Low Papp-A Levels - anyone have experience of this?

[SukieQ]

Had my 12 week scan today, and as I had a MMC at 12+2 in April I was a bit in shock and relieved that the baby was alive and I was still pregnant, so I didn't take everything in when I got the scan report.

With the Downs and Trisomy 13/18 screening I had good results and low adjusted risk for both (around 1:14000). Nasal bone present, NT 1.44mm.

But my bloods showed low Papp-A at 0.2913 MoM so they'll rescan in third trimester for growth they said. I took that at face value and didn't know what Papp-A was, but looked it up and realise the possible risk with still birth, premature labour, and IUGR. I figure they couldn't have calculated the Papp-A in my Downs risk as it was still so low. I'm going to call them tomorrow but it's sometimes hard to get through. Asking a couple friends who are doctors too.

My hCG was 0.5403 MoM so I don't know if this is low or high.

Does anyone have any experience of Papp-A and what is the course of action you took? Did you rescan privately? Or have 3rd tri scans? And did you have any problems in 3rd tri?

TIA.

[tholeon]

hi there,

I am 29 weeks now and had low papp a results (about .28). I'm getting extra growth scans - at the first one, last week, everything was normal so so far so good. I also terrified myself googling. I think that the thing to remember though is that yes it is a risk factor but the balance of probability is still that everything should be fine. I don't think that there is much point rescanning prior to the third trimester regarding growth/ placenta issues, and I doubt that the papp a results would change your chromosome issues score enough to be a concern (mine was about 1 in 500 for downs, I think, and I'm 38.) I am monitoring myself at home for blood pressure/ PE issues but I am also at risk for these as experienced them in my last pregnancy - again, so far, so good. I think that the main thing is to insist on careful monitoring in the last tri. I am also considering pushing for induction at 38 weeks even if all is well as I think it is possible that by then baby may be safer out than in. Keep me posted on anything you find out and best of luck. x

[mummytoh1]

Hi, I had low Papp-a, 0.39MoM. I also had a high risk down syndrome result which is characterised as low Papp-a, high hcg and high nuchal fold (plus age is a factor). The Papp-a and hcg results are indexed against 1 being average so your hcg being low rather than high is likely a factor in your low risk result.

As for the Papp-a Boone at my hospital was bothered so I paid for a private scan at 28 weeks which showed good growth (above average in fact!). It also identified a low lying placenta so I had another scan at 34 weeks which also did growth as a matter of course and my baby was still measuring above average! When he was born he was >75th centile for weight so all turned out great.

I also spoke to Abtenatal Results and Choices who said that there was no solid research to back up claims that low Papp-a led to growth problems, - although they couldn't say this wasn't the case there wasn't the evidence to say there was either.

The senior sonographer who did the private scan also said that she hadn't seen evidence of a link either...

I hope that helps you feel more positive.

[Jan2012]

I am also currently pregnant (33 weeks) with low Papp-a (0.4 MtM). My doctor did highlight the risks of low Papp-a to me, but said that, in his experience, it has never resulted in any problems, but he is monitoring me a bit more closely for growth issues now that I am in my third trimester. So far so good, and my baby is also actually measuring a bit ahead of average. He did, however, say that he might want to induce me early (37 weeks!), since at that stage, the baby will be seen as full term, and he doesn't see the need for taking any further risks given the low papp-a.
I haven't been able to find any research or treatment protocol that supports this, though, so will definitely go for a second opinion before agreeing to this.

[tholeon]

hi all,

How are you doing SukieQ? A bit less worried I hope.

Jan2012 can I ask you if you are in the UK? I mentioned a possible induction at 38 weeks at my last consultant's clinic appointment and they said that if all was still ok by then there would be no need. But I'm really not sure about this, so was interested to read that you had had different advice.

[leddeeburdee]

I had low Papp- A in my second pregnancy and was given a monthly scan all the way through from 12 weeks to check all was ok. It didn't give me any problems although I found the regular scans reassuring. DD was on time and totally fine.

[SukieQ]

hi - thanks for the responses. Sorry I posted this on two threads but didn't get much reply on the pregnancy thread and forgot to check this one again. So far so good.... Had 16 week check today and now have to wait for anomaly scan at 22 weeks, midwife at 25, and extra scan at 28. Get the impression (at UCLH london) that if all looks ok then, they leave it at that. I am trying to relax and cross that bridge when we come to it, as we won't know if it's nothing or if it's a bad indicator until then. I spoke to a friend who's a GP in canada and she said low papp-a does have a predicative value for risks like pre-term, pre-eclampsia, IUGR but that its a low predicative value so in canada they don't even test for it as a standalone. Another friend who is a GP here said the same - and just go with the flow for now. So I'm trying to do that but easier said than done. Thanks for everyone's comments though. Fingers crossed.

[SirCharles]

oh I am so relieved to find this thread!

I had a low PAPP-A score at my 12 week combined test and have been told that recent studies show this may indicate an increased risk of pre-eclampsia

I am under a Consultant at a London teaching hospital due to a separate health issue and she seemed reasonably relaxed about the PAPP-A being low but did basically tell me to do all I can to reduce all my manageable risk factors. As far as I can tell this means not putting on any more weight (I have a BMI of 30), taking more exercise and reducing stress. Unfortunately I am only 14 weeks so can see these objectives could be setting me up to fail!!!!! My mother had pre-eclampsia with all 4 babies and had each of us by CS prematurely - I have no idea if this adds to my risk factor or not but the Consultant was interested and wrote it all down.

I get the impression there is no point worrying until the 3rd trimester - if only I could resist the urge to google it I might be able to relax!!

The hospital wants to do extra tests at the 20 week scan to check the placenta and "flow". Fingers crossed these go well. I am off on a very long holiday at Christmas and am concerned I will need to come back early if the risks are still present. At least I will get monitored more though - every cloud has a silver lining ;)

Good luck!

[SirCharles]

oh, I forgot to add - I am now taking a low daily dose of aspirin (on Dr's advice) as this can help reduce the risks of pre eclampsia

[SukieQ]

good luck with your pregnancy Sir Charles. I'm taking the same road and just trying to not worry about it until the 20 week scan (when I'll be nuerotically asking about placenta blood flow) and the until the 3rd trimester. Just biding time until then. More often than not it seems to indicate nothing, so I'm going with that. I've got blood pressure on the low end of normal (100/60) so I've not go the same pre-eclampsia worry as you, but try not to stress. These things can't be helped to a large part. I know my mum's BP spiked when she was 2 weeks overdue with me. So like everything else, cross that bridge when I come to it! Take care for now.

[SirCharles]

Thanks SukieQ. Good luck with your 20 week scan. Mine is 19 Dec. fingers crossed all is well then!

[SukieQ]

Ah good luck. I'm not having next scan until mid Jan, so have all december, xmas etc to get through, which is why I'm opting to stick my head in the sand and just see where we are in January...

[tholeon]

Hi just to update have noe had 32 week scan and all still good! Docs didn't seem too worried about Papp a stuff at all. Hope to be able to post more good news in a few weeks.

[SirCharles]

Good news. Fingers crossed for you tholeon. Not long to go! Good luck

[SukieQ]

That's good news. I'm 17 weeks now and think have just started to feel the bubbly movements I felt with my first. Finally exhaling on that one, but now worried about the placenta, Papp-A all again. From one neurosis to the next I guess. Sigh.

Good to hear you are looking out of the woods. Let us know how you get on Tholeon. Interested to know if they let you go past 40 weeks, or if you decide with them not to sooner at 37 etc. Is that it for growth scans now for you or will you have another? Good luck with it all.

And good luck with your scan on 19th SirCharles. Fingers crossed all around but let's hope this is just early research that is more often than not not very indicative, and that I'm in a tizzy over nothing.

[summerpixie]

Hi. I thought I would add my experience on here.
I had a triple test at 12 weeks and my results came back with extremely low Papp a (0.17MoM). I had a CVS at queen charlottes which I cried through due to the emotions. I got my results back 3 days later and was told my baby was clear. They didn't do a full genetic test and don't give out the sex of the baby. However queen charlottes do research into the link between low Papp a/iugr/ds/premature birth so if you're London based you could contact them. They told me if i took part in the research I would have scans every month. I didn't participate due to work and distance to the hospital.
Anyway, the consultant who did my CVS advised for me to have an extra scan in 3rd trimester. I think I had one at 32 34 and 36 weeks. I know 36 was the last as DD arrived at 37weeks.
My scans ended up being for excessive growth as she was measuring on the 95th pc. She ended up being just over the 50th at 7lb 11oz. She was born early due to me having a sweep as my agonizing puppp rash had returned but consultant used the risk of premature birth as an excuse on paper.
So in all, IME Papp a levels do not always affect growth of baby. Enjoy your pregnancies and just look forward to having extra scans to see your LO's again.

[tholeon]

Thanks summer pixie. Final update from me: dd born on Friday at 37'.5 and a good weight, all well. There was talk of induction due to some dodgy blood pressure readings but in the end I went into labour naturally so no need. So no need to panic about papp a, it doesn't have to mean a lot. Best of luck to everyone on this thread.

[SukieQ]

Ah congrats. That's great. Good to know it had no negative implication on your pregnancy. I've got my anomaly scan tmrw at 22+1 and am bricking it worried about placenta blood flow and growth. argh. i hate scans.

[benne81]

Hi just wanted to post on here for others searching for information. I had a v low pappa 0.29 and raised trisomy 18 risk and was terrified aboutvwhat that meant. I was started on aspirin at 14 weeks and had reg growth scans which were all normal. I gave birth to a normal gorgeous DS who I am breastfeeding now!

My friend also had low pappa with poor growth (which improved with aspirin) and placental notchs and has a perfect 8 month old.

Although it is absolutely horrible getting the increased risk try to think positive that at least people will keep a closer eye on you during the pregnancy. I had so many scans (paid for a few privately) that I can't imagine having a 'normal pregnancy' and only having two. Also remember increased risk doesn't always mean a bad outcome.

[SirCharles]

thanks benne. I am now 27 weeks and still trying not to dwell on the "what ifs" so good to hear some good stories. fingers crossed!
I too cannot imagine having only 2 scans during the entire pregnancy - we have had 4 now and still got at least another 2 booked!!
As my consultant said - just because they have identified I am higher risk it still does not mean anything bad will happen!

[jodemontgros]

We had low PAPP-A at 12 weeks, and a follow up DS test which was negative. We had ongoing growth tests and these were very reassuring as we could see that the fetal growth rates were good. But then i had an abruption at 30 weeks (gushing blood in the middle of the night) and an emergency c-section. But we are now at home with a healthy little boy! In hindsight I should have been more aware of the risks of an abruption and taken things a little steadier. Had the c-section not been available within the hour, our baby may not have made it and I could also have suffered much more with the loss of blood. I would recommend having a back-up plan in place if you are travelling during later pregnancy. Anything you can do to keep your baby inside an extra week is good!

[HopefulHamster]

Hi jodemontgros, how low was yours? In the cases I've read it seems there's more risk when it's at the er, low end of the low scale! But results obviously vary too.

I'm glad to have found this thread though I know many of the posts are old.

I am pregnant with my second child. I had low papp-a with my first (.47) and it's even lower this time around (.41). I don't know whether to take comfort from the fact it's been low both times - my son was two weeks overdue and fine - or to worry (which is my natural reaction).

As it's .41 it hasn't been flagged up - I believe most hospitals do if it's under .40. But I'll mention it when I have my consultant appointment in May and hope I can have growth scans.

[Sabina198281]

Hi .
I had my 12 +3 week scan on 12 March and had very low pepp-a , because of low level pepp-a doc said I m at high risk 1/104 for ds , didn't want to go for chromosomal abnormality test .but waiting for 20 week scan which is on 29th April . Any one can advice what should I do to improve pepp-a level . :(

[KittyandTeal]

I'm the voice of grim I'm afraid.

I had low papp a and low hcg. Was deemed low risk for both T21 and T13 and T18. No soft markers at 12 week scan.

I had extra scans booked in but they found soft markers at my anomoly scan.

Amino came back positive for T18 and my dd was born at 22weeks.

My advice would be to pay for a harmony test privately or ask for a cvs. I was deemed low risk with my hospital but when kings ran my blood results they came out with a 1:43 chance.

I say this because if you did decide on a tfmr like I did it is slightly 'better' before 21 weeks. After that you have to go to a fetal specialist centre to stop the baby's heart, that was easily the worst part of the process for me.

I really don't want to stress you out or be the voice of doom but I wish I had pushed for a cvs earlier. The result would have been the same but I wouldn't have had to go through the termination injection at Kings. (Anyone who does have to go through it the staff are wonderful and make it as easy as possible but I'd still have opted for earlier)

I really hope his is just a random result for you though

[KittyandTeal]

Crap, zombie thread.

Sorry

[jodemontgros]

Hi there - sorry to hear about both of your experiences Sabina and Kitty.

Sabina - for me the DS risk was relatively low due to an ok NT result, so our concern was really more about baby growth and potential for early delivery rather than the early tests. But my understanding is that there isn't anything you can do to improve papp-a - i think it is thought to be a measure of the placenta efficiency. We pushed for monthly growth scans after 20 weeks, and took a lot of background research with us for the 20 week meeting (make sure you see a doctor/consultant at this stage, not just midwife) as the NHS in the UK does not yet have any guidance on papp-a risks, so the may say that they are unable to do anything. I expect you will get a good indication of growth at the 20 week scan, but I think that it is worth pushing for ongoing checks, as my understanding is that poor placental efficiency would be more likely to kick-in with growth restriction in the 3rd trimester. I wish there was more I could say as this period of waiting must be really hard for you. Wishing you all the best and also hoping that this is just a random low reading.

Kitty - I'm now 2.5 years on from a TFMR with my pregnancy before the low papp-a one. We had a suspected partial molar (baby looked fine, but placenta had massive growth on it) and also decided to opt for the earlier TMFR route given the very poor prognosis and associated health risks. I can't say that I regret the decision as I think it was the right one at the time, and we have been so lucky to go on to have another beautiful and happy boy. But there are definitely times when i wonder whether there could have been a chance of life worth trying harder for, of whether I would have had a girl or boy. I think it's ok to live with that sadness and some pain from events that I would never have chosen to go through (don't you get mad now when people suggest that pro-choice is simply all about dealing with unprepared teenagers) - but I really hope that things have turned out for you well since then and that the sadness is not still too raw.

All the best to you both