hypercoagulable state during pregnancy

Hi there,

I was wondering whether anyone might have any information about hypercoagulability (blood clotting disorders) during pregnancy, as it regards to Beta Thalassemia Minor?

I am a Beta Thalassemia Minor who recently lost my fourth out of five pregnancies. (I have one living child, also a carrier of Beta Thal.) My first three losses were first-trimester miscarriages, cause unknown. The last was a stillbirth at almost 24 weeks gestation due to severe placental complications. We recently received the placental pathology report from that pregnancy which indicated severe placental abruption and a massive subchorionic hematoma. Now my doctors suspect that I may have some sort of clotting disorder leading to a hypercoagulable state during pregnancy. Hopefully further testing (scheduled for Monday) will reveal some answers. 

I've done a little bit of research on this and found a definite connection between Thalassemia and hypercoagulability. However, so far the evidence seems to support a link only with Thalassemia Major and Intermedia. Does anyone have any knowledge of a link between hypercoagulability during pregnancy (or otherwise) with Thalassemia Minor?

Any information is greatly appreciated.

Thanks!
Elaine

Hi Elaine,

As you said, there is a definite connection between hypercoagulability (a blood-clotting disorder) and thalassemia major and intermedia. Your experience, and it's not the first time I've heard of minors having miscarriages, suggests that it can also happen in minors. My feeling is that many problems that affect majors also affect minors to a lesser degree. We have had too many reports from minors to believe that it is always a condition without symptoms. However, very little study has been done of anything regarding the health of minors, so we are often left to speculate as to what the minor condition really means. It is apparent that the amount of deletion of the hemoglobin gene is a factor in how severe symptoms are in thalassemia minor through major. Some minors have problems serious enough to be classified intermedia, so there is no one definition of minor that fits all cases.

It has been observed that the incidence of hypercoagulability is lessened in transfused patients. it is believed that this is higher in non-transfused patients and under-transfused patients because they have more circulating damaged RBCs and increased platelet counts.

Since the doctor made this discovery has he suggested blood thinners? There is a very technical article about hypercoagulability and thalassemia at http://www.bloodjournal.org/cgi/content/full/99/1/36

It is noteworthy that some thalassemic patients responded to treatment with platelet inhibitor drugs (aspirin and dipyridamole)

This article also has me wondering if transfusing during pregnancy might be of some help.

I would also suggest that if you do not already take them, that you should be supplementing with both Folic Acid and Vitamin E. These are both now standard recommendations for thal patients and more and more doctors are realizing the importance of Vitamin E supplementation in thalassemia. 400-600 iu natural Vitamin E complex and 250-1000micrograms (1mg) of Folic Acid are recommended. In addition to its anti-oxidant properties, Vitamin E is also a mild blood thinner and may have some use in preventing clotting.

Do we have any other minors in the group who have had a similar problem with pregnancies ending prematurely?

Thank you very much for your reply, Andy. I've seen that same article you referenced already, and though it only gives evidence for a hypercoagulation problem in Major and Intermedia, it's what really made me wonder about a possible link for Minors also.

I actually started wondering about a connection between the Thalassemia trait and miscarriage almost four years ago when I lost my first pregnancy. At that time, my obstetrician said there was no reason to believe they were related, and a general Internet search of "Thalassemia and miscarriage" didn't produce any relevant information.

Now that I've suffered four losses, we have reason to believe that my complications are related more specifically to a blood clotting issue, so of course I immediately wondered whether there might be a connection to my Thalassemia carrier state. A more specific Internet search of "Thalassemia and hypercoagulable state" yielded some interesting hits, especially the article you referenced.

I'm still awaiting my results from the thrombophilia testing, but I will be sure to bring the possible Thalassemia link up with my perinatologist (high-risk pregnancy specialist), and may try to get in touch with a hematologist as well. Whether they find I have a specific blood clotting mutation or not, my doctors want me to take anti-coagulants during my next pregnancy as a precautionary measure.

I'll update here if anything interesting comes of it, and I'd still love to hear from others who might have any experience with this.

Thank you very much for these informative posts and for sharing this information. I know these were posted last year but I just wanted to add a little and see if anyone has any comments or suggestions for me.
I am 22 and have had 4 miscarriages since I got married two years ago. I don't smoke, use drugs, etc. In short, I have always been very health, hardly even a cold in the winter. I have recently had some blood work done for the first time ever. I have not been able to talk to my doctor yet (I have an appointment in two weeks) but my sister who is a nurse thinks the blood work may be showing signs of Talassemia. Here is the pertinent info from the lab report:
WBC 4.4 (normal)
RBC 5.45 (high)
Hemoglobin 12.6 (normal)
Hematocrit 40.3 (normal)
MCV 74 (low)
MCH 23.2 (Low)
MCHC 31.3 (low)
RDW 23.1 (high)
Platelets 120 (low)
All the rest of the CBC was fine
Ferritin, Serum 38 (normal)
They also tested the thyroid
Thyroxine (T4) 7.8 (normal)
TSH 2.007 (normal)
Also, I am of Italian and Greek decent so and I believe Thal. more common among the Mediterranean.
I guess I am just wondering if anyone thinks I could have Thalassemia based on the blood work and if so could that be the cause of my recurrent miscarriages?
Has anyone else experienced this?
Thanks again Lainey and Andy for these posts, this is close to the only thing I have so far found connecting Thal and miscarriages.
Gabrielle

Hi Gabriela,

It does look to my uneducated glance that yes, you may be a Thalassemia carrier. That said, I still haven't found a solid link to being a Thalassemia carrier and recurrent miscarriage. After my last loss I was diagnosed with a VERY COMMON blood clotting disorder called MTHFR (50% of the population carries one mutation, about 15-20% carry both, like me) and, now that I'm pregnant again (30 weeks and going strong), I've been seeing a hematologist. She agrees with me that it's quite possible that Thalassemia trait might somehow exacerbate a clotting disorder.

I'm sorry for your losses and hope you have a successful next pregnancy.

Hi Gabriella,

Welcome to the forum,
In reading your posting I feel compel to chat with you in regard to having four miscariage in two years
As you may guess our body is like a machine that needs proper nutrients.When one has a pregnancy it takes so much out of ones' chemical and nutrient reserve.(e.g ,Like vitamins and minerals)
Maybe you need to take a break from trying to get pregnant,restore your body chemical with good diet and all the minerals you require to function properly .Then   when your body is in good form then try to get pregnant ,I said that because an already stressed body cann't functioned properly
At twenty -two you have plenty of time to get your body in a condusive mode for pregnancy,
I hope this posting is not misread I'm only trying to assist you in thinking outside the box.
Good luck and better luck next time.
with concern and kindness
Kathy

Hi!
Lainey, I am so happy for you about your healthy pregnancy, way to go! What a relief to know what your problem is and to be on the road with treatment. Thank you so much for the information, I will research and talk to my doc about these possibilities.

Kathy, thank you so much for your advice, I greatly appreciate it. I have been working on a very nutrient dense diet and trying to find out what the problem is. I don't want to start trying to conceive before I have some clue what is the problem and have made sure my body is not depleted of nutrient stores. I would love to have children now but I would not be distraught if it did not happen for a while. Mostly, I want to find out what is wrong with my body and focus on fixing/treating it with healthy food and lifestyle.

I am very anxious to talk to my doc about Thalassemia. My sister just told me today that this may be a possibility after we were rather puzzled for a week over my blood work. However, I don't think that Thal. has occurred to my doc because she told me (through the receptionist) to start on Iron and have my blood tested again in two weeks, just before my appointment. I was under the impression that iron anemia would show with low RBC.
Anyway, thank you both for your responses. What a great board!

Hi Lainey! I have two beautiful children, one who is a carrier of thal (my daughter.) I am Thal Minor and experienced Intrauterine Growth restriction in both pregnancies, my daughters due to calcification of the placenta causing oligohydramnios , and my son due to subchrionic hemhorraging and complications of my Thal.  Sometimes babies when faced with little to no nutrition coming from the placenta will suffer too much damage in the early trimesters to carry on.  I was lucky with my two live children - they stopped growing at 37 and 30 weeks, respectively.  I was hospitalized with Mychael, and recieved vitamin shots and transfusions.

I've had 3 miscarriages as well, 2 really early on, and the 3rd at 12 weeks.  My physician kept an eye on the subchrionic hemhorraging with biweekly ultrasound.  Is this available for you? They did it at a discounted rate because of the high risk.

Welcome to the group - As you can see, you are not alone, and we are here for you!

Hi again!
Lainey, you mentioned that you were diagnosed with a blood clotting disorder called MTHFR. I was just wondering what tests they did to arrive at this diagnose. Also, what kind of treatment has helped you and do they have to do anything special because of thal? I hope your pregnancy is going well! Thank you so much for your help, your story has helped me see that there is hope of being able to carry a pregnancy.
Courtenay, thanks for your post. You must be so happy to have your two children with all the complications you went through. And I am so sorry for your losses.
Thanks again,
Gabrielle

HI Gabrielle,

You should have a hemoglobin electrophoresis test done to further examine the possibility of thal minor. Some of your test results are slightly low but not enough to assume thal. However, because of your genetic background, it does warrant further investigation, especially since you've had the problem with miscarriages. An electrophoresis will give a view of what the blood cells look like and also the amounts of the different hemoglobins in your blood.

This group continues to see numerous thal minor women having difficulty with pregnancies. Thalassemia causes a hypercoagulable state and so does pregnancy. Obviously more needs to be researched about this combination, but it does seem to become cumulative in terms of the effect of the two combined. It may be that with closer monitoring of pregnancies and use of blood thinners (even aspirin and vitamin E) and transfusions when required, that many more of these pregnancies may reach full term.

I agree with Andy. The electrophoresis is a good idea. Your iron is not super low and shouldn't muddy that test too much. Your HB is better than mine. I don't think I have ever been more than 11 in my entire life. I want to have kids one day, but it sounds pretty discouraging at times. As I have said before, thalassemia minor may not alone make for a terrible pregnancy, but it certainly weighs in heavy once you add more conditions to the mix...My OB/GYN told me that I should be observed by a high-risk pregnancy specialist.

On the other hand, so many things can go wrong with pregnancy -- where does one start?

Btw, Lainey, Italians and Greeks have as much sickle cell as they do thalassemia percentages in the population. About 8% each. Electrophoresis would show if you are a carrier of either.

My physician kept an eye on the subchrionic hemhorraging with biweekly ultrasound.  Is this available for you?

Yes, I've been followed very closely by a perinatologist during the last two pregnancies -- the one we lost at 24 weeks as well as my current pregnancy.

Lainey, you mentioned that you were diagnosed with a blood clotting disorder called MTHFR. I was just wondering what tests they did to arrive at this diagnose. Also, what kind of treatment has helped you and do they have to do anything special because of thal? I hope your pregnancy is going well! Thank you so much for your help, your story has helped me see that there is hope of being able to carry a pregnancy.

Gabriela -- I was tested for a number of clotting disorders -- all done through blood tests. The MTHFR is a genetic mutation (or two, like for me). The treatment for me has been a combination of blood thinners -- low dose aspirin and injectible Heparin (twice per day in my belly). I discontinued the Heparin at about 16 weeks pregnant due to another placental abruption but have continued with the aspirin and so far (now at 30 weeks!) everything is going well. 

Btw, Lainey, Italians and Greeks have as much sickle cell as they do thalassemia percentages in the population. About 8% each. Electrophoresis would show if you are a carrier of either.

Thanks. I'm neither Italian nor Greek and I don't carry sickle cell, just beta Thalassemia.

Hi,

I suspect I am thal minor but have not been able to find free or inexpensive opportunities for testing yet. I am hoping to find someone willing to do the proper diagnosis as my daughter is thal minor and my symptoms seem to match much of what I have read on this site.

Your post regarding miscarriage really caught my attention. I had 3 miscarriages and had been wondering if thal minor could have been somehow involved in why I seemed to have such a hard time with pregnancy. I do have two beautiful children, one is for sure thal minor.

I just wanted to let you know that this was a major problem for me so perhaps there is a connection. But, I did have two successful pregnancies. Hopefully the doctors will start to learn more about the challenges that minors have so that lots of suffering can be alleviated.

Much joy to you and all the lovelies,
Linda Marie