HELLP (or pre-e) and subsequent miscarriage

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Expand view Topic review: HELLP (or pre-e) and subsequent miscarriage

Re: HELLP (or pre-e) and subsequent miscarriage

Post by Mari2013 » Thu Jan 09, 2014 11:12 am

Caryn, thank you. You are the best for typing all that out with a newborn. I am going to read the sources in depth later.

A couple of things stood out to me. First is the distinction between an autoimmune response and the immune response the way you described it. I thought the OB meant I had something like Lupus that was undiagnosed and causing me to have these complications. I was upset because I was tested for all of that right before this pregnancy, tests were fine, so not sure where the automimmune piece was coming in.

The other point I wonder about is if the Lovenox and LDA aspirin are relevant to this second stage of invasion. I will have to research that point. Just reading the description, I don't think so. And that would explain why they didn't make a difference with this pregnancy.

I also thought the information on pregnancy intervals was interesting. I have read about the two year interval helping with pre-eclampsia recurrence.

I was so focused on not getting pre-e and HELLP again that this loss has completely surprised and devastated me.

Re: HELLP (or pre-e) and subsequent miscarriage

Post by caryn » Wed Jan 08, 2014 09:16 am

You know, I'm just not sure what to think about chronic hypertension, either - because technically, I was considered an unmasked chronic due to the length of time my postpartum recovery lasted with Oscar. I was still 160/100 on the max dose of meds at my six week followup and was only able to wean off labetalol four-ish months postpartum, with bp that was borderline high for another year plus.

During my fourth pregnancy, my bp spiked immediately in the fifth week to ~130/85 from ~100/60, and I viewed that as likely an immune response to a foreign placenta. So I wasn't terribly surprised, just sad, when there was no heartbeat at week 16. And then in pregnancy number five, my bp was a steady ~100/60 through week 37…

Here's one of the publicly accessible recent papers on trophoblast invasion. It's ugly reading, very technical, but periodically there are sentences in normal English. :D

http://www.reproduction-online.org/cont ... 3.full.pdf

"Traditionally, a view has been held that a high-resistance pattern in the first trimester represents normal physiology and that it is only when women have a persisting high- resistance pattern beyond the second trimester that it becomes significant or pathological. This tied in with initial theories of two stages of trophoblast invasion and remodelling (Pijnenborg et al. 1983), with an early shallow wave in the first trimester followed by a second wave of deep trophoblast invasion in the second trimester that is completed by 18–20 weeks and leads to the conversion of the uteroplacental circulation into a low-resistance bed. This view has been questioned (Lyall 2002), with suggestion that remodelling progresses as a dynamic and continuous process, which will vary between individuals due to interacting fetal and maternal factors."

I lean "dynamic and continuous" - it's just that you see a point where invasion has begun to deepen into the myometrium sometime after about 10-12 weeks, and it's handy to call that "second-stage invasion." If that doesn't happen normally, the oxygen flow that the fetus needs to establish in the second trimester never really materializes - which is what I assume happened in my fourth pregnancy. (Beautiful first-tri ultrasound, genetically normal fetus.) That's an immune-mediated response, but that's not the same thing as an autoimmune response - and it can vary tremendously depending on the environment, and the environment includes things like how well-controlled your hypertension is, the genes in the placenta, and how recently you've been pregnant/ how exploitable bits of the uterine environment are.

It's a really tricky thing to predict or negotiate - I think of it as a targeting problem (embed juuuust deeply enough) coupled to an arms race (conflict between maternal and paternal genes over depth of embedment.) I got lucky. But we do now have some epidemiological data that suggest you can bias the odds in your favor with a shorter interpregnancy interval. I want to be completely clear that this will not always work - again, I got lucky. But it's a useful thing to know when you are making your decisions about subsequent pregnancies.

I also liked this abstract, but don't read Dutch and need to find a translator: http://www.ncbi.nlm.nih.gov/pubmed/24330800

"Many doctors still tell some patients that a (subsequent) pregnancy is contraindicated. Aside from the fact that the desire to have a (or another) child is often extremely strong, which often results in ignoring the message, this type of advice may have serious negative consequences… Women may postpone a subsequent pregnancy out of fear of preeclampsia, while this in fact increases the recurrence risk."

Re: HELLP (or pre-e) and subsequent miscarriage

Post by Mari2013 » Wed Jan 08, 2014 02:42 am

Caryn, congratulations on your daughter! Thank you so much for taking the time to respond. After the first pregnancy, I do have chronic hypertension that is well controlled with meds.

Whenever you have a chance, will you please share the link about the failure of the second stage arterial invasion? Again, thank you for sharing your experience.

Re: HELLP (or pre-e) and subsequent miscarriage

Post by caryn » Tue Jan 07, 2014 07:09 am

So, I'm the one with the new daughter delivered at 39 weeks after a couple 12 week miscarriages, a son delivered at 34 weeks after sPE, and a 16 week miscarriage (fetal loss in week 13.) I'm 2 for 5, and this last pregnancy was tightly monitored and very high risk, but we sailed through with only a few complications and none of them required early delivery.

I'm inclined to agree that the balance of evidence in your case suggests that your recent miscarriage was triggered by failure of second-stage arterial invasion, and that is often a result of maternal-fetal conflict over the depth of implantation of the placenta. That's the way I'd explain my most recent 16 week loss. But clearly I don't agree that means it's going to keep happening earlier every time and so you shouldn't get pregnant - first of all, what you *should* do is your decision to make, which will, of course, be informed by input from your care providers, and secondly, interpregnancy interval matters a lot in the absence of underlying medical conditions.

If you have no underlying conditions that have been diagnosed which predispose you to preeclampsia, like chronic hypertension or APS, then it's probably straight-up genetic arguing between you and your partner over how much blood you're going to allow the placenta to draw down. Or so the science is indicating at the moment. An area of the uterus that has recently been remodeled to support a foreign placenta is easier for subsequent placentas to exploit. My m/c was in January and I got pregnant again in April; my daughter was 8 pounds 10 ounces and we were actually worrying about things preeclamptics hardly ever worry about, like my bp dropping too low with the spinal, and whether or not she was macrosomic. My preliminary assumption is that this pregnancy went well because her placenta could jack right into my bloodstream effectively.

I've got links for most or all of this, but I've also got a nursing 1.5 week old so let me know what I can source for you!

Re: HELLP (or pre-e) and subsequent miscarriage

Post by Mari2013 » Sat Jan 04, 2014 08:01 am

Thanks Jen

Re: HELLP (or pre-e) and subsequent miscarriage

Post by jenh » Fri Jan 03, 2014 07:49 am

I can't speak to any specifics for your case, but I can share my own experience. I had severe PE and what I believe was undiagnosed HELLP at 35 weeks with my first child. I had a miscarriage with my second. My third was induced at 37 weeks with mild PE. My fourth was also lost to miscarriage. My fifth/sixth (twins) were born at 36 weeks with moderate PE. Miscarriages can happen to anyone and usually there isn't a known cause. However, many of the things that can predispose a woman to PE/HELLP also predispose to miscarriage. That doesn't mean, though, that you can't have a successful pregnancy.

Re: HELLP (or pre-e) and subsequent miscarriage

Post by Mari2013 » Fri Jan 03, 2014 03:18 am

Thank you, Diana. This discussion was with my OB. I was seeing a MFM during the pregnancy, but we did no follow-up after the miscarriage. I agree that OBs tend to be more conservative. My OB said she is more conservative in her advice than the MFM and RE ( who I also consulted pre- conception) because she is the only who actually has to take care of the patients when they get sick, whereas the specialists do not.

I had no unusual labs, BP, anything to indicate HELLP or pre-e. I had just done a 24 hour urine as a baseline a few weeks before the loss and everything was fine. Her opinion is based solely on the timing of the miscarriage and previous HELLP.

I am going to read about the second stage of the placenta that you mentioned. Thanks for that recommendation, your advice and the inspiring story. Glad to see your daughter is doing well!

Re: HELLP (or pre-e) and subsequent miscarriage

Post by lemons » Fri Jan 03, 2014 01:33 am

First, I am so sorry that you have lost your second child, especially after experiencing HELLP with your first..Just curious if you are seeing an OB or a Maternal Fetal Medicine (MFM) specialist? I believe that there is a second phase of placental invasion that happens at about the time of your miscarriage. Did your physician explain why she thought it was immune related and not a consequence of failed placentation due to another reason? And did you present with physical changes like higher BP, changes in protein excretion , or changes in liver or kidney labs (HELLP labs) during/after your miscarriage? I think I would want to consider all of this in deciding whether or not to consider another pregnancy. It is my personal experience that OBs tend to discourage another pregnancy while MFMs tend to talk about the realities of another pregnancy without giving their own opinion about whether to proceed with one. If you haven't discussed your situation with an MFM, I would highly recommend doing so.

To leave you with a bit of hope, one of our forum members just gave birth to a healthy, full term baby after having severe PE with her first, and a second trimester loss with her second. I will see if she has a minute to chime in.

Good luck in your search for answers and I hope you find peace with whatever decision you make.

Re: HELLP (or pre-e) and subsequent miscarriage

Post by Mari2013 » Fri Jan 03, 2014 07:02 am

Thanks, Lauren. No autoimmune issues showing up in my blood work. She is going by my history and the timing of the miscarriage

Re: HELLP (or pre-e) and subsequent miscarriage

Post by MomTimesThree » Fri Jan 03, 2014 12:13 am

I'm so sorry to hear of your miscarriage. Besides your history was there a specific reason she thought a autoimmune/placenta issue might be the cause? You might consider following up with the MFM again and reviewing things with them- although I'm guessing this was done already, but double checking that you were checked for autoimmune disorders.

Again, I'm so very sorry for your loss. I hope you receive answers that can help you chart the course ahead.
Lauren

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