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Interview l Desire to have a child in danger – miscarriage due to coagulation disorder

Miscarriages are still taboo in Germany; only a few women talk about them openly. Miscarriages are not uncommon and there are also many causes. If a woman has two or more consecutive "miscarriages, an unrecognized blood coagulation disorder could be the reason. We asked the coagulation expert Dr. Thomas Weikert what this means and what danger it poses. Robert Klamroth of Vivantes-Klinikum Friedrichshain asked.

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Dr. Klamroth, briefly and simply explained: What are coagulation disorders??

It can be that the blood clots too much, in which case – especially during pregnancy – there is a risk of developing thromboses. This is called thrombophilia. Due to weight gain, slower blood flow and hormonal changes, the blood of pregnant women generally tends to clot faster than usual.

However, the blood can also clot too little – this is called bleeding tendency.

The interlocutor

PD Robert Klamroth, MD (Image: Vivantes)

vivantes.en – Priv. Doz. Dr. med. Robert Klamroth

Chief Physician of the Clinic for Internal Medicine – Angiology and Hemostaseology
Center for Vascular Medicine
Hemophilia Center/Clotting Consultation Hour
Vivantes Clinic in Friedrichshain

Landsberger Allee 49
10249 Berlin

When does coagulation disorders pose a risk to pregnant women and their babies?

Not all clotting disorders that promote thrombosis also cause pregnancy complications and miscarriages. Even coagulation disorders that make the blood too thin do not necessarily lead to miscarriages.

This is what makes it so difficult: Only very specific clotting disorders are associated with a higher risk of miscarriage. At the same time, coagulation disorders that have already been diagnosed may sometimes have no effect at all on pregnancy, so that careful laboratory diagnostics are necessary.

This means: Only some coagulation disorders promote miscarriages. What are they and what happens in the body?

First, anything that happens before the eighth week usually has nothing to do with thrombophilia because no placenta has formed yet. These are mainly so-called genetic abortions: the fusion between the maternal and paternal chromosomes does not work and the pregnancy is terminated by the body.

From around the eighth week, micro-thromboses can occur in the placental vessels if a pregnant woman’s blood coagulates too much. Then the placenta is no longer supplied with blood properly and the embryo cannot be nourished. Among the disorders that cause the blood to clot too much, there is only one that can now be clearly said to cause miscarriages: That is antiphospholipid syndrome, or APS for short.

In contrast, women with an increased tendency to bleed – i.e. blood that is too thin – may not be able to attach the placenta properly, resulting in bleeding and therefore miscarriages.


Antiphospholipid syndrome (APS)

Antiphospholipid syndrome (APS) is one of the most common autoimmune diseases. Recurrent thromboses and frequent miscarriages may indicate APS. APS can occur alone or together with other autoimmune diseases such as lupus. In the laboratory, certain antibodies can be detected in APS – but the antibodies also occur in people with rheumatic diseases and healthy people, which makes the diagnosis more difficult.

When and how a coagulation disorder can be detected in pregnant women?

After two premature abortions, it makes sense to clarify a possible coagulation disorder as the cause. A simple blood test in the laboratory is sufficient, which gynecologists can also do themselves – however, gynecologists usually send patients to coagulation experts to ensure that the results are interpreted correctly.

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What medications can be considered for preventing miscarriage in cases of clotting disorders?

It depends and there is no panacea. For late pregnancy complications, can – z.B. in case of pre-eclampsia – acetysalicylic acid (ASA) is used to inhibit blood clotting.

Until ten years ago, it was thought that all clotting disorders could cause miscarriages and that the blood thinner heparin could reliably prevent miscarriages. Through studies we now know: this has been a fallacy. Heparin does not prevent abortions – except in antiphospholipid syndrome (APS).

Today, we use heparin mainly for thrombosis prophylaxis in women who have already had a thrombosis before their pregnancy or who are at high risk of thrombosis. The risk can be increased up to a hundredfold for these women during pregnancy.

Why is heparin still prescribed in some treatment centers to protect against miscarriage for women who have not been shown to have APS??

There have been small studies in the past in which treatment with heparin has been considered relatively promising – and some doctors still prescribe it for this reason.

The positive effect on the course of pregnancies attributed to heparin in old studies came from something else: We now know that a physician who is convinced that a drug works can have a therapeutic effect on the patient-without the drug itself having an effect on. Because patients have the feeling that the cause has been found and is being taken care of.

What really helps to minimize the risk of miscarriage?

The problem is that miscarriages can have many, very different causes. One must z.B. control the thyroid gland, gynecological and genetic changes – but the main cause of early miscarriages is the imperfect fusion of chromosomes and thus, unfortunately, often simply bad luck.

Basically, close and trustful monitoring of pregnant women is always very good to treat quickly and individually in case of complications.

What symptoms should a woman have to determine whether she has a bleeding tendency or a clotting disorder??

About the bleeding tendency: If a woman has more frequent bleeding, such as.B. If the mother has a nosebleed, bleeding gums, increased menstrual bleeding or bleeds for a longer period of time when she is injured, a blood clotting disorder should always be clarified so that she does not bleed to death – even completely independently of pregnancy. But this is rare.

The most common blood clotting disorder is Von Willebrand syndrome (VWS), but this is not associated with miscarriages.

Regarding thrombophilia
If the mother or father has had a thrombosis in the early years, the woman is also at increased risk of a clotting disorder. Then she should be alert and tell her gynecologist – not only before pregnancy, but also when it comes to which pill is suitable for hormonal contraception.


How bad are bruises?

"About 95 percent of the patients who come to me for increased hematoma formation have fragile vessels, i.e. increased vascular fragility – this has nothing to do with blood clotting. It is perfectly fine."

In such cases, should special tests be carried out before pregnancy??

If a woman already has a family history of increased risk of thrombosis, it makes sense to have her tested for this and to take thromboprophylaxis – because the risk of thrombosis in mothers is significantly increased, especially after giving birth.

As for the miscarriages, I would say no. Because the ASP is an acquired coagulation disorder. D.h. that needs a clinical event, such as a late miscarriage or multiple early miscarriages or thrombosis, as well as positive antibody detection twice at three-month intervals. The presence of antibodies alone does not mean that they have an effect on the course of pregnancy. Therefore, such a test would unnecessarily unsettle women in advance.

Info on the net

thelancet.com – Study: No protection by heparin in thrombophilia in pregnancy

Is there anything else you would like to share with our readers?

When you surf the Internet: Be critical, pay close attention to the sources and limit yourself to serious information.

If, for example, a woman writes in a forum that she has had three miscarriages, injected with heparin during the third pregnancy and everything worked out wonderfully as a result – this is unserious. In medicine, it is always dangerous to start from the individual case and, especially in forums, pregnant women quickly get scared or develop false hopes.

Thank you very much for the interview.
The interview was conducted by Ariane Bohm

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