FACTOR V LEIDEN MUTATION
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No Longer Brushed Off: A Minnesota Clinic Tries To Rewrite Medicine's Approach To Miscarriage
WOODBURY, Minn. — By the time Taylor Teske came to be sitting on an exam table in an obstetrician's office in Minnesota, her medical records marked a devastating journey: nine pregnancies, one baby, eight miscarriages.
The first miscarriage happened in June 2018, almost as soon as she found out she was pregnant. Teske told her boss at the vascular clinic where she worked that she was pregnant, and he asked if she wanted to sneak a look using the clinic's ultrasound. He searched for sounds on the black-and-white screen. Minutes passed, but nothing happened. An obstetrician-gynecologist later confirmed that Teske was having a miscarriage.
She would suffer another just a few months later. She was desperate for an answer, some bloodwork or a scan, that could tell her why, despite being young and healthy, she'd lost two pregnancies in such quick succession. Instead, she heard the same message as countless others: Miscarriages are usually just bad luck.
By early 2022, Teske, then 23, had experienced eight miscarriages, including six in less than two years after the birth of her only daughter, Aubrey. Teske felt it was impossible that so many losses could be bad luck. Of all her losses, only one pregnancy was found to have a genetic abnormality that, in medical terms, was "incompatible with life." Her physicians had largely written off the possibility she could ever carry another pregnancy to term. "The standard of care for her is to do nothing," one OB-GYN wrote in her medical record.
To Barbara Toppin, the physician treating Teske that day, the stories from patients are painfully consistent. They're told their losses are so early in pregnancy they're likely due to chromosomal abnormalities. They're told testing is unnecessary unless they've lost two, or sometimes even three, pregnancies. They're told to just try again.
She, along with a smattering of providers across the country, is pushing for a more aggressive approach. She asks patients about everything from their history of pregnancy loss to whether their immediate family members have developed heart disease or had strokes. She rules out known causes of miscarriage, such as uterine abnormalities. And she offers a battery of tests, which can reveal blood clotting problems, chronic inflammation, and autoimmune issues that could make it hard for a pregnancy to progress.
The philosophy behind her approach is simple: Treat miscarriages like a medical problem, not just a fact of life.
"Do physicians treat heart attacks like this? Strokes? Why do we make women wait for so many losses?" she said.
Estimates suggest that anywhere from 10% to more than 25% of all pregnancies end in miscarriage, though the Centers for Disease Control and Prevention told STAT there is no ongoing surveillance of miscarriage rates. It's also estimated that half of all recurrent miscarriages — two or more nonconsecutive losses — are "unexplained" and having lost pregnancies previously decreases a woman's odds of having a baby. One calculator predicted Teske had a 44% chance of delivering a healthy baby again.
What outraged Teske, and others who have had multiple unexplained miscarriages, is not just the losses they've suffered. It's also the lack of consistency in how most doctors — who follow guidelines issued by the American College of Obstetricians and Gynecologists (ACOG) — treat miscarriages. STAT spoke to a dozen women who have had miscarriages, generally defined as a pregnancy loss before 20 weeks gestation, and their treatment varied wildly across the country. Some said doctors ran tests on them, or sent fetal tissue for further analysis to understand what went wrong. Others said they were scared to get pregnant again for fear of developing dangerous complications. But all of them felt like their losses, or their requests for tests that could help prevent them, were brushed off.
Toppin's clinic is willing to navigate uncharted waters to help people like Teske carry their pregnancies to term.
Some of their strategies — in particular testing for genetic mutations and thrombophilias that increase the risk of blood clots and treating them with blood thinners, low-dose aspirin to stop platelets from forming clots, and anticoagulants to prevent blood clots — are controversial. ACOG, which sets treatment guidelines for recurrent miscarriages, doesn't approve of the use of blood thinners for miscarriage prevention, arguing there isn't enough evidence of benefit and carries risks.
But Toppin and others physicians are willing to try treatment without evidence from randomized clinical trials — the gold standard that ACOG relies on — to help people who felt like their OB-GYNs gave up on them. If it's an approach without rigorous scientific support, it's also an indictment of how desperately those individuals need more support, Toppin and other OB-GYNs argue. They say that treating miscarriages as routine has led doctors to do far less than they could do to prevent them.
"Benign neglect is a real problem," Toppin said. "If you neglect miscarriage, you miss that opportunity of really positively affecting not only the patient but her child, her parents, and her siblings for generations. That's a legacy."
Toppin meets with Taylor Teske at her clinic in Woodbury, Minn. Teske has suffered eight miscarriages in a short span of time. Jenn Ackerman for STATSitting in the exam room at her first appointment in February 2022, Teske was cautiously hopeful. Like all of Toppin's patients who've had a miscarriage, her first appointment was an hour long. For the first time, Teske felt like a doctor had all the time in the world. To Toppin, listening to her patient's story and validating their pain was as important as explaining the physiology behind pregnancy loss.
At 6'4," with dark hair and warm eyes, Toppin is a striking presence when she steps into the exam room. It only took a few minutes for Teske to start confiding in her.
"This is getting really old for me and I'm really scared and I'm just tired of going through this," Teske said. "Every other month, I'm pregnant. And then every other month, I'm right back to where I started."
Toppin knows how physically, emotionally, and financially devastating miscarriage can be. It can take away precious time from the window of when people can have children, and is costly to treat surgically, which is sometimes needed. Restrictions on mifepristone, a pill used to induce an abortion and treat miscarriage, have made it even harder to get care. Those restrictions and abortion bans have compounded the risks of miscarriage, which include a higher risk of infections, uterine scarring, severe bleeding, a hysterectomy, and even death.
"It stole my identity for a period of years," Megan Hanson, who co-founded the Recurrent Pregnancy Loss Association told STAT. "And it changed the entire course of my life."
By the time Toppin's patients show up at the clinic, which she runs with four other physicians and a 15-person staff, many have spent years ping-ponging from one doctor to another, searching for answers after difficult losses and, often, life-threatening complications.
Teske had thought her trouble was behind her in her third pregnancy. A doctor had put her on aspirin, which some research suggests can help women who have lost multiple pregnancies. Soon after Aubrey's birth in February 2020, Teske and her partner, Joe Teske, got pregnant again.
She had been so relieved, during that next pregnancy, to see a fetus that seemed to be growing healthily at a nine-week scan. But a few days later, with a sinking feeling that something was wrong, she returned for another ultrasound. Her fetus had stopped growing, and she had lost the pregnancy. That night, sitting on her bathroom's laminate floor, Teske's body began to bleed so heavily that she needed surgery.
That miscarriage broke her. It was also unexplained. Teske was angered by how little doctors could tell her or do. She lost five more pregnancies, and cycled through four more doctors until she found Toppin searching online for physicians that specialize in miscarriage treatment.
"I know you're sad," Toppin recalled telling Teske. But, she said, she was here to help. The first step was to run tests.
Since 1995, ACOG has recommended that doctors run tests for anyone who has had two miscarriages. In 2012 guidance, the American Society for Reproductive Medicine says those can include karyotyping to look for abnormalities in the number or structure of a person's chromosomes, as well as tests for uterine abnormalities, hormonal problems, and antiphospholipid syndrome, a condition that causes blood clots and is attributed to some recurrent miscarriages. Many OB-GYNs follow the standards of care set by professional organizations.
"Nobody actually suggested any sort of testing to me at all," said Alena Tardiff, a Minnesota-based dentist who suffered three miscarriages in a row that left her and her husband, Chris, reeling. After the second miscarriage, an OB-GYN suggested she take progesterone to support her uterine lining. After her third loss, the doctor told her she had a 50-50 shot of ever having a child. She walked out of the office crying.
Some international guidelines recognize that individual cases may call for testing and treatment based on their risk for blood clots in pregnancy. A 2023 guideline on recurrent miscarriage from the U.K-based Royal College of Obstetricians and Gynecologists says that "treatment can be considered given the association of thrombophilia with thrombotic events." The authors of the guideline say treatment decisions should involve a conversation with a patient, and should weigh other risk factors that make a person vulnerable to blood clots during pregnancy, such as smoking, obesity, and certain medical conditions. An Australian guideline published in March 2020 says physicians should consider risk factors including a personal or family history of blood clots, active autoimmune and inflammatory diseases, the presence of thrombophilia and medical conditions that increase the risk of clots. Depending on an individual's risk, the guidelines say, a preventive or full dose of anticoagulants may be warranted during and after pregnancy.
Standards can be a double-edged sword, some experts argue. They can create a uniform approach to patient care, but can also fail to meet the needs of patients that fall outside the norm.
"There are some people that really are intent on practicing evidence-based medicine," Wanda Adefris, a physician who co-founded the Minnesota clinic with Toppin, said. "And if you're practicing evidence-based medicine, you may not be at the forefront of some of these things."
By portraying miscarriages as "non-events," Toppin argues, the medical establishment widens the gap in care for those who experience miscarriage, recurrent pregnancy loss, and adverse outcomes such as a placental abruption, preeclampsia, fetal growth restriction, and stillbirth. (The Centers for Disease Control and Prevention does not explicitly track miscarriage as a cause of death in its maternal mortality surveillance.)
They also risk missing problems that could become more serious or even deadly later in pregnancy and even later in life. Long term, a miscarriage or adverse pregnancy complications during a woman's reproductive years has a direct correlation with a higher risk for heart disease, the nation's leading cause of death for women.
"You have to first realize that pregnancy loss is a problem and treat it as such," Toppin said. "If you have respect for it in that way, you're more likely to open your eyes to other things."
The lobby at the Adefris & Toppin Women's Specialists clinic. Jenn Ackerman for STATToppin thinks of herself as an expert in early pregnancy — which isn't a dedicated medical speciality, but is an area she's spent years building expertise in. Unlike a maternal-fetal medicine specialist (or MFM, also known as a perinatologist) who sees only patients at high risk of complications, or an IVF specialist who helps people try to get pregnant, she's focused on preparing her patients to get pregnant, prevent miscarriages, and carry a pregnancy safely to term.
To build that expertise, Toppin spent her hours outside the clinic learning about the science of early pregnancy, especially implantation, and using medications like blood thinners and supplements. The process required rethinking what she'd been taught in medical school — focusing on prevention, and not just treatment, and seeing pregnancy loss as part of a broader picture about a woman's whole health.
That kind of learning comes naturally to Toppin, who grew up at a time when astronauts were landing on the moon and opportunities felt limitless for a young Black girl in Mount Vernon, N.Y. It was her mother Barbara, a nurse, who introduced the language of medicine early in her daughter's life. She and Toppin's father, Bertram, a police sergeant, recognized her talent and nurtured her curiosity. Wellesley College, a summer job at Boston City Hospital, and physics courses at Massachusetts Institute of Technology cemented her path to medicine.
During her medical training in the 1980s, she admitted a 38-year-old woman to the New Jersey hospital where she was a resident for surgery to close the patient's fallopian tubes. Her medical history surprised Toppin: six pregnancy losses between six and 16 weeks, no living children. There was no explanation for her losses.
The patient wanted a child — so to Toppin, getting her tubes tied didn't make sense. But the patient's physician had told her they'd exhausted all their options, and she felt she couldn't survive any more losses.
Today, Toppin said, "I absolutely feel we could help her."
When Toppin and Adefris began their private practice in Minnesota, the two physicians were determined to help all of their patients, not only the ones that fit guidelines, which Adefris calls "the minimum standard of care." An OB-GYN can choose to do more for their patients, she said.
Toppin's method centers around the idea that each patient needs their own personal "formula" for care. Her priority is to consider the patient's individual case and make the correct assessment.
In Teske's case, there was a possible cause for her losses — though she didn't know it for years. Toppin suggested she get tested for genetic mutations and thrombophilias, an underlying predisposition for the body to form clots that can inhibit placental growth and destroy placental blood vessels. A woman can have more than one thrombophilia, which increases the risk of blood clots.
Scientists have long known that pregnancy is a hypercoagulable state, when a woman's body produces 45% more plasma blood volume and clots more easily. That process supports the pregnancy and prevents hemorrhage during birth.
Toppin's theory is that for people with an underlying thrombophilia or an autoimmune disorder that triggers blood clotting, that process goes awry. (Other researchers, meanwhile, suspect there are problems with the vagina's microbiome or a lack of stem cells in the lining of a woman's uterus).
Thrombophilias fall into two buckets: inherited and acquired. Guidelines recommend testing for antiphospholipid syndrome, an acquired thrombophilia that is also classified as an autoimmune disorder. The condition is typically treated with aspirin and low molecular weight heparin (LMWH) during pregnancy. But guidelines do not recommend screening for inherited thrombophilias such as factor V Leiden, and protein S and protein C deficiencies, among others. But experts said that lack of guidance — along with a dearth of data on the best treatments — deters many physicians from offering those tests to patients.
According to ACOG's guidance, those with a history of blood clots before pregnancy have the highest risk of developing one during pregnancy. To mitigate the risk of recurrence, they are treated with LMWH in pregnancy. The second most important risk factor is considered an inherited or acquired thrombophilia. These are present in anywhere between 20% to 50% of people who experience a blood clot during pregnancy, usually found in a deep vein of the legs, pelvis, and arms, and can become a pulmonary embolism, if that clot travels to the lungs. Together, a deep vein clot and a pulmonary embolism are known as venous thromboembolism (VTE).
The third crucial risk factor is the nature of pregnancy as a hypercoagulable state. The CDC, which estimates that pregnancy causes a fivefold increase in the risk of blood clots, has tried to raise public awareness about the issue. VTEs account for 9% of all pregnancy-related deaths.
While ACOG's guidance says that detecting thrombophilias before, during, and after pregnancy would be a "logical target for prevention of the morbidity and mortality" resulting from these blood clots, it also says the link between inherited thrombophilias and blood clots in the uterus causing the worst outcomes remains "controversial." The organization doesn't recommend testing unless there is a personal or immediate family history of VTE.
A 2004 meta-analysis of research on recurrent pregnancy loss found that women who carried certain inherited thrombophilias such as factor V Leiden had twice the risk of experiencing two or more miscarriages than those without them. Another meta-analysis published in 2021 also suggested there could be a link between inherited thrombophilias and recurrent miscarriages and those with repeated losses should be tested for them. Still, that's far from routine. Testing for inherited thrombophilias rarely occurs after a miscarriage, and typically only is suggested after a person has a VTE.
"Medicine is just not designed to prevent. It's only designed to treat acute problems," Toppin explained. "They're not looking to do that."
Tests showed Teske had a mutation in the MTHFR gene, factor V Leiden, and elevated levels of lipoprotein(a), all of which made her vulnerable to blood clots during pregnancy.
When Toppin explained her proposed treatment plan, she showed Teske two images.
"I want you to understand why we're doing what we do, and why, when you may have tried things in the past, it may not have worked," she said. The first image showed a fertilized egg making its way down the fallopian tube. The second showed the fertilized egg, now a cluster of cells called a blastocyst, burrowing deep into the uterine wall in a process known as implantation.
Some of those cells invade the mother's blood vessels, forming the placenta, while other cells become part of the developing fetus. But when a mother's blood vessels are disturbed, platelets show up to heal the area by forming clots. Toppin suspects it's that combination of a hypercoagulable environment and an underlying tendency to clot that damages the endothelial cells lining blood vessels, leading to a miscarriage or pregnancy complications.
Ultrasound images of Vanessa and Jake Benson's daughter Grace, who was born after Vanessa had multiple miscarriages. Courtesy Vanessa BensonGiven Teske's increased risk of blood clots, Toppin wanted her to start taking blood thinners at ovulation until shortly after birth. For some patients, Toppin only prescribes a low-dose aspirin, which reduces inflammation and stops platelets from binding together to form clots. For patients like Teske, Toppin combines low-dose aspirin with a daily injection of LMWH, an anticoagulant that prevents blood clots during pregnancy, including the placenta. (If a patient doesn't get pregnant when trying to conceive, Toppin advises them to continue aspirin but stop LMWH until they ovulate again). The gene mutation that put Teske at risk of blood clots also meant that Teske couldn't metabolize folic acid, which is important for fetal development, so Toppin also gave her folate. And she prescribed Claritin to tamp down what seemed to be a potentially harmful overactive immune response, as evidenced by a history of hives.
Toppin acknowledged these treatments won't always prevent pregnancy loss. Not everyone with these risk factors will lose a pregnancy, and not every test will reveal an underlying problem. And when tests do indicate a problem, patients will want treatment — and Toppin understands that some providers won't want to provide treatments they don't feel are yet backed by enough evidence.
Despite those caveats, the tests are still worth doing, she argues.
"It's not what patients know, it's what they don't know that will harm them," Toppin said.
If tests don't show any problems, Toppin will weigh personal and family history in deciding whether to prophylactically treat patients like Vanessa Benson.
By the time Benson arrived at Toppin's clinic, she and her husband, Jake, had four consecutive miscarriages that ended between nine and 12 weeks. A physician referred them to an infertility clinic that recommended IVF.
But Benson's grandmother had 10 miscarriages, an aunt died of heart disease at 46, and her own clinical history of loss indicated there could be a clotting problem not captured by testing. Toppin told Benson to keep taking the progesterone another doctor had prescribed, but added in low-dose aspirin and LMWH. The Bensons were counseled on the risks of using LMWH — the most significant is excessive bleeding or hemorrhage — but both felt confident in their decision.
Four years into their parenthood journey, and within months of starting the medicines, Benson became pregnant again. She and Jake held their breath during the first ultrasound. But the moment they saw the embryo, they sobbed. When they came out of the exam room, the clinic's staff hugged them. In 2015, the Bensons welcomed a son, Connor, and two years later, a daughter, Grace.
The approach Toppin and other providers are taking has drawn pushback from others in the field — in particular, given how little robust evidence there is to support the use of LMWH.
"You can't go according to anecdotal evidence, and 'I have experience.' Anyone can say I have experience on this and that. Experience is not the way we do science today," said Sam Schulman, director of the thrombosis service at Hamilton General Hospital in Canada.
Schulman, also a professor at McMaster University's medical school, said that most clinics don't run tests for inherited thrombophilias after pregnancy loss because guidelines do not recommend them. He will consider the use of blood thinners if patients ask, because certain guidelines say that physicians should take their patient's beliefs and values into account.
The Food and Drug Administration has approved the use of LMWH for the prevention or treatment of major blood clots, but physicians can prescribe it "off-label" if appropriate. It is not recommended by ACOG for use in patients with inherited thrombophilia and early pregnancy loss.
But one systematic review that informed ACOG's guidance on major blood clots in pregnancy concluded that "women with thrombophilia are at risk of developing VTE and complications in pregnancy." It also noted that, "Low-dose aspirin plus heparin was the most effective in preventing pregnancy loss in thrombophilic women."
"Our goal from an organizational perspective is to produce evidence-based guidance and that patients receive the appropriate information regarding benefits, harms, and ultimately participate in the shared decision-making process for whatever evaluation, whatever intervention might be done," Christopher Zahn, ACOG's interim CEO, told STAT.
"We recognize that there are gaps, we recognize that we do need additional research and to some degree, that's where the art of medicine comes in," Zahn said. He said physicians want to do as much as they can to help women, but ACOG would not suggest or recommend an intervention when the evidence doesn't support it. He added that a healthy pregnancy can happen after a loss regardless of whether a woman received treatment, which makes it difficult to discern the impact of a given regimen.
The kind of research that ACOG, Schulman, and others want to see are more randomized clinical trials, though such studies are often difficult to run on pregnant participants.
The largest randomized trial ever run on the use of LMWH in women with recurrent pregnancy loss and who tested positive for inherited thrombophilia found no difference in birth rate between those who used the medications and those who didn't. "On the basis of our findings, we do not advise routine use of LMWH in women with recurrent pregnancy loss and confirmed inherited thrombophilia, and we advise against routine testing for inherited thrombophilia in women with recurrent pregnancy loss," the study authors wrote in the 2022 paper. Women were given these medications if they were less than seven weeks pregnant, which Toppin argues is too late — she believes the key is to get ahead of implantation, based on her clinical experience, though there is no conclusive evidence to support that theory.
Patients who had miscarriages told STAT that they wished they knew the kind of information they could get from blood testing before they got pregnant. Insurers will typically cover thrombophilia blood tests after two losses. Genetic testing now costs only a few hundred dollars.
Toppin said she does not want to drive up health care costs, but noted that one-time tests can also give patients information about their cardiovascular health later in life.
"What costs more — having recurrent pregnancy loss and then having a heart attack later or doing a blood test that might cost 200 bucks and preventing the patient from having that?" Toppin said. She added that miscarriage treatment can be expensive, cost people time off work, and can lead to long-term mental health issues that will also warrant treatment.
Toppin is familiar with the arguments against the approach: that there isn't evidence to support the use of LMWH for those who have a miscarriage or recurrent pregnancy loss, that it's overkill, or the risk of hemorrhage is too high.
Any blood thinner like aspirin and LMWH has a baseline risk of excessive bleeding. Toppin said she carefully considers the patient's full medical history to determine if they have a condition that can cause internal bleeding.
Jawed Fareed, a professor of pathology and pharmacology and director of Hemostasis and Thrombosis Research Laboratories at Loyola University Medical Center, told STAT that a dose of LMWH used preventively — which is less than a standard dose used for therapeutic purposes — has a lower risk of bleeding, which physicians can manage through careful monitoring. Given that a woman's menstrual cycle stops during pregnancy, patients with the greatest risk of bleeding are those who experience trauma such as a car accident or gastrointestinal conditions like an ulcer in pregnancy.
Aside from these cases, Toppin argued it's more harmful not to help people who have miscarriages. "If you're not doing everything in your power to investigate what things could potentially be a problem for a patient, then you're harming them in a way because you're not figuring it out," Toppin said.
When OB-GYNs use treatment methods that aren't indicated for a patient based on guidelines, they practice in a legal gray zone. It doesn't help that there is a perception among doctors that obstetrics is among the most litigious areas in medicine.
"This is where things get really muddy," said Lindsey Wimmer, a nurse practitioner who founded the pregnancy nonprofit Star Legacy Foundation after her son, Garrett, was stillborn at 38 weeks. Professional guidelines set a legal standard, she said, even if providers have other insight they've gathered from their own experience. "Unfortunately, a lot of times it's the patient that's stuck in the middle."
Teske during a February 2023 visit at the clinic. Toppin gave Teske several medications to take before and during pregnancy in a bid to reduce her chances of miscarriage. Jenn Ackerman for STATWhat Toppin and her clinic are doing might seem radical to some, or obvious to others. But it isn't a new idea.
In 1985, Alexander Kofinas, an OB-GYN, maternal fetal medicine specialist, and researcher based in New York City told STAT, he began using aspirin on his high-risk patients based on two European randomized clinical trials that were published the year before. Today, he routinely treats patients with aspirin and LMWH and advocates for the use of blood thinners where necessary to prevent the worst pregnancy outcomes.
Another researcher, Rodger Bick, a hematologist at the University of Texas Southwestern Medical Center who died in 2008, published a series of studies on the use of low-dose aspirin before conception and standard heparin (a drug used before LMWH) after conception for patients with recurrent miscarriages and an underlying thrombophilia. In a paper published in 2000, Bick's method led to a live birth for all but two of his 149 patients. Another paper published in 2005 showed similar success.
ACOG encourages clinics to publish their research, Zahn said. But he added that controlled studies — in which one group receives an intervention and is compared to another group that doesn't — yield "the kind of evidence you need to really make a difference in clinical recommendations."
Uma Reddy, a maternal-fetal medicine specialist who helped develop ACOG's guidance on pregnancy loss and served as the ACOG representative at the Eunice Kennedy Shriver National Institute of Child Health Stillbirth Working Group of Council, acknowledged that there is evidence for the use of aspirin compared to LMWH during pregnancy. "We have learned about starting before pregnancy, and that it's safe, that it's associated with other benefits, lower rate of preterm birth, lower stillbirth," Reddy said.
Some researchers argue that aspirin should be universally prescribed. But ACOG's guideline for the use of aspirin, updated this year, is conservative, saying "current evidence does not support the use of prophylactic low-dose aspirin for the prevention of early pregnancy loss, fetal growth restriction, stillbirth, or preterm birth," the guideline states.
Kofinas argued ACOG's guidelines are "a very poor-quality cliff notes, and everybody's practicing based on the cliff notes."
During the mid-aughts, Toppin wanted to do more to help her patients who were having losses. She attended a talk about blood thinner protocols given by Majed AbuHajir, a hematologist and oncologist then based at the Medical College of Wisconsin. AbuHajir had previously treated patients who needed blood thinners in pregnancy in collaboration with a MFM specialist.
During the event, Toppin asked AbuHajir about using the drugs during pregnancy. AbuHajir shared his experience: how LMWH helps reduce the formation of blood clots shortly after injection, how to carefully select patients, the need to modify the dose for factors like gestational age and monitor the amount of LMWH in the mother's blood. After Toppin's conversation with AbuHajir, she began collaborating with another hematologist who prescribed blood thinners for her patients until she became comfortable.
Like Toppin, he acknowledged that there are limitations to testing, including that it can't catch everyone at risk of blood clots and won't provide an explanation for many other miscarriages. In these cases, patients should still be evaluated by an experienced specialist who can make clinical judgments and offer appropriate interventions.
He argues that if a woman has had multiple miscarriages — even if testing shows she doesn't have blood clotting risks — doctors should use their clinical judgment and consider how to intervene.
"When you have guidelines that say only positive testing deserves your attention. That's potentially a broken approach. That's based on a misconception," AbuHajir told STAT. "The yardstick you use to classify patients is insufficient."
AbuHajir told STAT that he is also "extremely concerned" that guidelines do not recommend testing for inherited thrombophilias, which he said may fail to meet the needs of some patients. He compared the current standard of managing recurrent pregnancy loss to the time when doctors once treated patients with a blood clot with no clear cause. They would prescribe prophylactic blood thinners for a few months and then stop. The cycle would continue until the patient had episodes of recurrent clots, at which point, they got blood thinners for life. But today, most patients are given blood thinners for life after the very first major clot.
"We realized it's an insufficient approach and we need to identify them sooner and treat them sooner," he said. "A similar thing needs to happen for women with recurrent pregnancy loss."
Teske's family at the clinic in February 2023, after her son, Nathan, was born. Jenn Ackerman for STATA few weeks after her appointment with Toppin, Teske and her partner, Joe, were ready to try again. On April 10, 2022 a dollar store pregnancy test gave her the good, nerve-wracking news: She was pregnant.
Because of Covid restrictions, Teske went alone for her first ultrasound. She gripped the exam table until she saw the embryo. She desperately wanted to be happy, but for weeks, she waited for "the other shoe to drop."
"I was very toxic to myself those first 10 weeks," Teske said.
An at-home Doppler was the only thing that relieved her anxiety. One afternoon, she spent 45 minutes searching for the sounds of fetal activity, the familiar panic rising in her chest. She drove to Toppin's clinic, embarrassed to show up without calling.
"You've been through a lot," Teske recalled the office's receptionist, Denise Hanson, reassuring her. "This happens all the time."
Toppin, passing through the waiting room, spotted Teske and understood why she'd come in. She grabbed a portable ultrasound, ushered Teske into an empty exam room, began scanning her abdomen, and found all was well. The two laughed when Toppin told Teske that her bladder was full and had pushed the uterus away from its usual spot. Teske had a similar scare at 24 weeks. But as the pregnancy progressed healthily, her fears slowly began to subside.
On Dec. 14, Teske had her last ultrasound before her scheduled induction the following week. Aside from an air vent in the teal exam room, and the occasional crinkle of the paper covering the table Teske lay on, the room was quiet. The nurses had nicknamed Teske's baby Squishy. Soon, the sound of his heart pounded through the speakers at 145 beats per minute. The grainy black-and-white ultrasound showed him wiggling.
"He keeps moving on me," the sonographer, Kimberly Ruben, said. Teske blamed it on the Wendy's burger and two pieces of chocolate she just ate. Already, he seemed to take after her.
A few days later, temperatures dipped to -12 degrees Fahrenheit and winds howled on the eve of winter storm Elliott. Woodbury ground to a halt. But at Woodwinds Hospital, Teske was in labor. She spent the day walking the ward, dipping into a massive tub of water to relieve pain, and bouncing on a ball.
That evening, Teske gave birth to a baby boy named Nathan. He didn't cry. "Why isn't he crying?" Teske asked Joe.
No one answered. Time slowed. His lungs were suctioned. Teske heard him cry — relieved that he was alive. A nurse cleaned him, checked his vitals, and brought him to Teske.
After years of pain, and months of anxiety, Teske cried when she held her baby against her chest.
Teske turned to the nurse. "He's finally here."
This story is part of ongoing coverage of reproductive health care supported by a grant from the Commonwealth Fund.
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» ECLT» Euglobulin Lysis
» Factor V Leiden Mutation Prior to performing the genetic test for the factor V Leiden mutation, the activated protein C resistance (APCR) assay should be performed as a screening test. The factor V Leiden mutation test is performed when the APCR is positive. » Factor VII Activity Assay» Factor VII Functional Assay» Factor VIII Activity Assay» Factor VIII Functional Assay» Factor VIII Inhibitor Titer» Factor X Activity Assay» Factor X Functional Assay» Factor XI Activity Assay» Factor XI Functional Assay» Factor XII Activity Assay» Factor XII Functional Assay» Fibrinogen» FII» Fitzgerald Factor Activity Assay» FIX» FIX Inh» FIX Inhibitor» Fletcher Factor Activity Assay» FV» FVII» FVIII» FVIII Inh» FVIII Inhibitor» FVL» FX» FXI» FXII» Heparin Cofactor Activity» High Molecular Weight Kininogen Assay (Flaujeac Factor)» HMW Kininogen Assay» HMWK Assay» INR
» LAC» Leiden Gene Mutation
Prior to performing the genetic test for the factor V Leiden mutation, the activated protein C resistance (APCR) assay should be performed as a screening test. The factor V Leiden mutation test is performed when the APCR is positive » LMWH Anti-Xa Assay» Low Molecular Weight Heparin Anti-Xa Assay» Low-dose RIPA» Low-dose Ristocetin Induced Platelet Aggregation» Lupus Anticoagulant Profile» Non-specific inhibitor
» Partial Thromboplastin Time» Partial Thromboplastin Time Mixing Study» Partial Thromboplastin Time Substitution» PC» PK Assay» Platelet Aggregation» Platelet Aggregometry» Platelet Lumiaggregometry» PLT AGG» Prekallikrein Activity Assay» Protein C Activity» Protein C Functional» Protein S Activity» Protein S Functional (free)» Prothrombin Assay» Prothrombin Mutation 20210» Prothrombin Mutation G20210A» Prothrombin Time» Prothrombin Time Mixing Study» Prothrombin Time Substitution» Protime» Protime Mixing Study» PS» PT» PT 20210» PT Mix» PT Substitution» PT/INR» PTT» PTT Mixing Study» PTT Substitution» Reptilase Time, Plasma» Ristocetin Cofactor, Plasma» Ristocetin Response Curve» Screen for Factor V Leiden» TCT» Thrombin Clotting Time» Thrombin Time, Plasma» Thrombotic Thrombocytopenic Purpura» TT
» UFH Anti-Xa Assay» Unfractionated Heparin Anti-Xa Assay» Von Willebrand Disease Profile» Von Willebrand Factor Activity» Von Willebrand Factor Antigen» Von Willebrand Factor Cleaving Protease» Von Willebrand Factor Multimeric Analysis» Von Willebrand Factor Multimers» Von Willebrand Profile, Plasma» VWD» VWF Activity» VWF Ag» VWF Cleaving Protease» VWF:RCo
