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

[caryn]

"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.

[LeosMom]

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.

[caryn]

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.

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?)

[midwestmom]

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

[caryn]

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.

[LeosMom]

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!

[caryn]

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.

[angieb]

Hmm.

So would this change after multiple pregnancies? (Based on the theories), or would every pregnancy be the same/ "starting over"?

[jean]

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?

[jean]

And when does the trophoblast die off? After 26 mos pp?