НМГ не повышает шансов на вынашивание при необъяснимом повторном раннем выкидыше

[Dr.Vad]

Назначение НМГ/эноксапарина при необъяснимом повторном (два или более) невынашивании на сроке до 15 недель не повышает шансов на вынашивание: частота донашивания на нем составила 67%, тогда как на плацебо 73%:

Blood. 2015 Jan 30.
Enoxaparin for prevention of unexplained recurrent miscarriage: a multicenter randomized double-blind placebo-controlled trial.
Pasquier Eи соавт.
Despite the lack of evidence, it is common practice in many centers to offer antithrombotic medications to women with unexplained recurrent miscarriage, in the presence and even absence of inherited thrombophilia. Whereas the absence of benefit of aspirin against placebo has been clearly demonstrated, a double-blind placebo-controlled trial on the effect of low-molecular-weight heparin is lacking. Before stopping for futility, we enrolled 258 pregnant women, who had a history of unexplained recurrent miscarriage (two or more consecutive miscarriages before 15 weeks' gestation) and a negative thrombophilia work-up. They were randomly assigned to receive one daily subcutaneous injection of enoxaparin 40 mg or placebo until 35 weeks' gestation. We included 256 women (mean age: 32 years, 3 or more miscarriages: 72%, mean gestational age: 39 days of amenorrhea) in the intention-to-treat analysis. 66.6% of the 138 who received enoxaparin had a live-birth, compared to 72.9% of the 118 who received placebo. The absolute difference was -6%, 95% CI -17.1 to 5.1, excluding a 10% increase in the rate of live-birth on enoxaparin (p=0.34). In this first randomized double-blind placebo-controlled trial, enoxaparin, 40 mg once daily, did not improve the chance of a live-birth in non-thrombophilic women with unexplained recurrent miscarriage.

Это исследование повторяет результаты предыдущего, когда эноксапарин с аспирином или без не повышали шансов на вынашивание в примерно аналогичном исследовании:

Thromb Haemost. 2011 Feb;105(2):295-301.
Thromboprophylaxis for recurrent miscarriage in women with or without thrombophilia. HABENOX: a randomised multicentre trial.
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Общий итог этих исследований одинаков - даже после 2-3 невынашиваний подряд на раннем сроке у женщин имеются 65-70% шансы доносить последующyю беременность.

[Dr.Vad]

НМГ не улучшает прогноз при повторных невынашиваниях у женщин и с тромбофилией - настало время перестать искать генетические тромбофилии у женщин с повторными невынашиваниями:

326 conceived and were randomly assigned (164 to LMWH and 162 to standard care). 116 (72%) of 162 women with primary outcome data in the LMWH group and 112 (71%) of 158 in the standard care group had livebirths (adjusted odds ratio 1·08, 95% CI 0·65 to 1·78; absolute risk difference, 0·7%, 95% CI -9·2% to 10·6%). 39 (24%) of 164 women in the LMWH group and 37 (23%) of 162 women in the standard care group reported adverse events.

Interpretation:
We do not advise use of LMWH in women with recurrent pregnancy loss and inherited thrombophilia, and we advise against screening for inherited thrombophilia in women with recurrent pregnancy loss.
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Heparin for women with recurrent miscarriage and inherited thrombophilia (ALIFE2): an international open-label, randomised controlled trial.

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