As mentioned previously, vitamins B6,B12, and folate are important in homocysteine metabolism, and hyperhomocysteinemia is linked to recurrent pregnancy loss (21,23,38,66,68,72). Women with recurrent pregnancy loss and isolated fasting hyperhomocysteinemia should be offered supplemental folic acid (0.4 to 1.0 mg per day), vitamin B6 (6 mg per day), and possibly vitamin B12 (0.025 mg per day) (448–451). Fasting homocysteine levels should be retested after treatment. If levels are normalized or remain only marginally elevated, no further therapy is necessary. Homocysteine levels will predictably decrease during pregnancy.
Treatment of women with recurrent pregnancy loss and an identified inherited or acquired thrombophilia should be based on accompanying history. Currently, there are no prospective controlled trials examining the benefit of anticoagulation for the prevention of miscarriage in the absence of APS, and, therefore, anticoagulation recommendations for patients with inherited thrombophilias are based on individualized risk of venous thromboembolic events in pregnancy (28).
If a venous thromboembolic event occurs during the index pregnancy, posthospi talization management requires therapeutic anticoagulation.
UFH: 10,000 to 15,000 U subcutaneous every 8 to 12 hours (monitor to keep aPTT 1.5 to 2.5 times normal) OR
LMWH: enoxaparin 40 to 80 mg subcutaneous twice a day or dalteparin 5,000 to 10,000 U subcutaneous twice a day). Consider monitoring trough factor
Xa levels in the third trimester.
If there is a personal history of venous thromboembolic events (particularly in a previous pregnancy or with hormonal contraceptive use) or a strong thrombophilic family history, treat with therapeutic anticoagulation. Thrombotic risk is greatest during the postpartum period.
Anticoagulation should be reinitiated after delivery in doses reﬂecting predelivery treatment regimens. Postpartum anticoagulation should be continued for 6 to 12 weeks postpartum (435). Women may continue injectable therapy or transition to oral anticoagulants (e.g., coumarin). Use of heparin or of coumarin derivatives does not prohibit breastfeeding.
Psychological Support There is no doubt that experiencing both isolated and recurrent losses can be emotionally devastating. The risk of major depression is increased greater than twofold among women with spontaneous pregnancy loss; in most women it arises in the first weeks following delivery (452). A caring and empathetic attitude is prerequisite to all healing. The acknowledgment of the pain and suffering couples have experienced as a result of recurrent abortion can be a cathartic catalyst enabling them to incorporate their experience of loss into their lives rather than their lives into their experience of loss (112). Referrals to support groups and counselors should be offered. Self-help measures, such as meditation, yoga, exercise, and biofeedback may also be useful.