Miscarriage (part 2)

Published September 5, 2015 by Jennie

Last week I wrote my first post-miscarriage post. It was difficult to write, but it also felt cathartic to share what happened. I had a few people email me some questions, which motivated me to write a follow up post. In this post I am sharing what I have learned about miscarriages from a medical perspective. Please know that I have no medical training. I am not attempting to give any type of medical advice. This is just my experience.

Some people have asked if I considered having any testing done after the miscarriage. We did in fact do a lot of testing. Most of the time doctors do not do this after one miscarriage. This is because often times, a miscarriage is due to random genetic issues. While this does not make a miscarriage any easier, random genetic issues do not increase the chance of miscarriage in the future. We had two reasons for testing. First, we are as certain as we can be that my baby had no genetic issues. Our microarray results found nothing. Microarrays are so comprehensive that they sometimes find genetic issues which turn out to be nothing. Ours found absolutely nothing. We also did PGS on our embryos, which tests for several genetic issues.

The second reason is because my miscarriage happened later than usual which can be more problematic. Most miscarriages happen before 12 weeks. Of course there is still the possibility that the CVS caused the miscarriage, but there is no way to know this for sure.

These are the tests I had: Factor V Leiden Mutation, D-Dimer, Lupus Anticoagulant Reflex (this is for APS), MTHFR ( A1298C and C677T), Anticardiolipin IgG/M, (quantitative), Factor II (DNA Analysis), Protein S-Functional, Antithrombin Activity, and Protein C-Functional.

Before my miscarriage, we learned that I had low papp-a, which some doctors have linked to thrombosis. There are several different types of thrombosis. My tests covered the main ones. Doctors who believe that thrombosis is an issue would say we are likely to have the same problem again if I get pregnant. Others doctors say it is random and we are at no increased risk of it again. My doctor and MFM specialist believe the latter. They do not think I am at an increased risk.

All tests came back normal except one. I found out that I am heterozygous for MTHFR C677T. This means I have one normal and one variant copy of the gene. Being homozygous (2 variant copies is worse). This is exactly what my test results said:

This individual is heterozygous for the MTHFR C677T variant (one copy). The MTHFR A1298C variant was not identified. This combination of results is not associated with an increased risk of hyperhomocysteinemia, venous thrombosis, coronary artery disease, or recurrent pregnancy loss.

If you do an internet search on MTHFR, you can find all kinds of people who think it’s a major issue. My doctor told me that even though a lot has been written about MTHFR mutations, most experts believe it has little if any health consequences. If may impact folate metabolism so it could help to take an active form of folate which is more absorbable than folic acid.

I did my own research on MTHFR and came to similar conclusions. By research I mean reading peer reviewed journals and not the first thing that comes up on a google search. One benefit of being a grad student is I have access to pretty much all published academic journals. I have also gotten pretty good at synthesizing information from journal articles (sometimes I feel like that is all I ever do). I do not think MTHFR is an issue for me but if I ever get pregnant again, I will take active folate just to be safe.

My biggest concern is that if I ever get pregnant again, I am going to have low papp-a again and the same thing will happen. Some doctors preemptively treat this with Heparin or Lovenox in the first trimester. Until recently, these medications used to be heavily prescribed to prevent thrombosis, which may impact papp-a. Recent research suggests that these medications may not be as effective as previously thought. The exception may be with individuals who have Antiphospholipid syndrome (APS), which I know I do not have.

My doctor sees no reason to use Heparin or Lovenox unless an individual has a history of blood clots . I am curious to see what people think of this. The rational part of me agrees with this. Another part of me does not see the harm in taking it. He did suggest taking baby aspirin which I take now.

Another question people asked me is what went wrong with the D&E. I had mentioned that I had some complications from it. The procedure itself actually went well. Physically, I felt less discomfort than I did with my IVF retrievals. What is happening now is that I am having trouble with my lining. When we did my first transfer, my lining was as good as I could ever expect. Also, when I did my IUIs, my lining was also very good. This month, I was on estradiol and Lupron. My lining got better but it was not nearly as good as it was when we did my first transfer. Because I have always had good lining pre-D&E, my RE think that my now thin lining is the result of this procedure.

Apparently after a D&C or D&E, it can sometimes take a while for lining to come back. In rare cases, they can lead to Asherman’s syndrome, which is characterized by uterine scar tissue. This is a more permanent issue that usually requires surgery to fix. It is more likely to happen with multiple D&C or D&Es (I have only had one). Even so, all I can do now is wait. My RE suggested waiting at least 2 cycles. I have gotten really good at waiting. I have been doing it for the last six years.

If anyone has any insight on any of these issues, I would greatly appreciate it. As I said, I am not a doctor so I am not sure what to make of all this.

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14 comments on “Miscarriage (part 2)

  • I’m hetero for FVL and homo MTHFR, and a history of RPL so anytime I’m pregnant I take Lovenox and baby aspirin the entire time. I also just switched prenatals to one containing folate as we prepare to try for #2 in a few months.

    I personally believe those two medications, in the correct dosages, and starting before I was pregnant, are the only reason I finally carried to term. I also had low papp-a (we opted against any further testing after two inconclusive maternit21 tests), but no one (OB, mfm, or hematologist) indicated it was related to the Lovenox, etc. or seemed concerned.

    This is how it was explained to me: EVERY woman is more prone to clotting when they’re pregnant. If you have any additional clotting factors your risk increases significantly. If you have a history of clots, even more so. The Lovenox does not cross the placenta, so it only protects mom from dvts and PEs etc. The baby aspirin does cross the placenta do that helps protect baby.

    The reason they think I lost my pregnancies was because I was waiting to start my Lovenox until BFP and little micro clots had already formed in the placenta. My last (and only successful) pregnancy I started my meds two weeks before my embryo transfer.

    In your case it’s probably overkill, but you might want to ask your doctors about just taking a baby aspirin.

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  • Thank you so much for your response! I totally forgot to mention that I am on BA (I just updated my post to add that). My RE also sees no need for Lovenox and or Heparin. I just feel that we have already been through so much and if it can’t hurt, it can only help. I may get a second opinion. Also, I am so glad you found a combination that worked for you. I hope you have success with #2.

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  • Hi jeenie, after 4 miscarriages I was tested and found to have a very small anti thrombin iii deficiency which is a hereditary condition related to blood clots. However there had been no family history of clotting and I have never had a clot. Nevertheless, when I fell pregnant the 5th time I was prescribed heparin which I have injected throughout this pregnancy and I am now 38 weeks pregnant. Like the previous poster, it was explained to me that pregnancy would increase my chances of a clot and any previous losses could have been down to clots formed in my placenta….I would definitely seek a second opinion on taking heparin and I wish you all the best on your continuing journey. Xx

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  • I am so sorry you’ve had to go through this. You and I transferred male PGS normal embryos about a week apart and I have thought of you often in the months that followed. I’ve had 2 prior miscarriages and I have anti-thrombin III deficiency. I have no history of clots, though my father has had a blood clot in his leg after an international flight. I was put on Fragmin for 28 weeks and may go on it for 6 weeks post-partum. My RE felt it wouldn’t hurt and said that the research regarding anti-thrombin III is not clear. I was subsequently transferred to an OB and a MFM who specialized in hematology who told me that she believes that anti-thrombin III deficiency does not have an impact on fetal development (including placenta, etc) but could be an issue for the mother during pregnancy due to increased chances of getting a clot, and this goes for shortly post-partum as well. So I was kept on it for my own well-being but they did not believe it had any benefit for the baby nor did they think it helped “keep me” pregnant. Through my own research I really couldn’t find a lot of negatives apart from bruising and potential calcium deficiency when used for long periods of time. But my calcium and platelets were monitored and were always in the normal range.

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    • I have not heard of Fragmin before but it sounds like Heparin. It seems like it may or may not help but does not hurt. I think I would feel much better taking an anticoagulant but neither my RE or obgyn think it’s necessary. I’m not sure how far I should push things. I think I would feel better if I could easily get pregnant but that’s not the case. If it ever happens again, I want to take every precaution possible. I am so glad things are working for you though! Thanks so much for your input.

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  • Interesting to hear that low papp-a can be linked to thrombosis, this was never mentioned to me… But sounds like the doctors don’t really like to treat for it anyway. If the medications that help this condition are not harmful, I say push for them. I’ve learned that you have to be your own advocate sometimes.

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    • Your dr probably didn’t mention it because it seems that most doctors not think they are linked. Mine doesn’t either but some do. You are so right that we have to be our biggest advocates!

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  • Hi Jennie, I had 2 miscarriages before I carried my twins to term. I tested positive for 2 auto-immune blood thickening issues (not sure if it was thrombosis, though that sounds familiar.). I was on BA before I got pregnant, and as soon as I found out I was pregnant again (After the 2 miscarriages), I started Lovenox right away, with baby aspirin for my 1st trimester. I went on Heparin at the end, and carried my twins til 37w1d, which is exactly what they wanted. Pregnancy was textbook. I don’t think starting lovenox should you become pregnant would hurt, and probably would give you some peace of mind! Miscarriages are so hard – blogging def. helped me get through mine. Praying you have a healthy pregnancy soon!

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    • I’m so glad it worked for you and I hope your twins are doing well 😄 It’s so helpful to have other people share their experiences. It gives me motivation to try to figure out what is going to work best for us. Thanks again!

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