anticoagulants, thrombophila, preeclampsia

[expert@preeclampsia.org]

Hello. My husband and I are currently trying to decide whether to have another baby, but I had a complicated first pregnancy.

My first pregnancy was spontaneous, and I was 33. The pregnancy was very normal and I had a 25 week appointment with my OB with normal blood pressure/ no protein in my urine. Around 27 weeks I started to have some swelling and at 27 weeks 5 days I felt odd and had my blood pressure tested (and headed to the hospital). When I was admitted it was about 170/90 and I believe my protein was 3+ but it may have been 4+. I was very close to convulsions but my condition came quickly under control with magnesium sulfate. I had my daughter 4 days later at 28 weeks 2 days, by classical caesarean as my liver function test started to go off slightly. She weighed 830 grams (SGA/ IUGR) with no other major problems. My blood pressure peaked the week after at 225/115.

About 2 weeks after the birth I developed severe back pain. I've had 2 back injuries in the past so thought nothing of it, finally going to the hospital approx 5 days later. I was diagnosed with multiple pulmonary emboli (on both sides) and went on anticoagulants for 6+ months. I have been off the medication for 7 months without no recurrence. Upon my referral to a haematologist, genetic testing was done and it was discovered that I have heterozygous prothrombin variant G20210A.

My grandmother lost a baby at approx the same gestation after she went into convulsions due to eclampsia. She went on to have a earlier miscarriage and 2 normal pregnancies. My mother did not have any issues with her pregnancies (3) other than some early labour (real labour, not false) that stopped in each case. We were also a bit small but she was a smoker. However, she has a cousin (my grandmother's nephew) who has had an unexplained clot, so it appears that the prothrombin variant did indeed come from that side of the family, which means that she probably has it too.

I am now 35.

Needless to say I have a lot of questions that I want answered before we make a decision. Many of them will need to be directed to my haematologist. But I would appreciate it if you would consider the following:

I have been told that in a future pregnancy I will definitely need to be anticoagulated. The last time I was initially on enoxoparin, so I assume that will be the drug, but I am unsure. I have also been told that there are some studies that a) associate thrombophilias with pre-eclampsia and other pregnancy issues and b) that anticoagulants may help to mitigate the risk. I am interested to hear your assessment of these studies and your opinion as to whether the fact that I would be on anticoagulants would be likely to make any difference.

Also, I am a bit confused about my baby being born SGA. She was symmetrical SGA (or I believe so as she was 3rd percentile for head, length and weight). I understand from a book that I own on preemies that babies born symmetrical SGA have usually been under stress for a long time. However, 2 ½ weeks prior to my admittance to hospital, there were no signs of preeclampsia. Is it possible that I could have been suffering the effects without the outward symptoms, or could there have been something else happening here?

Thanks very much for your help.

[expert@preeclampsia.org]

There are a number of complex issues regarding your last pregnancy and a future pregnancy. Some answers are straightforward - others are not.

1) You are definitely at risk for preeclampsia in a subsequent pregnancy. Some studies would suggest the risk is as high as a 20% chance of preeclampsia with a delivery at < 32 weeks. Prior to pregnancy we evaluate women for cardiovascular risks: hypertension and prehypertension (and treat to achieve normal BP), proteinuria (and treat to reduce), hyperlipidemia (and treat), autoimmune disease, diabetes, thyroid disease. Approaches to a future pregnancy vary a great deal between practicioners.

2) You are definitely at risk for thromboembolic disease with your next pregnancy. Pulmonary emboli are life threatening. You should definitely be anticoagulated during pregnancy (Lovenox or unfractionated heparin titrated to achieve therapeutic levels). You should check with your insurance company prior to pregnancy to check on coverage for Lovenox - it is expensive. We usually switch to coumadin postpartum (6 to 8 weeks): no shots, cheaper, easier to monitor and safe for breast feeding.

3) Will treatment with Lovenox reduce your risk for preeclampsia and IUGR to that of a woman who has never had preeclampsia? - probably not. You clotting disorder may have worsened your preeclampsia, but it is probably not the complete cause. You need to be anticoagulated to reduce your risk of a pulmonary embolus - so it is not important in deciding to be anticoagulated to weigh the benefits for the pregnancy. Lovenox should not be expected to be a magic bullet that makes your pregnancy risk free - but it may make it better. Studies are very limited.

Yes, preeclampsia and placental injury are present with the disease long before it is clinically evident.