IUGR

Since I'm making this blog public again, it's time for an update. I want to post a few things about my last pregnancy (2nd one on lovenox). There were many similarities to my 1st lovenox pregnancy. Namely, the anti-coagulant protocol was the same (daily shot of 40 ml lovenox from confirmation of pregnancy until switched to heparin 2x/day shots near delivery + 81mg aspirin until 35 wks.) I had subchorionic hemorrhages (aka SCHs) in both pregnancies that thankfully resolved themselves eventually. Also, there was still a lot of monitoring of the pregnancy including weekly bio-physical profiles in the 3rd trimester. Just like last time, baby was malpositioned, likely due to my large (12 cm) uterine fibroid. Thankfully, this baby followed her sister's example and turned on her own just before the scheduled external cephalic version, so I was able to be induced and deliver vaginally. It was a wonderful birth. We are so lucky to have our little miracles. Some differences: 1- My MFM moved out of state. The new one was kind and competent, but definitely had a different approach to FVL. He told me at the 1st consultation that he generally subscribes to the ACOG's recommendation that only women with prior clots be treated with injectable bloodthinners in pregnancy. I strongly advocated for treatment with lovenox. (I have a law degree and am emotionally invested, so you can use your imagination here on how difficult I was to convince that my history of recurrent pregnancy loss does not indicate treatment!) When I started citing studies on RPL and genetic thrombophilias, he realized that I was an educated patient and had good reasons not to follow ACOG's recommendations. 2- In part because of the change in MFM and partly because of a lab mix up my first time on lovenox, my anti-factor Xa levels were not checked this pregnancy. We just assumed the dose was adequate last time and continued with that. But in retrospect, perhaps I should have insisted on that again because there was was evidence that it wasn't optimal. 3- The baby's growth slowed significantly as we approached term. Her estimated weight was only in the 10%. (She had measured 50% earlier-- perfectly normal). Her femur length was still average, but her abdominal circumference was only 2.3 percentile. These measurement qualified as Intrauterine Growth Restriction (IUGR). The asymmetrically small abdomen can indicate placental insufficiency. Indeed, when I delivered the OB commented on how small her placenta was. I haven't found any studies linking clotting with a small placenta, but I have read some speculation on this. Thankfully, she has been busy catching up on her growth since birth. She is a joy and we are thankful we decided to try again. She weighed 5lb11oz at birth. 25 percentile for weight at 2 months. She is sweet, healthy & happy.

Kick counts

Tracking your baby's movements at approximately the same time every day is an inexpensive, non-invasive, effective way to monitor your baby's well being. It can potentially catch a problem before it affects the baby's heart rate. Kick counts are generally recommended for mothers starting at 28 wks. Mothers with high-risk pregnancies are admonished to start them at 24-26 wks. Here's a site with more information. And here's a convenient chart for recording your kick counts.

Many doctors will also do regular Biophysical profiles at the end of a high-risk pregnancy to check baby's movements, heart rate & responsiveness.

But for daily assurrance that baby is doing well, a kick count can be more informative than a doppler heart monitor. And what tired pregnant mom doesn't want a good reason to lie down for a bit & bond with her baby?

When to try again?

If you've had a previous loss, this question will arise and there are really two aspects to it: medically necessity and emotional readiness.

Medically, opinions vary. Research studies are conflicting. At a minimum, you should have one normal period before trying again. This helps date the next pregnancy more accurately and allows for normal buildup of the uterine lining. Generally, a longer wait is recommended for later losses. Some doctors recommend one month wait for each month along you were with the previous loss. This seems like a reasonable rule of thumb except that couples with stillbirths have a very long & difficult wait. (Though their grieving will undoubtedly be long & difficult no matter what, 9 months may be longer than truly necessary.)
Most readers of this blog will have a reason for their loss, but if you don't, it may take several months to complete testing so you know if there is anything that can prevent a recurrence. I strongly recommend testing if you've had multiple losses or even one loss after 12 weeks.

Emotionally, circumstances vary. You may feel ready at a different time than someone else with a loss- even at a different time than your spouse. I don't recommend waiting until "you are done grieving" or you may never try again. But it is often beneficial to give yourself a little time to start grieving the baby you lost before embarking on the very emotional quest for another. It takes time before the shock of the loss wears off and you genuinely start to process and grieve.

With a difficult history, you may wonder if you should EVER try again. Doctors, relatives, and friends will all have their opinions on this, but really it is something only YOU AND YOUR SPOUSE can decide. Talk together and chose together what's best for your family.

After 3 miscarriages, I talked to a woman who'd had 8 (she was now a grandmother & had to suffer through the losses before testing and treatment were available). I was in awe at her courage and tenacity. But I wondered...could I handle 3 more miscarriages? Could I handle 8 total miscarriages? How much heartbreak can you take? Then I decided I didn't have to determine beforehand my breaking point. We decided to take things one step at a time. We felt ready to try ONCE more and braced ourselves for the possibility of 1 more loss, while hoping of course for 1 more success. (Ok, my husband was hoping we'd concieve twins, so I guess he was hoping for 2 more successes at once!) But determining to not determine too much at once was helpful in gathering the courage to try again.

One baby doesn't replace another, but children do bring joy into your life. Though our miracle baby isn't in our arms yet, she's already brought joy to our hearts & we are glad we tried again.

Frequently asked questions

Q: What is Factor V Leiden?

Factor V Leiden (FVL) is a genetic mutation that makes you more prone to have blood clots. It is not all that uncommon in caucasians (between 5-15% of the population may have it) but it does not generally cause problems so most people who have it are unaware. It's usually discovered if a person or a close family member has deep vein thrombosis (DVT) or late or recurrent pregnancy loss.

Q: What health implications are there for those with FVL?

You should reduce your risk of forming clots by working on the risk factors that can be changed. You should not smoke, should exercise regularly & watch your weight. You should never take hormone supplements (birth control or hormone replacement therapies) that contain estrogen. If you are traveling or otherwise sitting for long periods of time, you should periodically take breaks to move around as much as possible. You should notify your doctor if you ever have surgery so you can be treated prophylactically with blood thinners. It is important to always stay well hydrated.

Q: Does FVL only affect women?

No, men are just as likely as women to have the mutation. However, many women are diagnosed in connection with a pregnancy because pregnancy is a hypercoagulative state. The body forms clots more easily when pregnant as a natural protection against hemorrhage.

Q: What is the treatment for FVL in pregnancy?

Many women with FVL have healthy pregnancies without treatment (I had 3 full-term babies before I had multiple miscarriages & testing). However, for those with a history of clots or pregnancy loss, most doctors recommend low-dose aspirin therapy and/or daily injections of heparin or lovenox. For patients without a history of clots or pregnancy loss who test positive for the mutation after a family member is diagnosed may be advised to take low dose aspirin, but opinions vary.

Q: I've heard pregnant women aren't supposed to take aspirin?

Generally they are not. Aspirin is a blood thinner and can cause bleeding problems. But, for pregnant women with FVL who clot too much, blood thinners help return the body to a state of equilibrium. Women should not take aspirin to prevent miscarriage unless their doctor has diagnosed or strongly suspects (due to late or recurrent pregnancy loss) that there is a clotting issue.

Q: How is FVL diagnosed?

Specific blood tests can reveal this mutation. FVL is also known as "Activated Protein C resistance". You doctor may simply order the APC resistance test or may order DNA analysis. The DNA test is slightly more accurate (about 2% of APC resistance is not caused by genes) but takes slightly longer to receive results (usually 7-10 day wait).