by expert on call (297 Posts), Tue Apr 22, 2003 10:06 am
This is a good question for which there is not any good evidence to support one or/over the other modalities.
First we need a bit more history:
1. Circumstances surrounding previous 13wk loss? were you quite sure about that being the actual week of pregnancy? Were there obvious problems with the baby?? (I presume this was her first loss, any previous successful pregnancies?)
2. Any personal or family history of venous thromboembolism?
3. Has she undergone (I presume yes by this point) testing for other thrombophilias & what were results?
Then we need to investigate her particular mutation. 11% of caucasians carry the AR MTHFR gene for hyperhomocyteinemia, which increases the risk of VTE 2-4x (Lockwood, 2002) How elevated are her fasting homocysteinie levels (mild/moderate/severe)? Which MTHFR mutations does she have (A/C)?
Treatment is a bit more controversial. There may or may not be a relationship between HHCemia & early pregnancy loss. I think putting her on folate, B6, & B12. (Vitamin E probably not harmful - especially if started @ <8wks but not certain of definite effect MTHFR). Heparin and low-dose Aspirin *may* improve birthweights but no conclusive evidence. Lockwood's flow charts for "lesser thrombophilias" advocate antepartum prophylactic heparin with history of adverse previous obstetrical event and postpartum if c-section or previous/family VTE.
I think you also need also consider the potential adverse effects of indiscriminate use of heparin (bleeding, thrombocytopenia, osteoporosis, 2x (or once with enoxaparin) daily injections) in situations of unproven benefit.
So to summarize, I think her physician is practicing good reasonable medicine at this point.
Expert on Call
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