Sickle cell disease and the incidence and etiology of preterm birth

Maternal and Infant Outcomes in a Subset of Patients with Sickle Cell Disease in South Carolina

OBJECTIVES

Sickle cell disease (SCD), which disproportionately affects minorities, increases complications during pregnancy. Severe maternal mortality is increased in women with SCD, including morbidity related to the disease and other nondisease-related complications. It also can have devastating complications for fetuses, with increases in premature birth and low birth weight. This study aimed to describe the characteristics of women with SCD in South Carolina, with a specific focus on fetal and maternal outcomes and complications. The secondary aim of this study was to identify the effect of maternal characteristics on birth outcomes, including social determinants of health.

METHODS

A secondary analysis of women from a single institution, the Medical University of South Carolina, which was part of the registry from the multi-institutional Sickle Cell Disease Implementation Consortium, was conducted. Patient demographics, self-reported pregnancy history, hydroxyurea use, and maternal and fetal outcomes were collected from patient-reported survey data. In addition, the number of vaso-occlusive episodes surrounding their pregnancies was collected for analysis.

RESULTS

Fifty-nine percent (116/195) of the female participants reported ever being pregnant. Seventy-two percent had live births, 15.8% had miscarriages, 1.8% had stillbirths, and 6.1% had an abortion. The mean age was 22.3 ± 4 years, with no difference in markers of severity between the groups. Most women were HbSS genotype with high rates of pain in the last year. No difference was found in age, education, employment, or income between these groups of women. Women in the nonlive birth cohort had higher body weights (78.7 versus 72.1 kg, P = 0.045). The Distressed Community Index was used as a marker for social determinants of health and was similar between the two groups, with a majority of both cohorts (61.7% and 52%) living in "at risk" and "distressed" communities. Complications related to SCD were high, including 43% of women experiencing pain during pregnancy, 5.2% developing acute chest syndrome, and 22.4% requiring transfusion. An additional 11% experienced preeclampsia. Unfavorable infant outcomes included 49% of the infants being premature and 40% having babies weighing less than 5.5 lb at birth.

CONCLUSIONS

High rates of complications to both mother and infant were found in the women with SCD. Although few statistically significant predictors were found, by identifying and addressing specific needs of pregnant women with SCD, we can work toward reducing fetal and maternal mortality in an already vulnerable population.

Perinatal risk factors and neurocognitive outcomes in children and adolescents with sickle cell disease

BACKGROUND

The literature on cognitive and academic outcomes for children with sickle cell disease (SCD) who experience perinatal risk factors is limited. We aimed to evaluate if low birthweight (LBW), gestational age, and history of neonatal intensive care unit (NICU) admission were associated with neurocognitive functioning, grade retention, or receipt of early intervention or formal educational support in children with SCD.

PROCEDURES

This prospective birth cohort study included 336 participants, ages 8-18, with SCD, who received cognitive testing as part of standard of care and whose caregivers completed behavioral rating scales. Multivariable generalized linear regression models were used to examine associations between perinatal risks and outcome variables, after adjusting for demographic and medical covariates.

RESULTS

The prevalence of NICU admission and LBW were 12.03% and 13.50%, respectively. Lower birthweight, earlier gestational age, and NICU admission were associated with worse working memory performance and receipt of early intervention services. Lower birthweight and NICU admission were also associated with slower processing speed. History of NICU admission was associated with caregiver ratings of hyperactivity and emotional dysregulation. The effects of perinatal risk factors on neurocognitive, academic, or educational outcomes were not dependent on SCD genotype.

CONCLUSIONS

History of LBW or NICU admission was associated with worse cognitive outcomes and increased use of early intervention services among children with SCD. Early identification of perinatal risk factors will help identify children who will benefit from formal developmental or neuropsychological evaluations to manage the comorbidity of SCD and perinatal risks and facilitate increased intervention.

Blood pressure thresholds for the diagnosis of hypertensive disorders of pregnancy in sickle cell disease

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.

How I treat sickle cell disease in pregnancy

ABSTRACT

Fifty years ago, people with sickle cell disease (SCD) were discouraged from becoming pregnant, but now, most should be supported if they choose to pursue a pregnancy. They and their providers, however, should be aware of the physiological changes of pregnancy that aggravate SCD and pregnancy's unique maternal and fetal challenges. Maternal problems can arise from chronic underlying organ dysfunction such as renal disease or pulmonary hypertension; from acute complications of SCD such as acute anemia, vaso-occlusive crises, and acute chest syndrome; and/or from pregnancy-related complications such as preeclampsia, sepsis, severe anemia, thromboembolism, and the need for cesarean delivery. Fetal problems include alloimmunization, opioid exposure, fetal growth restriction, preterm delivery, and stillbirth. Before and during pregnancy, in addition to the assessment and care that every pregnant patient should receive, patients with SCD should be evaluated and treated by a multidisciplinary team with respect to their unique maternal and fetal issues.

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

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.

The Effect of Sickle Cell Hemoglobinopathy on Pregnancy, Labor, Puerperium, and Fetal Outcome: A Retrospective Cohort Study From a Single Centre

INTRODUCTION

Sickle cell disease (SCD) is a major risk factor as far as pregnancy and obstetric complications are concerned. It possesses major perinatal and postnatal mortality. The management of pregnancy along with SCD requires a multispecialty team consisting of hematologists, obstetricians, anesthesiologists, neonatologists and intensivists.

OBJECTIVES

The objective of this study was to investigate the effect of sickle cell hemoglobinopathy on pregnancy, labor, puerperium, and fetal outcome in the rural and urban localities of Maharashtra, India.

MATERIAL AND METHODS

The present study is a comparative retrospective analysis of 225 pregnant women with SCD (genotype AS and SS) and 100 age- and gravida-matched pregnant women with normal hemoglobin (genotype AA) as a control who were treated between June 2013 to June 2015, in Indira Gandhi Government Medical College (IGGMC), Nagpur, India. We analyzed various data regarding obstetrical outcomes and complications in sickle cell disease mothers.

RESULTS

Out of 225 pregnant women, 38 (16.89%) were diagnosed with homozygous sickle cell disease (SS group) while 187 (83.11%) were diagnosed with sickle cell trait (AS group). The most common antenatal complications were sickle cell crisis (17; 44.74%) and jaundice (15; 39.47%) in the SS group whereas pregnancy-induced hypertension (PIH) was noted in 33 (17.65%) in the AS group. Intrauterine growth restriction (IUGR) was recorded in 57.89% of the SS group and 21.39% of the AS group. A higher chance of emergency lower segment cesarean section (LSCS; 66.67% in the SS group and 79.09% in the AS group) was recorded as compared with the control group at 32%.

CONCLUSION

In order to minimize risks to the mother and fetus and for better outcomes it is prudent to manage pregnancy with SCD vigilantly in the antenatal period. In the antenatal period mothers with this disease should be screened for hydrops or bleeding manifestations such as intracerebral hemorrhage in the fetus. Better feto-maternal outcomes can be achieved by effective multispecialty intervention.