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Thread: Questions about conceiving with anticardiolipin antibodies

  1. #1
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    Default Questions about conceiving with anticardiolipin antibodies

    Hello,

    I am 40 and have one 4yo who was born with no complications. Before her birth, I had one m/c around 9 weeks (growth stopped around 6 weeks) and since then, I have had two more losses, for a total of 3 miscarriages. For each loss, growth stopped at or before 6 weeks. My mw did b/w which came back ANA+ and + for anticardiolipin antibodies (Anticardiolipin Ab, IgM, Qn Result: 87). Referred to rheumatologist who did b/w and f/u b/w 6 months later. At the 6 mo check, I was neg. for ANA and my anticardiolipin antibodies were down 30% (Result: 56). I just went in for another 6 mo. b/w check (1 year from diagnosis) and am awaiting results. The rheumatologist checked for numerous things as well, and this is the only thing that came back atypical (and the ANA came back negative 6 months later).

    The rheumatologist did not think that the antibodies were what caused my m/c's, saying that normally the antibodies attack the placenta in the 2nd tri and that more likely, my losses were the result of my age (34, 38 and 39 at time of losses). He said that my numbers were so low that he wasn't sure if the benefits would outweigh the risks of treating with lovenox.

    However, my OB said that I were to be able to conceive again, I would need to be on lovenox because the antibodies are present. He is not a high risk OB and only treats with lovenox about 3x/year. My mw originally told me that when she has this show up, the client often opts to go to a high risk OB. I am not sure if that is warranted in my case.

    In line with the above, I have a few questions, please, assuming I am able to conceive again:

    1. What is normal protocol for beginning tx with lovenox? My dr. said they would not start it until we heard the hb at 6 weeks and that the antibodies have little to do with the pregnancy up to that point. I asked about taking a baby aspirin and he said that I could, but didn't seem to think it would make that big a difference up to that point. I hear very conflicting ideas on when lovenox treatment begins from other women being treated; perhaps it does have to do with their specific situation.

    3. How significant is the increased risk of hemorraging while on lovenox?

    4. What prenatal vitamin works well with lovenox? Should I be careful to avoid vitamin K? To avoid dark, leafy greens?

    5. Is it recommended to combine fish oil with lovenox since fish oil also thins the blood?

    6. Do levels of antibodies correspond to a certain dosage of lovenox?

    7. Lastly, do you know of any connection to these antibodies to high estrogen? I read a study that said when mice were injected with high estrogen levels, they developed anticardiolipin antibodies.

    8. Also, is there any connection to these antibodies being more common in the 30+ age group? I.e. they seem to develop with age? Or is it that more older women are being tested?

    Thanks for any help you can provide....

  2. #2
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    1. We usually treat with lovenox beginning with hte first postitive pregnancy test.
    3. Risk of hemorrage with lovenox is low especially with the prophyllactic doses used. If bleeding does occur ist is usally not as a result of the lovenox but rather the result of the reason loveonx was prescribed.
    4. Any regualr prenatal vitiamin is fine.
    5. We usually do not recommend fish oil for treatment fo antiphospholippid antibodies.
    6. We follow th antibodiy titers dudring the pregnancy and treat accordingly.
    7. Other than the fact that antiphospholipid antibodies are more common in women that in men, the is no association between estrogen levels and antiphospholipid antibodies.
    8. There si no association between andtiphospholipid antibodies and age.
    Dr. Coulam

  3. #3
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    Thank you so much for taking the time to respond. I have an appointment with a HR OB in a few weeks and it is invaluable to have as many perspectives as possible before coming to a decision.

    Thanks again!

  4. #4
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    You are welcome. Dr. Coulam

  5. #5
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    Hello again,

    I had an appointment with a HR OB today who said that since my IgG was <6 and my IgM was the only thing elevated at 88 (IgA was also <6), that there is NO association between IgM anticardiolipin antibodies and pregnancy loss and that he would not recommend treatment with lovenox. He said that ONLY IgG anticardiolpin antibodies were associated with pregnancy loss as IgM antibodies do not affect the placental barrier (as IgG antibodies do).

    My original labwork from Quest Diagnostics from 12/24/2008 (initial diagnosis) says at the bottom:

    "Anti Cardiolipin Abs, IgM: The Antiphospholipid Antibody Symdrome (APS) is a clinical-pathologic correlation that includes a clinical event.....pregnancy loss.... and persistent positive Antiphospholipid Antibodies (IgM or IgG ACA >40 MPL/GPL, IgM or IgG anti-B2GPI antibodies, or a Lupus Anticoagulant....."

    I also found this information, specifically question #46 on this link: http://www.apsfa.org/faq/faq5.htm

    I will say that neither the rheumatologist nor the regular OB suggested that IgM was less problematic for pregnancies. In fact, the OB I had spoken to previously said he would put me on lovenox if I became pregnant.

    Very generally speaking, on various forums, I see that often high IgM numbers are treated with 1xday baby aspirin, if not lovenox.

    Needless to say, I'm confused. Can you shed any light on this?


    Thanks so much!

  6. #6
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    We usually treat IgM APA the same as IgG APA. Dr. Coulam

  7. #7
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    Wow. Thanks. This HR OB was supremely confident that he was correct that IgM Anticardiolipin antibodies would not affect a pregnancy. I said, "So this means that I do NOT have sticky blood? And that I do NOT have an immunological issue?" And he said, "Correct." This was the last thing that I anticipated hearing from him.

    He began by explaining how the IgG antibodies attack the placenta and can cause eventual fetal demise. But then said that I don't have that particular problem.

    However, I understand from reading Lesley Regan's work, as well as the book Coming To Term by Jon Cohen (who also references Dr. Regan's work) that there is some evidence that the way APAs affect pregnancy is by the body's immunological rejection of the trophoblast and embryo at the time of implantation. And that some of the issues that result in later losses are actually the result of a problem that began way back when the embryo implanted incorrectly.

    This makes sense to me since APAs are autoimmune in nature. (And the embryo is implanting into a surface that is rich in a layer of blood that has these antibodies, right?) And it makes sense that if you are going to do lovenox, that it should start right at implantation -- I have even read of some whose doctors start it at ovulation.

    However, this clinic, when they do treat with lovenox, normally begin it at 6 weeks when you first hear the heartbeat. That's also what my original OB said he would do. It seems to me that for some of us, that might be too late to help with implantation and may be the reason that lovenox doesn't prevent some losses, i.e. perhaps it is started too late. I also think it is at least worth noting that all three of my losses occurred before we ever heard the heartbeat.

    Do you feel APAs are more likely to attack the implantation process or to cause clots in the eventual placenta?

    And is there any way to find a provider, some bank of doctors with the same line of thought, who approaches this issue similarly? Based on this information, I don't feel comfortable not having this condition treated during pregnancy, or at best only starting Lovenox around 6 weeks.

    Thank you again so much for your time.

  8. #8
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    APAs work through both inflammatory and clotting mechanisms. It appears the implantation failure is more through the inflammatory pathway and miscarriages more through the clottting pathway. Starting lovenos at 6 weeks will help to prevent the clotting problems. Dr. Coulam

  9. #9
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    A big thank you for your insight -- it has been tremendously helpful!

  10. #10
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    You a re welcome. Dr. Coulam

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