Cautionary cases| expectant mothers with antiphospholipid syndrome, heparin should be discontinued with caution!

Ms. Zhang, 36 years old, because she was not pregnant for many years after marriage, went to the Third Hospital of Guangdong Medical University for examination in 2018 and found a variety of problems parallel to uterine mediastinal electrosection + endometrial polyp removal + ovarian cyst removal, hysteroscopy also found endometritis, and improved after treatment with "metronidazole". "Everything is available, only the East Wind is owed", Ms. Zhang confidently performed the first embryo transfer, the reproductive doctor selected the best high-quality embryos into Ms. Zhang's uterine cavity, but on the 14th day, the blood test results hit Xiao Zhang's confidence hard, and the HCG test results suggested that the embryos did not implant!

After resting for 2 months, Xiao Zhang regained confidence, walked into the reproductive department again, for the second embryo transfer, this time the reproductive doctor put Xiao Zhang into D5 frozen embryos 2, 14 days after the transfer HCG was 260mIU/ml, prompting the embryo to implant, but Ms. Zhang was both happy and nervous, because one of her girlfriends recently stopped at 10 weeks of pregnancy after the transplant, and found out that there was a problem with antiphospholipid antibodies, Xiao Zhang was also worried about his own problems in this regard, so Xiao Zhang came to the Rheumatology and Immunology Department for treatment.

The rheumatologist asked about Xiao Zhang's condition and found that two years ago, he began to have a recurrent canthanous rash in both eyes, with mouth ulcers, no arthralgia, dry mouth, dry eyes, photosensitivity, Raynaud's phenomenon, etc. The rheumatologist prescribes a series of examinations based on Xiao Zhang's condition. Eight items of humoral immunity: IgG 16.6 IU/ml; IgA 3.57 IU/ml; six antiphospholipid antibodies: anti-β2 glycoprotein I antibody IgA 21.10 SAU; protein C: 46.6% ;D-dimer: 725 mg/L; total vitamin D: 20.56 ng/ml; folic acid metabolism capacity: weak.

Therefore, the culprit of Xiao Zhang's years of infertility and transplant failure was found: anticardiolipin antibody syndrome (atypical).

Although Xiao Zhang's transferred embryos have been implanted, but antiphospholipid antibodies will also have an impact on the entire subsequent pregnancy, so the rheumatologist gave Xiao Kai the following program: hydroxychloroquine sulfate + low molecular weight heparin + prednisone acetate, because Xiao Zhang has been intermittent vaginal bleeding, so there is no aspirin treatment, when Xiao Zhang is 6 weeks pregnant, Xiao Zhang performs a super, found intrauterine twins, one of the embryos 23mm, but the embryo two 3mm, has stopped fertility, and also found uterine effusion, Rheumatologist gives timely adjustment of heparin dosage ... Until 11 weeks of pregnancy + when Xiao Zhang performed normal NT examination; but B ultrasound suggested that there was still a uterine effusion, and rechecking B ultrasound at 15 weeks of pregnancy showed that the uterine effusion continued to increase compared with before, and Xiao Zhang stopped using low molecular weight heparin; at 22 weeks gestation + obstetric examination, B ultrasound found that the embryo was stopped, and the grief-stricken Xiao Zhang underwent induction of labor with the comfort and help of his family and medical staff and spent the darkest days, and there was no obvious abnormality in fetal genetic testing after surgery.

1 year passed, Xiao Zhang appeared in the rheumatology and immunology department again, this time, Xiao Zhang decided to carry out a complete examination! Xiao Zhang told the doctor that in this 1 year, she kept reflecting on herself, causing the baby to stillbirth, mainly because she relaxed her vigilance, thinking that after 12 weeks there was nothing to do, in addition, she thought that the increase in uterine effusion was caused by heparin, so she decided to stop heparin, and after stopping heparin, she did not test in time, if the fetal situation was closely monitored at that time, it may be possible to find some manifestations of the baby's ischemia and hypoxia, and return heparin in time, perhaps this outcome will not occur!

The rheumatologist listened to Xiao Zhang say this and showed a relieved smile, "Next time I will definitely succeed in holding the baby!" Ms. Zhang experienced not being in bed, the big month of fetal stoppage, these lessons will become her future experience, the next pregnancy may still be all the way to the wind and rain, but after the wind and rain is a rainbow! I wish Ms. Zhang's mother's dream come true!

The lessons and experiences of our predecessors,

Will help us avoid disaster

Infertility is medically defined as not having taken any contraception for less than a year, having a normal sex life, and still not getting pregnant. It is mainly divided into primary infertility and secondary infertility. The incidence of infertility in women of childbearing age in China is about 10% to 15%. Factors such as heredity, infection, prethrombotic status, immune abnormalities, and endocrine disorders are correlated with infertility. Infertile patients may still suffer serious complications such as miscarriage, fetal arrest, and umbilical cord twisting after ivy.

Ms. Zhang in this case has a history of infertility, and has a history of embryo transfer failure, with elevated D dimer, decreased protein C, considering the presence of prethrombotic state, which is caused by a variety of factors caused by coagulation, anticoagulation, fibrinolytic system dysfunction, blood in a hypercoagulable state, can change the blood flow state at the uterine placenta, locally formed microthrombosis can induce placenta fibrosis and ischemic infarction, embryonic tissue hypoxia, affecting the normal development of the embryo, resulting in fetal arrest. Low molecular weight heparin is a commonly used anticoagulant drug in the clinic, but also because of its anticoagulant effect, there may be skin ecchymosis, vaginal bleeding, uterine effusion and other manifestations after medication, at this time, it must be distinguished from antiphospholipid antibodies or immune factors caused by vascular infarction after bleeding, after infarction bleeding not only can not stop heparin, but to give a small dose of heparin anticoagulation. Ms. Zhang stopped using heparin due to persistent uterine effusions in the first and second trimesters, and embryonic cessation occurred about 7 weeks after she stopped heparin, and there were no abnormalities in fetal genetic testing, and the reason for fetal cessation of infertility was not excluded from being related to the discontinuation of heparin.

Low molecular weight heparin can continuously inhibit thrombosis by inhibiting the activity of coagulation factor Xa, improve the hypercoagulability of the blood system, promote normal blood flow, regulate hormone levels in the body, improve local microcirculation of the placenta, promote the formation of local endometrial neovascularization, protect the function of local vascular endothelial cells in the uterus, thereby promoting the normal development of embryos, and has an important pregnancy protection effect on expectant mothers with antiphospholipid antibody syndrome, and easily stop heparin prematurely. It is easy to lead to an increase in the risk of fetal arrest and the incidence of adverse pregnancies.

For patients with repeated adverse pregnancies during pregnancy, there is antiphospholipid syndrome, thrombophilia and other hypercoagulable states, if in the process of using low molecular weight heparin, there is vaginal bleeding, uterine effusion, etc., when the amount of bleeding is not too much, there is no active bleeding, we can dynamically monitor platelets and coagulation function, D dimer, protein C, protein S, thromboelastogram and other indicators, can reduce the dose of low molecular weight heparin as appropriate, and closely observe the situation of uterine effusion or bleeding, it is not recommended to easily stop low molecular weight heparin. In addition, in the middle and third trimesters, it is also recommended to regularly monitor the above coagulation indicators, as well as embryonic /fetal B ultrasound, umbilical cord blood flow, etc., according to which the dose and course of low molecular weight heparin are adjusted, and it is not recommended to stop heparin prematurely, so as to avoid adverse conditions such as fetal growth restriction and fetal suspension in the third trimester of pregnancy, and finally to obtain a better pregnancy outcome.

Source: Rouji Immunity