Q. I am bleeding during pregnancy. Should I discontinue Heparin injection?

Hello doctor,

I am eight weeks and six days pregnant and am currently on LMWH (Inj Innohep 40 mg) as tests prior to pregnancy indicated a positive ANA. I have a history of a previous mid-trimester miscarriage which was believed to be due to an incompetent cervix, and so have been on vaginal progesterone pessaries since I tested positive this time around. Last month, I had some PV bleeding. Scans at that time did not show an SCH. A week after the onset of the bleed, progesterone levels were found to be 6 and so I was started on tablet Duphaston 10 mg twice a day and a shot of Inj Proluton Depot 250 mg was given.

Sadly, I developed light bleeding again last night and USG showed a small 1.1 cm collection suggestive of an SCH. I was given a shot of Inj. Proluton Depot 250 mg before being discharged from the ER. I am doubtful as to whether I should continue taking the Inj Innohep while I have the bleed or if I should stop. My rheumatologist thinks I should continue on with the LMWH in spite of the bleeding in view of positive immunological markers. However, My RE thinks otherwise. He says the previous miscarriage was not due to APS (the baby was fine when I went into labor) and so he did not feel there to be an absolute indication for Heparin for this pregnancy. But what about the positive ANA? Or the Lupus anticoagulant?

Pre-pregnancy tests were as follows

• ANA: Positive -Homogeneous >1:1280
• Lupus anticoagulant: Negative

The rheumatologist wanted a repeat panel done and so the tests were done while I was pregnant.

• ANA: Positive - Homogeneous >1:2560 ( Increased )
• Lupus anticoagulant - Positive

In view of these test,

Should I be continuing on with the LMWH? Should LMWH be continued even with the presence of an SCH or vaginal bleeding? Does the increase in ANA indicate a definitive immune response from my body to the pregnancy? Can Lupus become positive just weeks / few months after it was found to be negative?

Hello doctor,

Thank you for your answer. In view of my case, would you agree that it would be beneficial for me to continue on with the LMWH so long as there is not too much active bleeding? Looking at my tests, would you say that the benefit of being on LMWH outweighs the risk? My ob and rheumatologist do not seem to be on the same page as to whether I should continue it. The rheumatologist says I "must" continue, but the ob does not think my tests show an absolute indication to continue on with the heparin. Your thoughts would be much appreciated.