Significance/treatments for positive ANA in early PG?

Lora

6 Posts
Reply Posted on: Oct 28, 2013 at 6:51am
Dr. Braverman,

I have Hashimoto's, Raynaud's, PCOS, endometrioisis, and am homozygous for MTHFR A1298C. We consulted with you last February during my most recent pregnancy loss (9wk loss after seeing heart beat multiple times, including at your office). My blood work at the time (run while 5.5 wks pregnant) only showed mildly elevated CD19 (16.9) and TNF:a (34.1). Your recommendations were to add prednisone and lovenox during future cycle should we lose the pregnancy.

A month after that pregnancy ended, routine labs at my endocrinologists' office revealed a high ANA (1:1250 speckled) and I was referred to rheumatology for further evaluation. It took nearly 4 months to get a rheumatology consult, and by that time the speckled ANA was back to normal levels. Rather, my ANA homogenous was elevated at 1:250. The rheumatologist was unconcerned and gave me the green light to try to conceive again (I had resumed birth control in the interim).

We did several failed cycles of injectable (gonal-f) timed intercourse and IUI this summer, and just completed our first IVF in September/October. I am currently 6wks pregnant from the IVF and we visualized an appropriately sized gestational sac in utero last week. I have been on dexamethasone since my baseline in mid-September, and on Lovenox, Baby Asprin, PIO, and Crinone since retrieval on 9/30. I did an initial intralipid infusion at the time of my retrieval, and have another scheduled for next week (7w2d pregnant).

I consulted with a new OB/GYN last week who was suspicious about my positive ANA history so he ordered another full autoimmune panel which again revealed ANA homogeneous at 1:250, a high C4 Complement (48, ref range 10-40), and a high sedimentation rate (35, ref range 0-20). I am waiting to hear back from his office, but suspect they will refer me to perinatology as this is what we discussed would be the plan.

I am becoming more and more certain that the very elevated ANA last March (1 month post-m/c) was, as you suspected, evidence that that pregnancy ended due to an immune attack agains the fetus. I am understandably worried that the same appears to be happening again.

In your professional experience, is a persistant 1:250 ANA elevation cause for concern? Are there treatments aside from pred, lovenox, and intralipids that you prescribe? Would additional testing with your office be advised considering that all my reprosource testing came back normal last time and I still lost the pregnancy?

Thanks in advance.

Dr. Braverman

2026 Posts
RE: Significance/treatments for positive ANA in early PG? Posted on: Nov 7, 2013 at 3:18pm
I am sorry that I missed this post. First I think you are on good tratments for the pos ANA , I would follow the levels of anti phospholipid antibodies in these cases and also would consdier IVIG in refractory cases. If you want me to consult with you on this pregnancy please call my office and I will get you right in for a consult and or blood work. I hope all is going well so far.
Dr. Jeffrey Braverman MD FACOG
Medical Director
Braverman Reproductive Immunology P.C.

Lora

6 Posts
Reply RE: Significance/treatments for positive ANA in early PG? Posted on: Jan 13, 2014 at 8:24am
Your reply in November came after several additional scans had allayed many of my fears, so I chose not to pursue the discussion any further. Now my ANA question has reared its ugly head again.

As of today I am 17 weeks - the first time we have ever reached the second trimester. I remain on baby aspirin and lovenox, in addition to my daily synthroid, B12, D, bioavailable folic acid, and prenatal. I had 3 IL infusions over the first trimester at egg retrieval, 7w2d, and 12w, and was on dexamethasone (RE would not prescribe prednisone) until 9wks.

I was released to my OB at 8 weeks, and all has been progressingly smoothly. At my prenatal visit on Thursday (1/9) we heard a strong heart beat, and scheduled my anatomy scan. At the visit I mentioned to my OB that symptoms I have previously associated with positive ANA findings had returned, namely an itchy hip rash and joint pain. He agreed to run another ANA panel.

The results posted today and I am, once again, off the charts. The result was 1:1,250 for the homogenous pattern. This is up from 1:250 on October 24 at around 6wks.

What is the significance of an elevated ANA in the second trimester? Am I already covering my bases with the Lovenox and BA? Could removal of the first tri support (namely, dex and ILs) have led to this spike? I am currently waiting for a call back from my OB to see how he wishes to proceed.

Thanks in advance,

Lora

Dr. Braverman

2026 Posts
RE: Significance/treatments for positive ANA in early PG? Posted on: Jan 13, 2014 at 8:45am
check your heparin anti XA level to be sure you are on right dose, check your anti phospholipid antibodies. But at this time you are most likely covered correctly sometimes with significant findings we increase the dose to twice daily. But you also need to have a diagnosis as to the cuase of the high ANA titers.
Dr. Jeffrey Braverman MD FACOG
Medical Director
Braverman Reproductive Immunology P.C.