Pregnancies with unexplained low PAPP-A are at increased risk for adverse perinatal outcomes including fetal death. In most patients, this is the result of poor placental development and placental insufficiency. First we test such patients for thrombophilia and immune issues to identify the most probable cause so we can treat the patient accordingly. Patients who test positive are treated with anticoagulants for thrombophilia and if they have immune issues also, they are treated with steroids or other immune treatments according to the findings. Most patients in our experience suffer from thrombophilia and are treated with anticoagulants only. At Kofinas Perinatal we monitor such pregnancies with ultrasound, fetal, placental, and uterine Doppler every two weeks. The treatment is adjusted according to the findings and the outcomes are excellent without any losses or any of the severe complications that have been reported in the literature.