by kbielec (254 Posts), Tue Jun 22, 2010 11:15 am
I met with my MFM yesterday to have a preconception consult. She was so helpful, and I appreciated her hour of time. Having said that I am more fearful, more concerned, more unsure about trying for another baby than I was before.
Going into the appointment I knew - I had lost my baby 2 years ago when I had HELLP at 25 weeks. And I knew that I had one gene (heterozygous) for Factor V Leiden
What I learned...
First my BP was 128/79 which she said is normal isn't that a little high?
I learned my 24 hour urine was GREAT three weeks ago and showed my liver and kidneys to be in good shape
I learned that during my ICU stay two years ago..."You lost very little blood with the Cesarean itself but your platelet count and other coagulation labs became quite abnormal (something called Disemminated Intravascular Coagulation or DIC) AFTER delivery, which can happen with HELLP syndrome. This led to the transfusion described" this once I looked up DIC was SCARY to say the least...
A pregnancy in 2000 was complicated by severe fetal growth restriction (FGR) at 27.4 weeks. She underwent an indicated cesarean delivery of a male infant weighing 615 grams, who has some physical and mental handicaps. The second pregnancy in 2008 was with a different (and current) husband. That pregnancy was complicated by severe and early FGR at 24 weeks, HELLP syndrome (AST as high as 1076) and laboratory evidence of DIC requiring transfusion with PRBC, cyroprecipitate and platelets. Of interest, uteroplacental blood flow was normal at 20 weeks suggesting normal placentation, but a creatinine clearance was abnormally low at 110 mL/min. According to Ms. Shriver, genetic screen results were normal. She delivered of a female infant weighing 400 grams, who died 2 weeks later from complications of extreme prematurity. Pathology report revealed a normal placental weight (158 grams) with focal infarction and fibrosis. Because the clinical presentation was strongly suggestive of antiphospholipid syndrome (acquired thrombophilia) or some inherited thrombophilia, appropriate testing was requested. These results were remarkable for heterozygosity for Factor V Leiden and MTHFR gene mutation (C677T). The former is of much more concern than the latter, which is seen in 40-50% of Caucasions.
Her past medical and surgical histories are otherwise unremarkable
And I learned...
We discussed the likelihood of recurrent preeclampsia and developed a management scheme for a future pregnancy. The recurrence rate may be as high as 20-40% but in her favor are two factors. 1) An underlying diagnosis that is potentially treatable has been identified (FVL heterozygosity) and 2) this pregnancy is fathered by the same man has her last. Below are summarized my recommendations for a future pregnancy:
1) Start folic acid 1 mg daily now
2) To start daily baby ASA and Lovenox 40 mg daily at conception
3) Early ultrasound for dating and viability
4) Patient will use home blood pressure cuff in future pregnancy and inform us of her home BPÃ¢â‚¬â„¢s
5) Baseline labs/24 hour urine in the first trimester
6) 12 week first trimester screening
7) Repeat labs /24 hour urine in second trimester
8) 18 week anatomic survey
9) Uterine Dopplers at 20-22 weeks though as these were normal in her second pregnancy would interpret with caution
10) Serial ultrasound/lab tests after 22 weeks, frequency to be dictated by circumstances but likely on Q2 week range.
11) APT starting in third trimester, dating to be determined by how pregnancy is going
12) If all going well would consider switch to unfractionated heparin at 36 weeks
13) Repeat CD at 39 weeks if all is optimal with low threshold to do earlier pending clinical situation
14) Will need LMWH for 6 weeks post-partum.
SORRY SO LONG...
I am no so much more unsure (ALTHOUGH I got the green light to try again from here)- it appears to the NON-medical student (me) that I have a lot of "issues"...and I don't know really what my chances are of being successful...guess I am just looking for some feed back from others that have been through this...
What is MTHFR and why did nobody tell me that came back positive for one gene 2 years ago?
I am so frustrated...and scared...and wanting a baby...(tears)...