Outcomes after first preg. w/sPE + deliv. before 34 weeks

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Outcomes after first preg. w/sPE + deliv. before 34 weeks

Postby caryn » Wed Jan 16, 2013 09:23 am

"The only risk factor for recurrent gestational vascular complications in subsequent pregnancy was a long time interval between two pregnancies, with an increased risk in case of delay beyond 26 months."

http://www.ncbi.nlm.nih.gov/pubmed/23313394

Oh look, there's the two-year window again! So the idea is this: the remodeling of the spiral arteries persists to some degree postpartum, and that remodeling makes implantation of subsequent placentas easier. This seems (anecdotally, and in several small studies like this one) to reduce risk of PE/HELLP and other placental bed disorders.
Science! The articles you don't want to miss:
The Preeclampsia Puzzle (New Yorker) and Silent Struggle: A New Theory of Pregnancy (New York Times)
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Caryn, @carynjrogers, who is not a doctor and who talks about science stuff *way* too much
DS Oscar born by emergent C-section at 34 weeks for fetal indicators, due to severe PE
DD Bridget born by C-section after water broke at 39 weeks after a healthy pregnancy
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Re: Outcomes after first preg. w/sPE + deliv. before 34 week

Postby LeosMom » Wed Jan 16, 2013 02:34 pm

Hi Caryn,

I'm so confused. Are you saying studies are showing you should have a subsequent pregnancy within two years to minimize risk of recurrence? Because we had consults with two different MFM teams about when to try again, and both advised us to wait two years before trying to conceive again to minimize risk of HELLP recurrence. So that's what we did.
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Re: Outcomes after first preg. w/sPE + deliv. before 34 week

Postby caryn » Wed Jan 16, 2013 04:55 pm

This (small) study showed a decrease in hypertensive disorders with conception before 26 months postpartum. That said, I agree with your docs in the case of HELLP - for complex reasons that I will try to explain sensibly. :D

All of these conditions seem to have different progressions and different triggers, but to share a common final pathway. It's beginning to look like some placental bed disorders (preeclampsia with IUGR and late miscarriage when the placenta doesn't take over at the end of the first trimester) are downstream from a shallow implantation caused by an immune response to a foreign placenta, and some placental bed disorders (HELLP or preeclampsia with a fetus that is large for dates) are downstream from an immune response to a foreign placenta that's demanding too much from the mother's metabolism. In either case you get a very annoyed maternal immune system and a lot of other symptoms in common.

So if this holds up: if you had HELLP, and a decent-sized kiddo, you *don't* want to conceive until some of the trophoblast that remodeled the spiral arteries supplying the uterus have died off, postpartum. But if you had PE with a small kiddo, you *do* want to conceive before that trophoblast has died off.

It's all a targeting problem to implant the placenta Just Right, not too hot or too cold. (Do you feel like Mama Bear yet?)
Science! The articles you don't want to miss:
The Preeclampsia Puzzle (New Yorker) and Silent Struggle: A New Theory of Pregnancy (New York Times)
Looking for recent articles and studies? Lectures from researchers?
A chance to participate in research? For us on Facebook or Twitter?

Caryn, @carynjrogers, who is not a doctor and who talks about science stuff *way* too much
DS Oscar born by emergent C-section at 34 weeks for fetal indicators, due to severe PE
DD Bridget born by C-section after water broke at 39 weeks after a healthy pregnancy
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Re: Outcomes after first preg. w/sPE + deliv. before 34 week

Postby midwestmom » Wed Jan 16, 2013 05:09 pm

Caryn,
First of all, I LOVE your descriptions of the complexities of PE. I read your message, and am trying to figure out which "camp" I would fall into - I delivered my son at 29+2 wks from severe PE but no HELLP but a "decent size kiddo" :-) no IUGR.
Thanks Caryn! Lauren :-)
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Son born by emergency C-section due to severe preeclampsia in August 2009. Born 29wks2days weighing 3lbs, he is a healthy toddler now.
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Re: Outcomes after first preg. w/sPE + deliv. before 34 week

Postby caryn » Wed Jan 16, 2013 05:34 pm

I also had a decent-sized kiddo with sPE at 34 weeks - and prior miscarriage. My guess there? My kid *would* have been a HELLP baby with a standard implantation - because he was metabolically demanding - but the placenta couldn't implant quite that well, because my immune system was cranky and kept it from doing so.

This syndrome is weird - but I think of it as a targeting problem coupled to an arms race. The race is between maternal and paternal strategies designed to control depth of implantation, and the targeting problem is getting just the right depth. At a conference this summer on this problem a lot of the researchers were saying that it might be the case that our predisposition towards some cancers might be a consequence of our need to tolerate invasive placentas to reproduce. So strange.
Science! The articles you don't want to miss:
The Preeclampsia Puzzle (New Yorker) and Silent Struggle: A New Theory of Pregnancy (New York Times)
Looking for recent articles and studies? Lectures from researchers?
A chance to participate in research? For us on Facebook or Twitter?

Caryn, @carynjrogers, who is not a doctor and who talks about science stuff *way* too much
DS Oscar born by emergent C-section at 34 weeks for fetal indicators, due to severe PE
DD Bridget born by C-section after water broke at 39 weeks after a healthy pregnancy
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Re: Outcomes after first preg. w/sPE + deliv. before 34 week

Postby LeosMom » Thu Jan 17, 2013 11:40 am

Thanks for the explanation Caryn! Unfortunately, I had HELLP with an IUGR baby (born 1 lb 15 oz at 29 weeks). So, I'm not sure where I fit in. Blargh, I hate this condition so much!
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Re: Outcomes after first preg. w/sPE + deliv. before 34 week

Postby caryn » Thu Jan 17, 2013 01:42 pm

We're not anywhere close to an exact science on this yet... :( There are something like 240 genetic networks involved, and all we've got at this point is guesses about strategies. The ways to protect the life and health of an IUGR baby are more robust than the ways to protect the life and health of both participants in a HELLP case, so if I were a doc and having to give my best advice on a strategy, I'd probably pick the same one they recommended, for what that's worth. I'm so not a doc, though, just a curious voracious reader.

This is just a really rough decision for anyone to have to make. Gentle good wishes to you and yours.
Science! The articles you don't want to miss:
The Preeclampsia Puzzle (New Yorker) and Silent Struggle: A New Theory of Pregnancy (New York Times)
Looking for recent articles and studies? Lectures from researchers?
A chance to participate in research? For us on Facebook or Twitter?

Caryn, @carynjrogers, who is not a doctor and who talks about science stuff *way* too much
DS Oscar born by emergent C-section at 34 weeks for fetal indicators, due to severe PE
DD Bridget born by C-section after water broke at 39 weeks after a healthy pregnancy
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Re: Outcomes after first preg. w/sPE + deliv. before 34 week

Postby angieb » Tue Jan 22, 2013 09:12 am

Hmm.

So would this change after multiple pregnancies? (Based on the theories), or would every pregnancy be the same/ "starting over"?
Me (29) DH (30)
#1-Olivia Caetlyn-9-28-09-9-28-09, 23+2 wks, emergency classic c-section, class I HELLP, IUGR
#2- Lucas Oliver (rainbow baby)- April 2011, 36+2 wks, HELLP and pre-e free! (lovenox and LDA pregnancy)
#3-Matthew, late October 2012...mostly normal, 37 wks, (lovenox and LDA again)
My blog: http://www.butterflies-and-rainbows.blogspot.com/
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Re: Outcomes after first preg. w/sPE + deliv. before 34 week

Postby jean » Sat Jan 26, 2013 09:06 am

I'm not sure if my first was a decent sized kiddo or not...he was behind in growth a week..born at 29 wks at 2lbs 1 oz.......then with my second he was decent sized, but was FT...so if we were to try for a third, would it still be best for us to try to get pg within 26 mos of the previous pg?
Our first son was born and passed in Feb of 2010. Born at 29 weeks due to HELLP and passed due to NEC. We miss him every day. :~(

Our second son was born at 39 weeks gestation in Nov of 2011. No HELLP or pre-e! Took LDA starting at week 12 and went off of it at week 38!

http://findingtherainbowconnection.blogspot.com/
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Re: Outcomes after first preg. w/sPE + deliv. before 34 week

Postby jean » Sat Jan 26, 2013 09:08 am

And when does the trophoblast die off? After 26 mos pp?
Our first son was born and passed in Feb of 2010. Born at 29 weeks due to HELLP and passed due to NEC. We miss him every day. :~(

Our second son was born at 39 weeks gestation in Nov of 2011. No HELLP or pre-e! Took LDA starting at week 12 and went off of it at week 38!

http://findingtherainbowconnection.blogspot.com/
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