Case Studies - LabMedicine

More documents

Recommendations

Info

Case Studies 5. The therapy of choice for women with thrombotic tendencies before and during pregnancy includes low dose aspirin and either unfractionated (UHF) or low molecular weight heparin (LMWH). 26-28 6. The prognosis for this patient is very good. Patients with RPL due to thrombotic tendencies that are treated with aspirin and heparin have a 72%–80% chance of having a successful pregnancy outcome. 28,29 Patient’s Treatment and Follow Up The patient’s hypothyroidism was well controlled with Synthroid. Bromocriptine was used to lower her prolactin level. She conceived spontaneously and due to her history of RPL and the Factor V Leiden mutation, she was placed on daily, low-dose aspirin and LMWH therapy. The aspirin therapy was discontinued early in the pregnancy due to vaginal bleeding. Her pregnancy was uneventful, and she recently delivered a healthy baby. Acknowledgements: The author wishes to express her appreciation to the patient and Dr. Tiffany VonWald for providing permission to access medical records and to the laboratory staff at the Center for Reproductive Medicine for their assistance with this case study. Keywords: recurrent pregnancy loss, thrombophilia, infertility, Factor V Leiden mutation, activated protein C resistance, thrombophilic gene mutations Table 1_Laboratory Findings Test Patient’s Result “Normal” Reference Range Lupus anticoagulant reflex PTT-LA(s) 36.2 0.0-50.0 seconds dRVVT(s) 38.5 0.0-44.5 seconds Phosphatidylserine antibodies IgM 13 0-25 MPS IgM IgG 4 0-11 GPS IgG APTT Mixing studies APTT 26.4 23.4-36.4 seconds APTT 1:1 normal plasma 26.1 23.4-36.4 seconds APTT 1:1 mix saline 28.4 0.0-37.0 seconds APTT 1:1 NP mix, 60 min. incubation 27.6 23.4-36.4 seconds APTT 1:1 mix NP incubation mix Ctl 28.3 23.4–36.4 seconds Anticardiolipin antibodies IgG
Case Studies 1. Practice Committee of the American Society for Reproductive Medicine. Definitions of infertility and recurrent pregnancy loss. Fertil Steril. 2008;89:1603. 2. Carp HJ. Recurrent miscarriage: Genetic factors and assessment of the embryo. IMAJ. 2008;10:229–231. 3. Migeon BR. Non-random X chromosome inactivation in mammalian cells. Cytogenet Cell Genet. 1998;80:142–148. 4. Porter TF, Scott JR. Evidence-based care of recurrent miscarriage. Best Pract Res Clin Obstet Gynaecol. 2005;19:85–101. 5. Abalovich M, Gutierrez S, Alcaraz G, et al. Overt and subclinical hypothyroidism complicating pregnancy. Thyroid. 2002;12:63–68. 6. Kalro BN. Impaired infertility caused by endocrine dysfunction in women. Endocrinol Metab Clin North Am. 2003;32:573–592. 7. Craig LB, Ke RW, Kutteh WH. Increased prevalence of insulin resistance in women with a history of recurrent pregnancy loss. Fertil Steril. 2002;78:487–490. 8. Hanson U, Persson B, Thunell S. Relationship between hemoglobin A1C in early type 1 (insulin dependent) diabetic pregnancy and the occurrence of spontaneous abortion and fetal malformation in Sweden. Dibetologia. 1990;33:100–104. 9. Szekeres-Bartho J, Balasch J. Progesterone therapy for recurrent pregnancy loss. Hum Reprod Update. 2008;14:27–35. 10. Lin PC. Reproductive outcomes in women with uterine anomalies. J Women Reprod Health. 2004;13:33–39. 11. Pihusch R, Buchholz T, Lohse P, et al. Thrombophilic gene mutations and recurrent spontaneous abortion: Prothrombin mutation increases the risk in the first trimester. AJRI. 2001;46;124–131. 12. Glueck CJ, Gogenini S, Munjal J, et al. Factor V Leiden mutation: A treatable etiology for sporadic and recurrent pregnancy loss. Fertil Steril. 2008;89:410– 416. 13. Ornoy A, Chen L, Silver RM, et al. Maternal autoimmune diseases and immunologically induced embryonic and fetoplacental damage. Birth Defects Res A Clin Mol Teratol. 2004;70:371–381. 14. Vinatier D, Dufour P, Cosson M, et al. Antiphospholipid syndrome and recurrent miscarriages. Eur J Obstet Gynecol Reprod Biol. 2001;96:37–50. 15. Raziel A, Kornberg Y, Friedler R, et al. Hypercoagulable thrombophilic defects and hyperhomocysteinemia in patients with recurrent pregnancy loss. AJRI. 2001;45:65–71. 16. Rai R, Backos M, Elgaddal S, et al. Factor V Leiden and recurrent miscarriageprospective outcome of untreated pregnancies. Hum Reprod. 2002;17:442– 445. 17. Grandone D, Margaglione M, Colaizzo D, et al. Factor V Leiden is associated with repeated and recurrent unexplained fetal losses. Thromb Haemost. 1997;77:822–24. 18. Dahlback B. Activated protein C resistance and thrombosis: Molecular mechanisms of hypercoagulable state due to FVR506Q mutation. Semin Thromb Hemost. 1999;25:273–289. 19. Hirahara U, Andoh N, Sawai K, et al. Hyperprolactinemic recurrent miscarriage and results of randomized bromocriptine treatment trials. Fertil Steril. 1998;70:246–252. 20. Davis LB, Leveko KJ, Cunningham FG. Hypothyroidism complicating pregnancy. Obstet Gynecol. 1988;72:108–112. 21. Haddow JE, Palomaki GE, Allan WC, et al. Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child. NEJM. 1999;341:549–555. 22. Clark P, Brennand J, Conkle JA, et al. Activated protein C sensitivity, protein C, protein S and coagulation in normal pregnancy. Thromb Haemost. 1998;79:1166–1170. 23. Goodman CS, Coulam CB, Jeyendran RS, et al. Which thrombophilic gene mutations are risk factors for recurrent pregnancy loss? Am J Reprod Immunol. 2006;56:230–236. 24. Pihusch R, Buchholz T, Lohse P, et al. Thrombophilic gene mutations and recurrent spontaneous abortion: Prothrombin mutation increases the risk in the first trimester. AJRI. 2001;46:124–131. 25. Unfried G, Griesmach A, Weismuller W, et al. The C677T polymorphism of the methylenetetrahydrofolate reductase gene and idiopathic recurrent miscarriage. Obstet Gynecol. 2002;99:614–619. 26. Badaway AM, Khiary M, Sherril, LS, et al. Low-molecular weight heparin in patients with recurrent early miscarriages of unknown aetiology. J Obstet Gynaecol. 2008;28:280–284. 27. Stephenson MD, Ballem PJ, Tsang P, et al. Treatment of antiphospholipid syndrome (APS) in pregnancy: A randomized pilot trial comparing low molecular weight heparin to unfractionated heparin. J Obstet Gynaecol Can. 2004;26:729–734. 28. Rai R, Cohen H, Dave M, et al. Randomized controlled trial of aspirin and aspirin plus heparin in pregnant women with recurrent miscarriage associated with phospholipid antibodies (or antiphospholipid antibodies). Br Med J. 1997;31:253–257. 29. Kutteh WH. Antiphospholipid antibody-associated recurrent pregnancy loss: Treatment with heparin and low-dose aspirin is superior to low dose aspirin alone. Am J Obstet Gynecol. 1996;174:1584–1589. 134 LABMEDICINE ■ Volume 41 Number 3 ■ March 2010 labmedicine.com
Page 1: Case Studies Recurrent Pregnancy Lo

Case Studies - LabMedicine

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?