CASE REPORT

1
CASE REPORT

• Triple therapy in recurrent aborter thrombophilic
  patient

Dr. Mohammed Abdalla Egypt, Domiat G. Hospital
2
10 Abortions ,10 DVTs the 11th,12th Pregnancies
Were Full Term
3

• Mrs. S. aged 29 years married 6 years ago with no
  living children .
•  
• When I examined her for the first time she had
  been experienced recurrent 10 abortions non
  exceeded 20 wk. gestation .BUT all of them were
  associated with femoral or iliac vein thrombosis
  .

the symptoms of DVT appear as early as 4 wk.
Gestation, they looked like a diagnostic symptom
of pregnancy.
4

• The case was diagnosed as primary anti
  phospholipid syndrome

( had a positive lupus anticoagulant test,
positive for anticardiolipin and prolonged
activated partial thromboplastin time (APTT) ).
APTT is an adequate screening test for lupus-like
anticoagulant antibodies (prolonged)
Protein c and protein s were not investigated.
5

• The family history was highly suggestive of
  thrombophilia as her father had recurrent
  episodes of DVT, and an episode of pulmonary
  embolism . till now he is on long term oral
  anticoagulant.

her sister at that time was not married yet (
but later when she conceived she developed DVT. )
she is also my patient.
6

• Low dose aspirin and 5000u /12 h sc.
  Unfractionated heparin was the prophylactic
  regimen once she got pregnant in most of previous
  pregnancies.

but unfortunately it did not guard against the
occurrence of DVT and fetal death .
7

• According to that frightening history she was
  advised never to get pregnant again. But she
  visited my clinic insisting to try another
  pregnancy risk.

(by her own words I want to be mother even for
one day).
8

• After proper counseling I advised ..

TRIPLE daily THERAPY once serum HCG get ve at 25
th . day cycle.

• low dose aspirin
• 20,000 u unfractionated heparin on three doses sc
  
• 30mg Prednisone on three doses/ calcium and iron
  preparations Rx were provided..

NB. LMWH was excluded for financial causes.
9
Follow up
APTT

• was done weekly for the first month and monthly
  for the rest of pregnancy. To be kept within the
  lower limit of the target therapeutic range

10
Follow up
Platelet count

• was assessed at the first week of therapy then
  every two months

11
Follow up
Glucose tolerance test

• was done at 10 wk. And 28 wk

12
Follow up
Routine antenatal visits

• Every two weeks assessing BP, HB, urine testing,
  wt. Gain. AND dose adjustment which was not
  needed.

13
Follow up
Ultrasonographic assessment

• At 10 wk 20 32wk revealed normal progressive
  growth, no congenital
• Anomalies , and good biophysical
• Profile

14
Follow up

• Superficial phlebothrombosis was marked all over
  the lower abdomen, flanks and lower limbs.

15
Labour

• At 37 wk. PROM occurred, so I stopped heparin and
  aspirin and CS was done after 12 hours.
• The fetus weighed 2,500 grams with good apgar
  scoor at 1 and 5 minutes .the placenta was of
  average wt. With multiple infarcts.
•  

16
Labour

• 12 hours post partum heparinisation was resumed
  in a prophylactic dose (5000u/12h) sc. With
  warfarin , after 5 days heparin was stopped and
  warfarin(5 mg/day ) continued . corticosteroid
  had been gradually withdrown over three weeks.

17
After 2 Years

• In spit of strict instructions of injectable
  contraceptive use ,she got pregnant again because
  she stopped contraception .
• The same protocol was applied again and an
  elective CS was done at 38 wk on a single viable
  fetus.
• She refused tubal ligation.

18
comment

• The immune system works by identifying proteins
  as normal or foreign
• Autoimmune response represents the immunologic
  response of the mother to a pregnancy (woman is
  rejecting her own proteins)

19
comment

• There are four different autoimmune problems that
  can cause recurrent abortion
• Antiphospholipid antibodies
• antithyroid antibodies
• Antinuclear antibodies
• Lupus-like anticoagulant

20
comment

• The antibodies themselves do not cause
  miscarriage, but their presence indicates that an
  abnormal autoimmune process will likely interrupt
  the ability of the phospholipids to do their job,
  putting the woman at risk for miscarriage, second
  trimester loss, intrauterine growth retardation
  (IUGR) and pre-eclampsia.

21
comment

• Heparin is administered to combat possible
  clotting problems.
• Prednisone is given to decrease autoantibody
  levels, provide blood-thinning and
  anti-inflammatory reactions, and reduce the risk
  of clotting.
• low dose Aspirin is a prostaglandin inhibitor
  which decreases agglutination of the platelets
  (clotting), and has some anti-inflammatory
  action.

22

• Thank you

Dr. Mohammed Abdalla Egypt, Domiat general
hospital