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Low dose aspirin and low-molecular-weight heparin in the treatment of pregnant Libyan women with recurrent miscarriage

– Reported, May 22, 2014

Recurrent pregnancy loss is a major women’s health issue; 1% to 2% of women of reproductive age have experienced three or more successive pregnancy losses, and approximately 5% have lost at least two successive pregnancies. A small proportion of these losses are associated with identifiable causes in the mother or fetus, but the underlying cause in most cases of recurrent pregnancy loss remains unknown. There is evidence to suggest that successful pregnancy outcome depends on the development and maintenance of adequate utero-placental circulation, and that the hypercoagulability associated with thrombophilia might result in recurrent miscarriages. However, there is no clear consensus on what constitutes appropriate thrombophilia testing or, indeed, a standardized laboratory method for thrombophilia assessment.

Heparin has been shown to have potentially beneficial effects on trophoblast implantation and influence trophoblast apoptosis. To be beneficial, heparin may need to be given at the time of implantation. LMWHs are administered subcutaneously once a day. They have considerable theoretical benefit over unfractionated heparin (UFH) including better bioavailability, a longer plasma half-life, more predictable pharmacokinetics and pharmacodynamics, and less potential to cause osteoporosis. LMWH is also less likely to induce thrombocytopenia. LMWH inhibits factor Xa more effectively than factor IIa to produce its antithrombotic effect. LMWH does not cross the placenta and is safe for the fetus.

Aspirin is increasingly used to reduce the risk of miscarriage and improve pregnancy outcome in women who have suffered recurrent miscarriage. An important factor controlling tissue perfusion is the equilibrium between thromboxane A2 (in addition to its platelet aggregating properties, it also has a vasoconstrictor effect) and prostacyclin (has vasodilatory properties). The daily administration of LDA induces a shift in the balance away from thromboxane A2 and towards prostacyclin, leading to vasodilatation and enhanced blood flow.

A combination of LDA and LMWH leads to a significantly lower rate of miscarriages and higher rate of live births in pregnant women with a history of recurrent miscarriages than does LDA treatment alone. These findings are comparable with those of previous studies, which also concluded that the combination of heparin and aspirin is superior to aspirin alone in achieving higher rates of live births. Another recent study also concluded that the use of LMWH is a safe and reliable treatment resulting in a high live birth rate and no maternal or fetal complications.

However, other measures that these women received, such as strict follow-up of all women, might have also affected the results because close follow-up has been reported to have a significant beneficial effect on pregnancy outcome in women with a history of recurrent miscarriages. The combination of LDA and LMWH is better than LDA alone for the maintenance of pregnancy in patients with recurrent first trimester miscarriages.

CREDITS:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3892062/
Mohamed O Elmahashi, Aisha M Elbareg, Fathi M Essadi, Bashur M Ashur, and Ishag Adam

 

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