Inherited Thrombophilia is Inherited Thrombophilia is Associated with:Associated with:

Recurrent pregnancy lossesRecurrent pregnancy losses PreeclampsiaPreeclampsia Intrauterine growth retardationIntrauterine growth retardation StillbirthsStillbirths Preterm laborsPreterm labors Maternal deathsMaternal deaths

Recurrent Miscarriage Recurrent Miscarriage Predisposes Women to:Predisposes Women to:

Preterm laborPreterm labor Intrauterine growth retardationIntrauterine growth retardation PreeclampsiaPreeclampsia Fetal anomaliesFetal anomalies

New Actions of New Actions of Antiphospholipid AntibodiesAntiphospholipid Antibodies

Cause increased serum tumor Cause increased serum tumor necrosis factor (TNF) alphanecrosis factor (TNF) alpha

Alters the TH1:TH2 balance Alters the TH1:TH2 balance towards TH1towards TH1

Decreases Decreases interleukin-3 interleukin-3 (IL-3)(IL-3) TNF alpha can initiate the release TNF alpha can initiate the release

of tissue factor and initiate the of tissue factor and initiate the clotting cascadeclotting cascade

Inherited ThrombophiliasInherited Thrombophilias

Rey et al. in a meta-analysis found:Rey et al. in a meta-analysis found:• Increased incidence of factor V Leiden mutationIncreased incidence of factor V Leiden mutation• Prothrombin gene mutation factor IIProthrombin gene mutation factor II• MTHFR gene mutation in patients with MTHFR gene mutation in patients with

recurrent miscarriagerecurrent miscarriage Screening for inherited thrombophilia Screening for inherited thrombophilia

in women with recurrent spontaneous in women with recurrent spontaneous abortion (RSA), infertility and abortion (RSA), infertility and implantation failure is indicatedimplantation failure is indicated

Heparins 1Heparins 1

Heparin increases serum TNF Heparin increases serum TNF binding protein protecting against binding protein protecting against harmful systemic manifestationsharmful systemic manifestations

Low molecular weight (LMW) Low molecular weight (LMW) heparins inhibit TNF alpha heparins inhibit TNF alpha productionproduction

Heparin and LMW heparin are Heparin and LMW heparin are antiinflammatoryantiinflammatory

Heparins 2Heparins 2

LMW heparin limits neutrophil LMW heparin limits neutrophil extravasionextravasion

LMW heparin decreases vein wall LMW heparin decreases vein wall permeabiolitypermeabiolity

Prevents accumulation of Prevents accumulation of proliferating vascular smooth proliferating vascular smooth muscle that encroaches on the muscle that encroaches on the lumen of arterieslumen of arteries

Inherited and Acquired Inherited and Acquired ThrombophiliaThrombophilia

Pregnancy is a hypercoagulable state Pregnancy is a hypercoagulable state (Stirling et al., 1984)(Stirling et al., 1984)

Antiphospholipid antibodies (aPL), an Antiphospholipid antibodies (aPL), an acquired thrombophilic defect, are an acquired thrombophilic defect, are an important and treatable cause for important and treatable cause for pregnancy losses at all gestational ages pregnancy losses at all gestational ages (Rai et al., 1997)(Rai et al., 1997)

Inherited thrombophilias are a greater Inherited thrombophilias are a greater cause for pregnancy losses and cause for pregnancy losses and complications at all gestational agescomplications at all gestational ages(Rai et al., 2002)(Rai et al., 2002)

Factor V Leiden and RSA Factor V Leiden and RSA Outcome of Untreated Outcome of Untreated

PregnanciesPregnancies

Early Losses FVLEarly Losses FVL ++ 37.5%37.5%

Early Losses FVLEarly Losses FVL -- 69.3%69.3%

Late Losses FVLLate Losses FVL ++ 11.1%11.1%

Late Losses FVLLate Losses FVL -- 48.9%48.9%

Factor V Leiden TreatmentFactor V Leiden Treatment

Increase LMW heparin to twice daily Increase LMW heparin to twice daily with a positive pregnancy testwith a positive pregnancy test

LMW Heparin 30 or 40 mg once LMW Heparin 30 or 40 mg once daily started on cycle day 6daily started on cycle day 6

Continue until 6 weeks postpartumContinue until 6 weeks postpartum Aspirin 81 mg daily starting cycle Aspirin 81 mg daily starting cycle

day one of conception cycleday one of conception cycle

Factor V Leiden Outcome Factor V Leiden Outcome with Treatment on RSA with Treatment on RSA

WomenWomen

Carp et al., 2002Carp et al., 2002

Without Without treatmenttreatment 33.2%33.2%

With treatmentWith treatment 85.7%85.7%

Recommended TestsRecommended Tests

LAC screen APTT and dRVVTLAC screen APTT and dRVVT Antiphospholipid antibodiesAntiphospholipid antibodies Factor V Leiden gene mutationFactor V Leiden gene mutation Prothrombin gene factor II gene Prothrombin gene factor II gene

mutationmutation Methylenetetrahydrofolate Methylenetetrahydrofolate

reductase reductase (MTHFR) gene mutation(MTHFR) gene mutation Antinuclear Antibody (ANA)Antinuclear Antibody (ANA)

Importance of ANA TestingImportance of ANA TestingInfertility, RSAInfertility, RSA

Ogasawara et al., 1999Ogasawara et al., 1999• 25% of RSA patients have low titer 25% of RSA patients have low titer

positive ANA with speckled patternpositive ANA with speckled pattern• 21% of Infertility patients have low 21% of Infertility patients have low

titer positive ANA with speckled titer positive ANA with speckled patternpattern

• A positive ANA mandates a full A positive ANA mandates a full immunological workupimmunological workup

Mechanisms of ThrombosisMechanisms of Thrombosis

Protein C and S and AT III slow Protein C and S and AT III slow down the forward momentum of down the forward momentum of clot formationclot formation

Factor V Leiden is a mutated Factor V Leiden is a mutated variant of factor V that is partially variant of factor V that is partially resistant to inactivation by resistant to inactivation by activated protein Cactivated protein C

Mechanisms of Thrombosis in Mechanisms of Thrombosis in Placenta AntibodiesPlacenta Antibodies

Stern et al., 1998Stern et al., 1998• Increased localization of Increased localization of

prothrombotic proteinsprothrombotic proteins• Blocking of natural anticoagulantsBlocking of natural anticoagulants• Transmembrane signalingTransmembrane signaling

Treatment for MTHFR Hetero Treatment for MTHFR Hetero and Homozygous Women and Homozygous Women

Folgard RXFolgard RXTMTM 2.2 daily (lifetime) 2.2 daily (lifetime) Aspirin 81 mg daily (lifetime)Aspirin 81 mg daily (lifetime) LMW heparin 30 – 40 mg daily, LMW heparin 30 – 40 mg daily,

cycle day 6, increasing to twice cycle day 6, increasing to twice daily until 6 weeks postpartumdaily until 6 weeks postpartum

Treatment of Prothrombin Treatment of Prothrombin Gene Factor II VariantGene Factor II Variant

Aspirin 81 mg daily Aspirin 81 mg daily LMW heparin 30 – 40 mg daily, LMW heparin 30 – 40 mg daily,

cycle day 6, increasing to twice cycle day 6, increasing to twice daily until 6 weeks postpartumdaily until 6 weeks postpartum

MTHFR Outcome with and MTHFR Outcome with and Without TreatmentWithout Treatment

Carp et al., 2004Carp et al., 2004

With treatmentWith treatment 66.7%66.7%

Without Without treatmenttreatment

3.5%3.5%

Factor VII+ Tissue Factor VII+ Tissue Factor Factor

Coagulation Coagulation CascadeCascade

ThrombiThrombinn

PlateletPlateletss

Fibrinogen Fibrinogen FibrinFibrin

Factors V and Factors V and VIII VIII

Activated Factors V and VIII (Va and Activated Factors V and VIII (Va and VIIIa)VIIIa)

Further Coagulation Further Coagulation ActivationActivation

Different direction in intact vessels...Different direction in intact vessels...

Vessel Vessel WoundWound

Protein C System ActivationProtein C System Activation

Activated C (APC) and Protein S and Factor VActivated C (APC) and Protein S and Factor V

Deactivation of Va & VIIIaDeactivation of Va & VIIIa

Normal conditions Normal conditions Anticoagulant mechanisms Anticoagulant mechanisms Procoagulant mechanisms Procoagulant mechanisms

Wound conditions Wound conditions Procoagulant mechanisms Procoagulant mechanisms Anticoagulant mechanisms Anticoagulant mechanisms

Thrombin + Thrombomodulin (Endothelial Surface)Thrombin + Thrombomodulin (Endothelial Surface)

Intact Blood VesselIntact Blood Vessel

European Prospective European Prospective Cohort on Thrombophilia Cohort on Thrombophilia (Lancet 1996)(Lancet 1996)

n=1384n=1384 PregnanciPregnancieses

FetalFetal

LossLoss

Stillbirth/Stillbirth/

MiscarriaMiscarriagege

Stillbirth,Stillbirth,

CombineCombinedd

DefectsDefects

StillbirtStillbirth,h,

Factor V Factor V LeidenLeiden

ThrombophiliaThrombophilia

(n=843)(n=843)n=1524n=1524 1.351.35 3.63.6 14.314.3 22

ControlControl

(n=541)(n=541)n=1019n=1019 11 11 11 11

Position 1691, leading to Arg506Gln protein Position 1691, leading to Arg506Gln protein (factor V Leiden) (factor V Leiden)

Most frequent genetic defect associated with Most frequent genetic defect associated with diseasedisease

In Europe 3-7% with APC-R, 1% homozygotesIn Europe 3-7% with APC-R, 1% homozygotes ““Mitera” study: 4.5% carriers (Greek blood Mitera” study: 4.5% carriers (Greek blood

donors)donors)

Missense Mutation G to A in the Missense Mutation G to A in the FV GeneFV Gene

Hypercoagulability has Positive Hypercoagulability has Positive Genetic (Natural) Selection Genetic (Natural) Selection

EffectsEffects

In the past In the past survival advantage survival advantage (war and hunting wounds, (war and hunting wounds, deliveries)deliveries)

Now Now artifacts of modern life style artifacts of modern life style

Mutated Factor Va (FV Leiden) Mutated Factor Va (FV Leiden) Less Sensitive to APC Less Sensitive to APC

DeactivationDeactivation

APC-Resistance APC-Resistance frequent to frequent to general population, 3-5%general population, 3-5%

Carriers have an increased risk for Carriers have an increased risk for thrombosesthromboses

Most important factor of venous Most important factor of venous thromboembolismthromboembolism

More than half of the patients with More than half of the patients with hereditary thrombophiliahereditary thrombophilia

SevereSevere

Pre-Pre-eclampsieclampsi

aa

NormotensiNormotensiveve

Women onWomen on

Oral Oral ContraceptiContracepti

on and on and ThrombosesThromboses

Women onWomen on

Oral Oral ContraceptiContracepti

on and on and Cerebral-Cerebral-

Vein Vein ThrombosesThromboses

Stroke Stroke in in

Young Young WomenWomen

FV FV Leiden Leiden SubjectsSubjects

8.9%8.9% 4.2%4.2% 30%30% 20%20% 0.9%0.9%

No No MutatioMutationn

10%10% 3%3% 4.1%4.1%1.1. Domna S. Dizon-Townson et al, Salt Lake City, Utah, Am J Obstet Domna S. Dizon-Townson et al, Salt Lake City, Utah, Am J Obstet

Gynecol, 1996Gynecol, 1996

2.2. Margareta Hellgren et al, Mohndal and Malmo, Sweden, Am J Obstet Margareta Hellgren et al, Mohndal and Malmo, Sweden, Am J Obstet Gynecol, 1994Gynecol, 1994

3.3. Longstreth WT Jr et al, Washington, Seattle, Stroke, 1998Longstreth WT Jr et al, Washington, Seattle, Stroke, 1998

4.4. Martinelli I et al, Milan, N Engl J Med, 1998Martinelli I et al, Milan, N Engl J Med, 1998

Br J Haematol, 1997Br J Haematol, 1997Brenner B et al., Bruce Brenner B et al., Bruce Rappaport Faculty of Medicine, Rappaport Faculty of Medicine, Haifa, IsraelHaifa, Israel

Women Women with Fetal with Fetal Losses Losses (n=39)(n=39)

PregnanciPregnancieses

First First TrimesteTrimeste

r r AbortionAbortion

ss

Late Late AbortionAbortion

ss

IntrauterinIntrauterine Deathe Death

Live Live BirthsBirths

FV Leiden FV Leiden (n=19)(n=19) 128128

50%50% 17%17% 47%47% 18%18%With APC-With APC-R (n=9)R (n=9) 5656

Prothrombin Gene G20210A Prothrombin Gene G20210A VariantVariant

Inherited in an autosomal dominant Inherited in an autosomal dominant mannermanner

Gene on chromosome 11p11-q12 (21kb, Gene on chromosome 11p11-q12 (21kb, 14 exons) encodes a plasma 14 exons) encodes a plasma glycoprotein, activated to thrombin by glycoprotein, activated to thrombin by FXa and FvaFXa and Fva

Point mutation G20210A in the 3' Point mutation G20210A in the 3' untranslated region is associated with untranslated region is associated with elevated prothrombin levelselevated prothrombin levels

Title Needed???Title Needed???

Accounts for ~18% of inherited Accounts for ~18% of inherited thrombophiliathrombophilia

Accounts for ~6% of unselected Accounts for ~6% of unselected patients with deep-vein thrombosispatients with deep-vein thrombosis

Frequently co-inherited with other Frequently co-inherited with other genetic risk factors like factor V genetic risk factors like factor V LeidenLeiden

Title Needed???Title Needed???

Carriers have a 2 to 5 fold Carriers have a 2 to 5 fold increased risk of venous increased risk of venous thrombosis, including cerebral-vein thrombosis, including cerebral-vein thrombosisthrombosis

Carriers using oral contraceptives Carriers using oral contraceptives have a highly elevated risk of have a highly elevated risk of cerebral-vein thrombosiscerebral-vein thrombosis

1.1. Longstreth WT Jr et al., Washington, Seattle, Stroke, 1998Longstreth WT Jr et al., Washington, Seattle, Stroke, 1998

2.2. Rosendaal FR et al., Leiden, Netherlands, Blood, 1997Rosendaal FR et al., Leiden, Netherlands, Blood, 1997

3.3. Martinelli I et al., Milan, N Engl J Med, 1998Martinelli I et al., Milan, N Engl J Med, 1998

Women with Women with Myocardial Myocardial InfarctionInfarction

Women on Oral Women on Oral Contraception Contraception and Cerebral-and Cerebral-

Vein Vein ThrombosesThromboses

Stroke in Young Stroke in Young WomenWomen

Prothrombin Prothrombin Gene Variant Gene Variant SubjectsSubjects

5.15.1 20%20% 1.9%1.9%

No MutationNo Mutation 1.61.6 3%3% 1.6%1.6%

Title Needed???Title Needed???

Carrier frequency of 1 to 4% in different Carrier frequency of 1 to 4% in different populationspopulations

Carrier frequency in southern Europe is Carrier frequency in southern Europe is nearly twicenearly twice

As high as in northern EuropeAs high as in northern Europe "Mitera" study: 3.8 % among healthy "Mitera" study: 3.8 % among healthy

Greek blood donorsGreek blood donors Geographical distribution probably due Geographical distribution probably due

to founder effectto founder effect

HyperhomocysteinemiaHyperhomocysteinemia

Cystathionine ß-synthase (CBS) Cystathionine ß-synthase (CBS) deficiency causes the metabolic deficiency causes the metabolic disorder "homocystinuria" (including disorder "homocystinuria" (including premature arteriosclerosis and premature arteriosclerosis and thrombosis)thrombosis)

MTHFR deficiency is an inborn error of MTHFR deficiency is an inborn error of folate metabolism (with increased risk folate metabolism (with increased risk of arteriosclerosis and thrombosis) of arteriosclerosis and thrombosis)

HyperhomocysteinemiaHyperhomocysteinemia(Cont.)(Cont.)

Mild hyperhomocysteinemia has been Mild hyperhomocysteinemia has been recognized as a risk factor for recognized as a risk factor for arteriosclerosis and thrombosisarteriosclerosis and thrombosis

Mild hyperhomocysteinemia due to a Mild hyperhomocysteinemia due to a thermolabile variant of the MTHFR thermolabile variant of the MTHFR enzyme has been associated with enzyme has been associated with premature vascular diseasepremature vascular disease

Homocysteine is presumed to damage Homocysteine is presumed to damage the endothelial cell, but the exact the endothelial cell, but the exact mechanism of its toxicity is unknownmechanism of its toxicity is unknown

Title Needed???Title Needed???

Homozygous individuals show Homozygous individuals show reduced MTHFR activity, increased reduced MTHFR activity, increased thermolability and thermolability and hyperhomocysteinemiahyperhomocysteinemia

Homozygotes may have an Homozygotes may have an increased risk of cardiovascular increased risk of cardiovascular disease and neural tube defectsdisease and neural tube defects

Title Needed???Title Needed???

Relatively high frequency Relatively high frequency throughout the world: allele throughout the world: allele frequency from 6% in Africa to frequency from 6% in Africa to 40% in some European populations40% in some European populations

Selective advantage to explain Selective advantage to explain high frequencyhigh frequency

1.1. J. I. P. de Vries et al., Amsterdam British Journal of J. I. P. de Vries et al., Amsterdam British Journal of Obstetrics and Gynaecology, 1997Obstetrics and Gynaecology, 1997

Placental Placental AbruptionAbruption

(n=31)(n=31)

IntrauterinIntrauterine Fetal e Fetal Death Death (n=18)(n=18)

Small for Small for Gestational Gestational Age Infants Age Infants

(n=13)(n=13)

Women with Mild Women with Mild HyperhomocysteineHyperhomocysteinemiamia

25%25% 8%8% 38%38%

““Mitera” Study, ASH 1998Mitera” Study, ASH 1998Haematology Dept, Haemostasis LabHaematology Dept, Haemostasis Lab

GroupGroup Aborters > 2, Aborters > 2, (n=37)(n=37)

Non-Aborters, Non-Aborters, (n=102)(n=102)

Age Median (range)Age Median (range) 34 (19-51)34 (19-51) 34 (20-54)34 (20-54)

PlateletsPlatelets All NormalAll Normal All NormalAll Normal

PTPT All NormalAll Normal All NormalAll Normal

INRINR All NormalAll Normal All NormalAll Normal

APTTAPTT All NormalAll Normal All NormalAll Normal

Fibrinogen > 400 mg/dlFibrinogen > 400 mg/dl 30%, n=1130%, n=11 14%, n=1414%, n=14

Fibrinogen < 400 mg/dlFibrinogen < 400 mg/dl 70%, n=2670%, n=26 86%, n=8886%, n=88

LA Positive (by confirmative LA Positive (by confirmative test)test) 16%, n=1616%, n=16 9%, n=99%, n=9

AT III < 75%AT III < 75% 3%, n=13%, n=1 3%, n=33%, n=3

PC < 75%PC < 75% All NormalAll Normal All NormalAll Normal

PS < 75%PS < 75% Unreliable TestUnreliable Test Unreliable TestUnreliable Test

Increased APC-R (suggesting Increased APC-R (suggesting FV Leiden)FV Leiden) 22%, n=822%, n=8 11%, n=1111%, n=11

ConsultationConsultation

Extended family screeningExtended family screening Anticoagulant prophylaxis in Anticoagulant prophylaxis in

selected casesselected cases

Inherited Thrombophilia Inherited Thrombophilia (Prothrombotic Gene (Prothrombotic Gene

Mutation)Mutation)

Acquired Acquired ThrombophiliaThrombophilia

HypercoagulabilityHypercoagulability

ThrombosiThrombosiss

LMW HeparinLMW Heparin

Given subcutaneously to maintain Given subcutaneously to maintain trough anti-Xa activity of 0.15-trough anti-Xa activity of 0.15-0.2U/ml and 2 h post injection 0.2U/ml and 2 h post injection levels of 0.4-0.6 U/mllevels of 0.4-0.6 U/ml

Checking of levels are no longer Checking of levels are no longer recommendedrecommended

May check monthly during May check monthly during pregnancypregnancy

LMW Heparin ComplicationsLMW Heparin Complications

Epidural anesthesia is managed by Epidural anesthesia is managed by omitting a dose or inserting the omitting a dose or inserting the needle 6 hours after the previous doseneedle 6 hours after the previous dose

There were no thromboembolic events There were no thromboembolic events or excessive hemorrhagesor excessive hemorrhages

There is one report of osteoporotic There is one report of osteoporotic vertebral collapse post partumvertebral collapse post partum

Hunt BJ et al., Hunt BJ et al., 19971997

LMW Heparin ComplicationsLMW Heparin Complications

No local or systemic side effects reportedNo local or systemic side effects reported No excessive intrapartum or postpartum No excessive intrapartum or postpartum

bleeding in vaginally or c-sectioned bleeding in vaginally or c-sectioned delivered patientsdelivered patients

Epidural was done without complicationsEpidural was done without complications No intraventricular hemorrhages in any No intraventricular hemorrhages in any

infantinfant No effect on platelet countNo effect on platelet count

Dulitzke M. et al., Dulitzke M. et al., 19961996