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Pecker LH, Cameron K. Sickle cell disease and infertility risks: implications for counseling and care of affected girls and women. Expert Rev Hematol 2024:1-12. [PMID: 38913857 DOI: 10.1080/17474086.2024.2372320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 06/21/2024] [Indexed: 06/26/2024]
Abstract
INTRODUCTION Sickle cell disease (SCD), its treatments and cures present infertility risks. Fertility counseling is broadly indicated for affected girls and women and fertility preservation may appeal to some. Several streams of evidence suggest that the reproductive lifespan of women with SCD is reduced. Pregnancy is associated with high miscarriage rates. There are enduring questions about the effects of highly effective hydroxyurea treatment on female fertility. Current conditioning regimens for gene therapy or hematopoietic stem cell transplant are gonadotoxic. Fertility preservation methods exist as non-experimental standards of care for girls and women. Clinicians are challenged to overcome multifactorial barriers to incorporate fertility counseling and fertility preservation care into routine SCD care. AREAS COVERED Here we provide a narrative review of existing evidence regarding fertility and infertility risks in girls and women with SCD and consider counseling implications of existing evidence. EXPERT OPINION Addressing fertility for girls and women with SCD requires engaging concerns that emerge across the lifespan, acknowledging uncertainty and identifying barriers to care, some of which may be insurmountable without public policy changes. The contemporary SCD care paradigm can offer transformative SCD treatments alongside comprehensive counselling that addresses fertility risks and fertility preservation opportunities.
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Affiliation(s)
- Lydia H Pecker
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katie Cameron
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Reproductive Endocrinology and Infertility, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Mendez GG, Nocek JM, Brambilla DJ, Jacobs S, Cole O, Kanter J, Glassberg J, Saving KL, Melvin CL, Gibson RW, Treadwell M, Jackson GL, King AA, Gordeuk VR, Kroner B, Hsu LL. Social determinants of health and treatment center affiliation: analysis from the sickle cell disease implementation consortium registry. BMC Health Serv Res 2024; 24:291. [PMID: 38448911 PMCID: PMC10916176 DOI: 10.1186/s12913-024-10717-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/13/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Adults with sickle cell disease (SCD) suffer early mortality and high morbidity. Many are not affiliated with SCD centers, defined as no ambulatory visit with a SCD specialist in 2 years. Negative social determinants of health (SDOH) can impair access to care. HYPOTHESIS Negative SDOH are more likely to be experienced by unaffiliated adults than adults who regularly receive expert SCD care. METHODS Cross-sectional analysis of the SCD Implementation Consortium (SCDIC) Registry, a convenience sample at 8 academic SCD centers in 2017-2019. A Distressed Communities Index (DCI) score was assigned to each registry member's zip code. Insurance status and other barriers to care were self-reported. Most patients were enrolled in the clinic or hospital setting. RESULTS The SCDIC Registry enrolled 288 Unaffiliated and 2110 Affiliated SCD patients, ages 15-45y. The highest DCI quintile accounted for 39% of both Unaffiliated and Affiliated patients. Lack of health insurance was reported by 19% of Unaffiliated versus 7% of Affiliated patients. The most frequently selected barriers to care for both groups were "previous bad experience with the healthcare system" (40%) and "Worry about Cost" (17%). SCD co-morbidities had no straightforward trend of association with Unaffiliated status. The 8 sites' results varied. CONCLUSION The DCI economic measure of SDOH was not associated with Unaffiliated status of patients recruited in the health care delivery setting. SCDIC Registrants reside in more distressed communities than other Americans. Other SDOH themes of affordability and negative experiences might contribute to Unaffiliated status. Recruiting Unaffiliated SCD patients to care might benefit from systems adopting value-based patient-centered solutions.
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Grants
- 3U01HL134042-04S2 NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NIH HHS
- 5U01HL134042-S2 NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NIH HHS
- U24HL133948, U01HL133964, U01HL133990, U01HL133996, U01HL133994, U01HL133997, U01HL134004, U01HL134007, U01HL134042 NIH HHS
- NIH
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Affiliation(s)
- Gustavo G Mendez
- University of Illinois Chicago, 840 S. Wood St., MC 856 Pediatrics, 60612, Chicago, IL, USA
| | - Judith M Nocek
- University of Illinois Chicago, 840 S. Wood St., MC 856 Pediatrics, 60612, Chicago, IL, USA
| | | | - Sara Jacobs
- RTI International, Research Triangle Park, USA
| | | | - Julie Kanter
- University of Alabama at Birmingham, Birmingham, USA
| | | | - Kay L Saving
- University of Illinois College of Medicine at Peoria, Peoria, USA
| | | | | | | | - George L Jackson
- Duke University, Durham, USA
- Durham Veterans Affairs Health Care System, Durham, USA
- University of Texas Southwestern Medical Center, Dallas, USA
| | | | - Victor R Gordeuk
- University of Illinois Chicago, 840 S. Wood St., MC 856 Pediatrics, 60612, Chicago, IL, USA
| | | | - Lewis L Hsu
- University of Illinois Chicago, 840 S. Wood St., MC 856 Pediatrics, 60612, Chicago, IL, USA.
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Early ML, Raja M, Luo A, Solow M, Matusiak K, Eke AC, Shehata N, Kuo KH, Lanzkron S, Malinowski AK, Pecker LH. Blood pressure thresholds for the diagnosis of hypertensive disorders of pregnancy in sickle cell disease. Br J Haematol 2024; 204:1039-1046. [PMID: 38093478 PMCID: PMC10939908 DOI: 10.1111/bjh.19248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/11/2023] [Accepted: 11/27/2023] [Indexed: 01/19/2024]
Abstract
In this retrospective cohort study of singleton pregnancies in people with sickle cell disease (SCD) delivered at two academic centres between 1990 and 2021, we collected demographic and SCD-related data, pregnancy outcomes, and the highest systolic and diastolic blood pressure (SBP and DBP) at seven time periods. We compared the characteristics of subjects with new or worsening proteinuria (NWP) during pregnancy to those without. We then constructed receiver operating characteristic (ROC) curves to determine the blood pressure (BP) that best identifies those with NWP. The SBP or DBP thresholds which maximized sensitivity and specificity were 120 mmHg SBP (sensitivity: 55.2%, specificity: 73.5%) and 70 mmHg DBP (sensitivity: 27.6%, specificity: 67.7%). The existing BP threshold of 140/90 mmHg lacked sensitivity in both genotype groups (HbSS/HbSβ0 : SBP = 21% sensitive, DBP = 5.3% sensitive; HbSS/HbSβ+ : SBP = 10% sensitive, DBP = 0% sensitive). Finally, percent change in SBP, DBP and MAP were all poor tests for identifying NWP. Existing BP thresholds used to diagnose hypertensive disorders of pregnancy (HDP) are not sensitive for pregnant people with SCD. For this population, lowering the BP threshold that defines HDP may improve identification of those who need increased observation, consideration of early delivery and eclampsia prophylaxis.
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Affiliation(s)
- Macy L. Early
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Maidah Raja
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amy Luo
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Marissa Solow
- Division of Haematology, Department of Medicine, University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Kristine Matusiak
- Division of Haematology, Department of Medicine, University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Ahizechukwu C. Eke
- Division of Maternal-Fetal Medicine & Clinical Pharmacology
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nadine Shehata
- Division of Hematology, Sinai Health System, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kevin H.M. Kuo
- Division of Haematology, Department of Medicine, University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Sophie Lanzkron
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ann Kinga Malinowski
- Division of Hematology, Sinai Health System, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Maternal-Fetal Medicine, Sinai Health System
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Lydia H. Pecker
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Early ML, Luo A, Solow M, Matusiak K, Eke AC, Shehata N, August P, Kuo KH, Lanzkron S, Malinowski AK, Pecker LH. Natural history of blood pressure in sickle cell disease pregnancy. Br J Haematol 2024; 204:658-667. [PMID: 37803527 PMCID: PMC10903988 DOI: 10.1111/bjh.19133] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/05/2023] [Accepted: 09/19/2023] [Indexed: 10/08/2023]
Abstract
In this retrospective cohort study of singleton pregnancies in people with sickle cell disease (SCD) delivered at two academic centres between 1990 and 2021, we collected demographic and SCD-related data, pregnancy outcomes, and the highest systolic and diastolic blood pressure (SBP and DBP) at seven time periods. We compared blood pressure values and trajectories in the composite cohort and in each genotype group to control values in a non-SCD pregnancy dataset. There were 290 pregnancies among 197 patients with SCD. Sixteen per cent (n = 47) of pregnancies had a hypertensive disorder of pregnancy (HDP); the rates did not differ by genotype. The mean SBP and DBP were lower in the HbSS/HbSβ0 group than in the non-SCD control group at all timepoints. Mean SBP and DBP trajectories were similar between the HbSS/HbSβ0 group and non-SCD controls, whereas the mean SBP and DBP in the HbSC/HbSβ+ group decreased between the first and second trimesters and plateaued between the second and third trimesters. There were no differences in blood pressure trajectory by haemoglobin >/< 10 gm/dL or by chronic transfusion status. Overall, pregnant people with SCD have lower blood pressure than unaffected pregnant people, raising the possibility that HDP are underdiagnosed, particularly in people with HbSS/HbSβ0 .
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Affiliation(s)
- Macy L. Early
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Amy Luo
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore MD, USA
| | - Marissa Solow
- Division of Haematology, Department of Medicine, University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Kristine Matusiak
- Division of Haematology, Department of Medicine, University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Ahizechukwu C. Eke
- Division of Maternal-Fetal Medicine & Clinical Pharmacology
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nadine Shehata
- Division of Hematology, Sinai Health System, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Phyllis August
- Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Kevin H.M. Kuo
- Division of Haematology, Department of Medicine, University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Sophie Lanzkron
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Ann Kinga Malinowski
- Division of Maternal-Fetal Medicine, Sinai Health System
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Lydia H. Pecker
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD USA
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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5
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Sinkey RG, Ogunsile FJ, Kanter J, Bean C, Greenberg M. Society for Maternal-Fetal Medicine Consult Series #68: Sickle cell disease in pregnancy. Am J Obstet Gynecol 2024; 230:B17-B40. [PMID: 37866731 PMCID: PMC10961101 DOI: 10.1016/j.ajog.2023.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Pregnant individuals with sickle cell disease have an increased risk of maternal and perinatal morbidity and mortality. However, prepregnancy counseling and multidisciplinary care can lead to favorable maternal and neonatal outcomes. In this consult series, we summarize what is known about sickle cell disease and provide guidance for sickle cell disease management during pregnancy. The following are Society for Maternal-Fetal Medicine recommendations.
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Joseph L, Driessen M. A comprehensive view of pregnancy in patients with sickle cell disease in high-income countries: the need for robust data and further decline in morbidity and mortality. Lancet Haematol 2024; 11:e75-e84. [PMID: 38135375 DOI: 10.1016/s2352-3026(23)00310-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 12/24/2023]
Abstract
Sickle cell disease is a major public health concern due to its prevalence and associated morbidities. In high-income countries, diagnosis and treatment advancements have extended patient's lives and enabled women to embrace motherhood. Although the provision of care in specialist centres has reduced maternal-fetal complication rates, the mortality rate among pregnant women with sickle cell disease remains disproportionately high. Complications arise from vaso-occlusive events, worsening organ damage, thrombotic risks, infections, and pregnancy-related issues, such as pre-eclampsia, premature birth, small-for-gestational-age, and pregnancy loss. Effective management during pregnancy includes preconception planning, genetic counselling, education, and collaborative care. There is no consensus on the overall approach to managing pregnant women with sickle cell disease; however, fostering a collaborative relationship between health-care professionals and researchers is crucial for advancing the understanding and management of this illness. The disparities in health-care outcomes associated with ethnicity and economic insecurity affect patients with sickle cell disease but have not been examined extensively. Hence, health-care personnel need sufficient training to address these issues alongside broader societal efforts to confront racism and discrimination. Comprehensive national and global action plans are required to address the multifaceted challenges of sickle cell disease.
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Affiliation(s)
- Laure Joseph
- Biotherapy Department, French National Sickle Cell Referral Centre, Biotherapy Clinical Investigation Centre, Hôpital Necker-Enfant Malades, Assistance-Publique Hôpitaux de Paris, Paris, France.
| | - Marine Driessen
- Department of Obstetrics and Fetal Medicine, Hôpital Necker-Enfant Malades, Assistance-Publique Hôpitaux de Paris, Paris, France
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Agarwal S, Stanek JR, Vesely SK, Creary SE, Cronin RM, Roe AH, O’Brien SH. Pregnancy-related thromboembolism in women with sickle cell disease: An analysis of National Medicaid Data. Am J Hematol 2023; 98:1677-1684. [PMID: 37551881 PMCID: PMC10592294 DOI: 10.1002/ajh.27045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/05/2023] [Accepted: 07/16/2023] [Indexed: 08/09/2023]
Abstract
Pregnancy and sickle cell disease (SCD) both individually carry a risk of thromboembolism (TE). Pregnancy in people with SCD may further enhance the prothrombotic effect of the underlying disease. The objectives of this study were to determine the rate and risk factors for arterial and venous thrombosis in pregnant people with SCD. Administrative claims data from the United States Centers for Medicare and Medicaid Service Analytic eXtract from 2006 to 2018 were used. The study population included people with SCD from the start of their first identified pregnancy until 1 year postpartum and a control cohort of pregnant people without SCD of similar age and race. Outcomes of interest were identified with ICD-9 or 10 codes. Logistic regression analyses were used to analyze risk factors. We identified infant deliveries in 6388 unique people with SCD and 17 110 controls. A total of 720 venous thromboembolism (11.3%) and 335 arterial TE (5.2%) were observed in people with SCD compared to 202 (1.2%) and 95 (0.6%) in controls. People with SCD had an 8-11 times higher odds of TE compared to controls (p < .001). Within the SCD cohort, age, hemoglobin SS (HbSS) genotype, hypertension, and history of thrombosis were identified as independent risk factors for pregnancy-related TE. Pregnancy-specific factors (pre-eclampsia, eclampsia, multigestational pregnancy) were not associated with TE. In conclusion, the risk of pregnancy-related TE is considerably higher in people with SCD compared with controls without SCD. Hence, people with SCD, particularly those with multiple risk factors may be candidates for thromboprophylaxis during pregnancy and the postpartum period.
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Affiliation(s)
- Shreya Agarwal
- Division of Hematology/Oncology/BMT, Nationwide Children’s Hospital, Columbus, OH
| | - Joseph R Stanek
- Division of Hematology/Oncology/BMT, Nationwide Children’s Hospital, Columbus, OH
- Biostatistics Resource at Nationwide Children’s Hospital, Columbus, OH
| | - Sara K. Vesely
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma, Oklahoma City, OK
| | - Susan E. Creary
- Division of Hematology/Oncology/BMT, Nationwide Children’s Hospital, Columbus, OH
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Robert M Cronin
- Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - Andrea H. Roe
- Department of Obstetrics and Gynecology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Sarah H. O’Brien
- Division of Hematology/Oncology/BMT, Nationwide Children’s Hospital, Columbus, OH
- Center for Child Health Equity and Outcomes Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
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Linton EA, Williams EC, Early ML, Prince E, Stewart RW, Lanzkron S, Pecker LH. Family planning needs of young adults with sickle cell disease. EJHAEM 2023; 4:587-594. [PMID: 37601884 PMCID: PMC10435671 DOI: 10.1002/jha2.711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/04/2023] [Indexed: 08/22/2023]
Abstract
Sexual and reproductive healthcare standards for adolescents and young adults with sickle cell disease (SCD) are not established. A total of 50 young adults entering adult SCD care completed a Family Planning Survey assessing sexual and reproductive health needs from March 2019 to July 2020. Clinical data were abstracted from respondents' electronic medical records. Linear and logistic regression was applied to explore associations between clinical characteristics and survey results. Few respondents (8%) wished to be pregnant in the coming year, and 46% answered yes to at least one of four needs assessment questions. Those who were not employed full time were more likely to endorse needing help with getting sickle cell trait testing for a partner (ORadj = 9.59, p-value = 0.05). Contraceptive use was associated with having an obstetrician-gynecologist (OR = 6.8, p-value = 0.01). Young adults with SCD entering adult care have diverse reproductive health needs, highlighting opportunities to provide multidisciplinary, SCD-specific reproductive healthcare.
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Affiliation(s)
- Elizabeth A. Linton
- Center on Aging and Health, Department of EpidemiologyJohns Hopkins Bloomberg School of Public HealthBaltimoreMarylandUSA
| | | | - Macy L. Early
- Division of Hematology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Elizabeth Prince
- Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Rosalyn W. Stewart
- Division of General Internal Medicine, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Sophie Lanzkron
- Division of Hematology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Lydia H. Pecker
- Division of Hematology, Department of MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of Gynecology and ObstetricsJohns Hopkins University School of MedicineBaltimoreMarylandUSA
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Li Q, Wang H, Wang H, Deng J, Cheng Z, Lin W, Zhu R, Chen S, Guo J, Tang LV, Hu Y. Association between serum alkaline phosphatase levels in late pregnancy and the incidence of venous thromboembolism postpartum: a retrospective cohort study. EClinicalMedicine 2023; 62:102088. [PMID: 37533415 PMCID: PMC10393549 DOI: 10.1016/j.eclinm.2023.102088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/20/2023] [Accepted: 06/22/2023] [Indexed: 08/04/2023] Open
Abstract
Background Two previous studies found alkaline phosphatase (ALP) levels were related with the development of venous thromboembolism (VTE) in hospitalised patients. VTE is a leading cause of death during pregnancy and postpartum. No prior study has investigated the associations of ALP levels and VTE postpartum, and the related mechanisms remain unclear. This study aimed to investigate the associations between ALP levels and VTE postpartum, and to reveal the potential mechanisms. Methods In this retrospective cohort study, we included pregnant women who planned to deliver at the Department of Obstetrics and Gynecology in the three designated hospitals in a multicentre cohort of pregnant women in Wuhan, China, during two recruitment periods of January 1, 2018 to December 31, 2019, and May 14, 2020 to March 25, 2022. A total of 10,044 participants with serum ALP and whole blood hemoglobin measurements in late pregnancy (median, 37 (35, 39) weeks) were enrolled. The participants' incidences of VTE (deep venous thrombosis and/or pulmonary embolism) postpartum were confirmed from the medical records. Pregnant women with new-onset VTE postpartum (within 6 weeks after delivery) were confirmed as VTE cases. Findings Approximately 0.8% (79/10,044) of the pregnant women were diagnosed with VTE postpartum. In the unadjusted model, pregnant women with the lowest quintile of serum ALP levels (≤116 U/L) in late pregnancy had higher risk of VTE postpartum compared with those with the highest quintile (≥199 U/L) (OR, 2.83 [1.32, 6.05]). After adjusting for covariates of demographic, life style, birth outcomes, and other liver enzymes, pregnant women with the lowest quintile of serum ALP levels (≤116 U/L) in late pregnancy had increased risk of VTE postpartum compared with those with the highest quintile (≥199 U/L) (OR, 2.48 [1.14, 5.40]). A one standard deviation decrease of ln-transformed ALP levels were associated with elevated risk of VTE postpartum (OR, 1.29 [1.02, 1.62]). Significant negative associations of ALP with VTE were found in the unadjusted and adjusted models. The negative associations between ALP and VTE remained consistent in sensitivity analyses among participants with non-GDM, single pregnancy, non-preeclampsia, non-postpartum hemorrhage, non-extremely/very preterm and cesarean delivery. Decreased serum ALP levels significantly (P < 0.05) related to decreased hemoglobin, which was significantly (P < 0.05) related to increased risk of VTE postpartum. Decreased hemoglobin significantly (P < 0.05) mediated 7.59% of ALP-associated VTE postpartum. Interpretation This study suggested that low serum ALP levels in late pregnancy were associated with increased risk of VTE postpartum, and the ALP-associated VTE risk may be partially mediated by hemoglobin, suggesting that serum ALP in late pregnancy could be a promising biomarker for the prediction of VTE postpartum. Funding The National Natural Science Foundation of China, and the Program for HUST Academic Frontier Youth Team.
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Affiliation(s)
- Qian Li
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Hongfei Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Huafang Wang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jun Deng
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhipeng Cheng
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wenyi Lin
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ruiqi Zhu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shi Chen
- Department of Biobank, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jinrong Guo
- Department of Medical Records Management and Statistics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Liang V. Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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