 wk –20 – 32wk revealed normal
progressive growth, no congenital
Anomalies , and good biophysical
Superficial phlebothrombosis was
marked all over the lower
abdomen, flanks and lower
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.
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
She refused tubal ligation.
The immune system works by
identifying proteins as normal or
Autoimmune response represents the
immunologic response of the mother
to a pregnancy (woman is rejecting
her own proteins)
There are four different autoimmune
problems that can cause recurrent
1. Antiphospholipid antibodies
2. antithyroid antibodies
3. Antinuclear antibodies
4. Lupus-like anticoagulant
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.
Heparin is administered to combat possible clotting
Prednisone is given to decrease autoantibody
levels, provide blood-thinning and anti-
inflammatory reactions, and reduce the risk of
low dose Aspirin is a prostaglandin inhibitor which
decreases agglutination of the platelets (clotting),
and has some anti-inflammatory action.
Dr. Mohammed Abdalla
Egypt, Domiat general hospital