Low Molecular Weight Heparin and/or Aspirin in Prevention of Habitual Abortion (HABENOX)

Role of LMWH (Enoxaparine) With or Without Aspirin in the Prevention of Habitual Abortion; Special Attention to the Thrombophilic Status of the Mother

1 % of all pregnancies end in habitual/recurrent abortion. In about half of women with habitual abortions (HAB) hereditary or acquired (antiphospholipid antibodies) thrombophilia are observed. The investigators wanted to test whether antithrombotic treatment (Low-Molecular Weight Heparin, LMWH, ASA or both combined)would prevent these women from a subsequent abortion. Depending on thrombophilic status the women included in one of the three sub-studies: HABENOX 1 (mild, single thrombophilia), HABENOX 2 (no known thrombophilia), HABENOX 3 (moderate to severe thrombophilia, with combined thrombophilia or moderate to high titer antiphospholipid antibodies).

Study design: Randomised placebo controlled multicenter study.

Number of patients per study: 90 patients per group, 270 altogether.

Timetable: Starting 2/2002, finishing 31.12.2007.

Time frame: >37 weeks of gestation and >24, but <37 weeks of gestation (premature)

Treatment started before 7. gw.

HABENOX 1 and 2:

Study groups:

Group 1 : Enoxaparin 40 mg+ placebo, Group 2: Enoxaparin 40 +ASA 100 mg, Group 3: ASA.

HABENOX 3:

Study groups:

Group 1: Enoxaparin 40 twice daily+ placebo o.d., Group 2: Enoxaparin 40 mg twice daily +ASA 100 mg o.d.

Primary end-points:

Pregnancy outcome: livebirths ( ≥37 weeks of gestation), premature livebirths (≥24, but <37 weeks of gestation)

Secondary end-points: Bleeding complications, intrauterine growth retardation (<-2SD), pre-eclampsia, abruptio placentae,

Ending: In the group of combined medication, tablets will be stopped at 36 weeks of gesta-tion. LMWH will be started in all patients after delivery and continued 6 weeks postpartum.

Study Overview

• Status: Completed
• Conditions: Habitual Abortion
• Intervention / Treatment: Drug: Aspirin; Drug: Klexane; Drug: Klexane and ASA

Detailed Description

Background: The prevalence of spontaneous abortions is 1000-1500/10000 pregnancies per year meaning that 10-15% of all pregnancies will end in an abortion; 1/10 of these abortions are recurrent (1 % of all pregnancies). In about half of women with habitual abortions (HAB) hereditary (F V Leiden, F II (prothrombin) mutation, Protein C, S deficiency and anti-thrombin) or acquired (antiphospholipid antibodies) thrombophilia are observed. Efficacy of the medical treatment of patients with a history of HAB has yet to be completely demonstrated. We have recently shown that low-molecular-weight heparin (LMWH) is as effective as unfractionated heparin in prevention of thromboembolic complications in pregnant women and causes less bleeding complications (UFH) and has no osteoporotic effect. LMWH could be safer than UF-heparin during long treatment periods (7-8 months).

Study design: Randomised placebo controlled multicenter study.

Centers: Helsinki (2), Oulu (1), Stockholm (1), Leiden (1)

Number of patients per study: 90 patients per group, 270 altogether

Timetable: Starting 2/2002, finishing 31.12.2007

Drugs:

HABENOX 1 and 2: Study groups Group 1 : Enoxaparin 40 mg+ placebo, Group 2: Enoxaparin 40 +ASA 100 mg, Group 3: ASA.

HABENOX 3: Study groups Group 1: Enoxaparin 40 twice daily+ placebo o.d., Group 2: Enoxaparin 40 mg twice daily +ASA 100 mg o.d.

Time frame: one year since entering the study with primary end-points:livebirths (> 37 weeks of gestation) and premature livebirths (> 24, but <37 weeks of gestation)

Primary end-points: Pregnancy outcome: livebirths (>37 weeks of gestation), premature livebirths (> 24, but <37 weeks of gestation) Secondary end-points: Bleeding complications, intrauterine growth retardation (<-2SD), pre-eclampsia, abruptio placentae,

Inclusion criteria: Three or more consecutive abortions of first trimester (ad h 12+6 wks) or two second trimester abortions (ad h 13 wks-23+6 wks) or one third trimester abortion (24 weeks or more) with one first-second trimester abortions. Depending on the thrombophiliatest (tested before pregnancy) result the patients will included in one of the three sub-studies:

1. HABENOX 1: those who have one thrombophiliatest positive: F V Leiden (heterozygote) or protein C or S deficiency, or anticardiolipin antibodies (low to moderate level), prothrombin gene mutation, or high level of F VIII.
2. HABENOX 2: those with thrombophilia test negative
3. HABENOX 3:those with "high risk" thrombophilia: positive combined thrombophilia, F V Leiden (homozygote), anticardiolipin antibodies (high level >40) , lupusanticoagulant, or AT III deficiency.

During next pregnancy the patient, with inclusion criteria fulfilled, will be asked to sign informed consent and she will be allocated into one of the three treatment groups. The treatment will be started before 7 weeks of gestation. At baseline and follow-up visits plasma, serum and 20 ml morning urine will be frozen (analysed later for antithrombin, protein S, C, APC ratio, PAI1, PAI2, U-PAR, D-dimer, thrombin-antithrombin (TAT) complex, CRP, TNFalpha(+ receptor), ICAM, VEGF(+receptor), urinary stabile metabolites of thromboxane and prostacyclin.

Follow-up: US/Doppler + obstetric check-up at 8, 10, 14, 18, 24, 28, 32 and 36 weeks of gestation Ending: In the group of combined medication, tablets will be stopped at 36 weeks of gesta-tion. LMWH will be started in all patients after delivery and continued 6 weeks postpartum.

• Study Type: Interventional
• Enrollment (Actual): 220
• Phase: Phase 3

Contacts and Locations

Study Locations

• Finland
  • Helsinki, Finland, 00290
    • Helsinki University Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: Female

Description

Inclusion Criteria:

• Habenox 1: Three or more consecutive abortions of first trimester (ad h 12+6 wks) or two second trimester abortions (ad h 13 wks-23+6 wks) or one third trimester abortion (24 weeks or more) with one first-second trimester abortions and one thrombophiliatest positive: F V Leiden (heterozygote) or protein C or S deficiency, or anticardiolipin antibodies (low to moderate level), prothrombin gene mutation, or high level of F VIII.
• HABENOX 2: The thrombophilic tests above are negative.
• HABENOX 3:positive combined thrombophilia, F V Leiden (homozygote), anticardiolipin antibodies (high level >40) , lupusanticoagulant, or AT III deficiency.

Exclusion Criteria:

• History of DVT or pulmonary embolism.
• Significant bleeding history.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: ASA; The patients received either Enoxaparine+placebo, Enoxaparine+ASA (Aspirin 100 mg) or ASA alone.ASA or placebo were blinded in the two first groups.	Drug: Aspirin; ASA 100 mg once daily per os
Active Comparator: Klexane; Clexane (enoxaparine) 40 mg sc	Drug: Klexane; Klexane 40 mg sc once daily (HABENOX 1 and 2), Klexane 40 mg twice daily in HABENOX 3
Active Comparator: Aspirin and Enoxaparine	Drug: Klexane and ASA; Klexane 40 mgx 1 sc and ASA 100 mg po

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Pregnancy outcome: livebirths (>37 weeks of gestation), premature livebirths (> 24, but <37 weeks of gestation)	gestational weeks >37 and gestational weeks > 24, but <37

Secondary Outcome Measures

Outcome Measure	Time Frame
Bleeding complications, intrauterine growth retardation (<-2SD), pre-eclampsia, abruption placenta	gestational weeks > 37 and gestational weeks >24, but <37

Collaborators and Investigators

• Sponsor: University of Helsinki
• Collaborators: Karolinska University Hospital; Oulu University Hospital; Leiden Hospital, Leiden, The Netherlands
• Investigators: Principal Investigator: Veli-Matti Ulander, MD, Helsinki University Hospital, Finland; Study Chair: Laure Morin-Papunen, MD, Oulu University Hospital; Study Chair: Katja Lampinen, MD, Karolinska University Hospital; Study Chair: Kitty Bloemenkamp, MD, Leiden University Hospital, Leiden, The Netherlands; Study Chair: Janvier Visser, MD, Leiden University Hospital, Leiden, The Netherlands

Publications and helpful links

General Publications

• Hamulyak EN, Scheres LJ, Marijnen MC, Goddijn M, Middeldorp S. Aspirin or heparin or both for improving pregnancy outcomes in women with persistent antiphospholipid antibodies and recurrent pregnancy loss. Cochrane Database Syst Rev. 2020 May 2;5(5):CD012852. doi: 10.1002/14651858.CD012852.pub2.

Study record dates

Study Major Dates

• Study Start: January 1, 2002
• Primary Completion (Actual): December 1, 2004
• Study Completion (Actual): December 1, 2008

Study Registration Dates

• First Submitted: July 21, 2009
• First Submitted That Met QC Criteria: August 13, 2009
• First Posted (Estimate): August 14, 2009

Study Record Updates

• Last Update Posted (Estimate): August 14, 2009
• Last Update Submitted That Met QC Criteria: August 13, 2009
• Last Verified: August 1, 2009

More Information

Terms related to this study

• Keywords: aspirin; premature birth; preeclampsia; Habitual abortion; ASA; miscarriage; thrombophilia; recurrent abortion; hereditary and acquired; stillbirth; LMWH (low molecular weigh heparin)
• Additional Relevant MeSH Terms: Pregnancy Complications; Abortion, Spontaneous; Abortion, Habitual; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Peripheral Nervous System Agents; Enzyme Inhibitors; Analgesics; Sensory System Agents; Anti-Inflammatory Agents, Non-Steroidal; Analgesics, Non-Narcotic; Anti-Inflammatory Agents; Antirheumatic Agents; Fibrinolytic Agents; Fibrin Modulating Agents; Platelet Aggregation Inhibitors; Cyclooxygenase Inhibitors; Antipyretics; Aspirin
• Other Study ID Numbers: HABENOX