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Poliektov NE, Vuncannon DM, Ha TK, Lindsay MK, Chandrasekaran S. The Association between Sickle Cell Disease and Postpartum Severe Maternal Morbidity. Am J Perinatol 2024. [PMID: 38653453 DOI: 10.1055/s-0044-1786174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE To compare the risk of severe maternal morbidity (SMM) from the delivery admission to 42 days' postdischarge among persons with sickle cell disease (SCD) to those without SCD. STUDY DESIGN This retrospective cohort study included deliveries ≥20 weeks' gestation at an urban safety net hospital in Atlanta, GA from 2011 to 2019. The exposure was SCD diagnosis. The outcome was a composite of SMM from the delivery admission to 42 days' postdischarge. SMM indicators as defined by the Centers for Disease Control and Prevention were identified using the International Classification of Diseases, Ninth and Tenth Revisions (ICD-9/10) codes; transfusion of blood products and sickle cell crisis were excluded. RESULTS Of N = 17,354 delivery admissions, n = 92 (0.53%) had SCD. Persons with SCD versus without SCD had an increased risk of composite SMM (15.22 vs. 2.29%, p < 0.001), acute renal failure (6.52 vs. 0.71%, p < 0.001), acute respiratory distress syndrome (4.35 vs. 0.17%, p < 0.001), puerperal cerebrovascular disorders (3.26 vs. 0.10%, p < 0.001), sepsis (4.35 vs. 0.42%, p < 0.01), air and thrombotic embolism (5.43 vs. 0.10%, p < 0.001), and ventilation (2.17 vs. 0.09%, p < 0.01). Ultimately, those with SCD had an approximately 6-fold higher incidence risk ratio of SMM, which remained after adjustment for confounders (adjusted incidence risk ratio [aIRR]: 5.96, 95% confidence interval [CI]: 3.4-9.19, p < 0.001). Persons with SCD in active vaso-occlusive crisis at the delivery admission had an approximately 9-fold higher risk of SMM up to 42 days' postdischarge compared with those with SCD not in crisis at the delivery admission (incidence: 25.71 vs. 8.77%, p < 0.05; aIRR: 8.92, 95% CI: 4.5-10.04, p < 0.05). Among those with SCD, SMM at the delivery admission was primarily related to renal and cerebrovascular events, whereas most postpartum SMM was related to respiratory events or sepsis. CONCLUSION SCD is significantly associated with an increased risk of SMM during the delivery admission and through 42 days' postdischarge. Active crisis at delivery further increases the risk of SMM. KEY POINTS · Sickle cell disease was associated with an approximately 6-fold increased risk of SMM.. · Active vaso-occlusive crisis at delivery was associated with an approximately 9-fold increased risk of SMM.. · 48% of SMM events in persons with SCD occurred postpartum and were respiratory- or sepsis-related..
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Affiliation(s)
- Natalie E Poliektov
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
| | - Danielle M Vuncannon
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
| | - Thoa K Ha
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
| | - Michael K Lindsay
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
| | - Suchitra Chandrasekaran
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia
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James AH, Strouse JJ. How I treat sickle cell disease in pregnancy. Blood 2024; 143:769-776. [PMID: 37979134 DOI: 10.1182/blood.2023020728] [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: 07/24/2023] [Revised: 09/15/2023] [Accepted: 10/12/2023] [Indexed: 11/19/2023] Open
Abstract
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.
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Affiliation(s)
- Andra H James
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Duke University, Durham, NC
- Division of Hematology, Department of Medicine, Duke University, Durham, NC
| | - John Joseph Strouse
- Division of Hematology, Department of Medicine, Duke University, Durham, NC
- Division of Hematology/Oncology, Department of Pediatrics, Duke University, Durham, NC
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Saif Said AL Harthi S, Arulappan J, Al Yazeedi B, Al Zaabi AHS. Adverse pregnancy, fetal and neonatal outcomes in women with sickle cell disease in a Middle Eastern country. WOMEN'S HEALTH (LONDON, ENGLAND) 2024; 20:17455057231220188. [PMID: 38308541 PMCID: PMC10838028 DOI: 10.1177/17455057231220188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 11/06/2023] [Accepted: 11/22/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Sickle cell disease in pregnancy is associated with high maternal and fetal mortality. However, studies reporting pregnancy, fetal, and neonatal outcomes in women with sickle cell disease are extremely limited. OBJECTIVES The objectives of the study are to determine whether women with sickle cell disease have a greater risk of adverse pregnancy, fetal, and neonatal outcomes than women without sickle cell disease and identify the predictors of adverse pregnancy, fetal, and neonatal outcomes in women with sickle cell disease. DESIGN A retrospective pair-matched case-control study was conducted to compare 171 pregnant women with sickle cell disease to 171 pregnant women without sickle cell disease in Muscat, Sultanate of Oman. METHODS All pregnant Omani women with sickle cell disease who delivered between January 2015 and August 2021 at Sultan Qaboos University Hospital and Royal Hospital, who were either primipara or multipara and who had a gestational age of 24-42 weeks, were included as patients, whereas women who had no sickle cell disease or any comorbidity during pregnancy, who delivered within the same timeframe and at the same hospitals, were recruited as controls. The data were retrieved from electronic medical records and delivery registry books between January 2015 and August 2021. RESULTS Women with sickle cell disease who had severe anemia had increased odds of (χ2 = 58.56, p < 0.001) having adverse pregnancy outcomes. Women with sickle cell disease had 21.97% higher odds of delivering a baby with intrauterine growth retardation (χ2 = 17.80, unadjusted odds ratio = 2.91-166.13, p < 0.001). Newborns born to women with sickle cell disease had 3.93% greater odds of being admitted to the neonatal intensive care unit (χ2 = 16.80, unadjusted odds ratio = 1.97-7.84, p < 0.001). In addition, the children born to women with sickle cell disease had 10.90% higher odds of being born with low birth weight (χ2 = 56.92, unadjusted odds ratio = 5.36-22.16, p < 0.001). Hemoglobin level (odds ratio = 0.17, p < 0.001, 95% confidence interval = 0.10-3.0), past medical history (odds ratio = 7.95, p < 0.001, 95% confidence interval = 2.39-26.43), past surgical history (odds ratio = 17.69, p < 0.001, 95% confidence interval = 3.41-91.76), and preterm delivery (odds ratio = 9.48, p = 0.005, 95% confidence interval = 1.95-46.23) were identified as predictors of adverse pregnancy, fetal, and neonatal outcomes in women with sickle cell disease. CONCLUSION As pregnant women with sickle cell disease are at increased risk for pregnancy, fetal, and neonatal adverse outcomes; improved antenatal surveillance and management may improve the outcomes.
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Affiliation(s)
| | - Judie Arulappan
- Department of Maternal and Child Health, College of Nursing, Sultan Qaboos University, Muscat, Oman
| | - Basma Al Yazeedi
- Department of Maternal and Child Health, College of Nursing, Sultan Qaboos University, Muscat, Oman
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Bala NS, Stanek JR, Vesely SK, Cronin RM, Creary SE, Roe AH, Xu W, O’Brien SH. Comparison of thromboembolism outcomes in patients with sickle cell disease prescribed hormonal contraception. Blood Adv 2023; 7:6140-6150. [PMID: 37585480 PMCID: PMC10582388 DOI: 10.1182/bloodadvances.2023010204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/09/2023] [Accepted: 07/25/2023] [Indexed: 08/18/2023] Open
Abstract
Patients with sickle cell disease (SCD) are at a risk of thromboembolism (TE), and use of hormonal contraception can further increase that risk. This study aims to assess patterns of hormonal contraceptive use and compare risk of contraception-related TE between combined hormonal contraceptives (CHCs) and progestin-only contraceptives (POCs). Patients with SCD aged between 12 and 44 years with a new prescription of a hormonal contraceptive in the Centers for Medicare and Medicaid Services Medicaid Analytic eXtract database (2006-2018) were followed up to 1 year. We identified 7173 new users: 44.6% initiated CHC and 55.4% initiated POC. Combined oral contraceptive pills (OCPs; 36.5%) and progestin-only depot medroxyprogesterone acetate (33.9%) were the most frequently prescribed agents. A total of 1.8% of contraception users had a new diagnosis of TE within 1 year of the first identified contraception prescription. There were no significant differences in TE event rates between CHC and POC users (17.2 and 24.7 events per 1000 person-years, respectively). In patients prescribed OCP, there were no differences in TE event rates based on estrogen dose or progestin generation. Transdermal patch had a 2.4-fold increased risk of TE as compared with that of OCP. Although limited by the retrospective study design and use of administrative claims data, this study found no significant differences in TE rates between new users of CHC and POC in patients with SCD. Careful evaluation of underlying TE risk factors should be considered for each patient with SCD before initiation of hormonal contraception.
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Affiliation(s)
- Natasha S. Bala
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital and The Ohio State University, College of Medicine, Columbus, OH
| | - Joseph R. Stanek
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital and The Ohio State University, College of Medicine, Columbus, OH
- Biostatistics Resource at Nationwide Children's Hospital, Columbus, OH
| | - Sara K. Vesely
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, The University of Oklahoma, Oklahoma City, OK
| | - Robert M. Cronin
- Department of Internal Medicine, The Ohio State University, College of Medicine, Columbus, OH
| | - Susan E. Creary
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital and The Ohio State University, College of Medicine, Columbus, OH
- Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Andrea H. Roe
- Department of Obstetrics and Gynecology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Wendy Xu
- Division of Health Services Management and Policy, The Ohio State University, College of Public Health, Columbus, OH
| | - Sarah H. O’Brien
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital and The Ohio State University, College of Medicine, Columbus, OH
- Center for Child Health Equity and Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
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Eltyeb EE, Ibrahim Mokhasha A, Ali Al-Makramani A, Murtada Abdelmageed M, Amin Basheer R. Sickle cell anemia in pregnant Saudi women and its impact on birth weight and gestational maturity. J Chin Med Assoc 2023; 86:892-896. [PMID: 37528521 DOI: 10.1097/jcma.0000000000000974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND It is well documented that sickle cell anemia (SCA) in pregnancy increases the risk of problems that can influence the growth and maturation of the newborn. To assess the gestational maturity and birth weight of babies born to Saudi mothers with SCA in the Jazan region. METHODS A case-control study was conducted in three hospitals in the Jazan region. An interview with a semi-structured questionnaire was used to collect data from the participants' women, and then the birth weight was taken. RESULTS Of 187 delivered women, 20.3% had SCA (13% had sickle cell disease, and the remaining had sickle cell trait). Among the 38 affected mothers, 15.7% were considered to have an additional risk (7.9% had diabetes mellitus, 5.3% had hypertension, and 2.6% were smokers). The mean birth weight was 2.95 ± 0.40 kg and 2.99 ± 0.55 kg in the case and control groups, respectively. However, the low birth weight babies constitute 31% of the delivered babies in the SCA group with a weight of 2.33 ± 0.16 kg and 15% of the control group with a mean weight of 2.16 ± 0.30 kg. The gestational age was 39.36 ± 1.02 weeks in the SCA group compared to 39.5 ± 1.17 weeks in the control group. Maternal age and hypertension significantly influence the birth weight in the SCA group compared to the influence of diabetes mellitus on the birth weight in the control group. CONCLUSION This study indicates that SCA in pregnant mothers influences birth weight, which is more impacted by maternal age and co-morbidities. Therefore, a multidisciplinary approach must monitor these risky pregnancies well to avoid undesirable neonatal outcomes.
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Affiliation(s)
| | | | - Ali Ali Al-Makramani
- Department of Paediatrics, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| | | | - Randa Amin Basheer
- Department of Nursing, Farasan University College, Jazan University, Saudi Arabia
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Mortara M, Turay MS, Boyle S, Caracciolo C, Bah S, Kargbo H, Hanciles E, John-Cole V, Scapini E, Benoni R, Dissanayake V, Beane A, Haniffa R, Adetunji AO, Taylor W, Pisani L. Impact and burden of sickle cell disease in critically ill obstetric patients in a high dependency unit in Sierra Leone-a registry based evaluation. BMC Pregnancy Childbirth 2023; 23:580. [PMID: 37573345 PMCID: PMC10422830 DOI: 10.1186/s12884-023-05888-9] [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: 11/14/2022] [Accepted: 07/31/2023] [Indexed: 08/14/2023] Open
Abstract
INTRODUCTION Sickle cell disease (SCD) in pregnancy is associated with worse maternal and neonatal outcomes. There is limited available data describing the burden and outcomes of critically ill obstetric patients affected by SCD in low-income settings. OBJECTIVES We aimed to define SCD burden and impact on mortality in critically-ill obstetric patients admitted to an urban referral hospital in Sierra Leone. We hypothesized that SCD burden is high and independently associated with increased mortality. METHODS We performed a registry-based cross-sectional study from March 2020 to December 2021 in the high-dependency unit (HDU) of Princess Christian Maternity Hospital PCMH, Freetown. Primary endpoints were the proportion of patients identified in the SCD group and HDU mortality. Secondary endpoints included frequency of maternal direct obstetric complications (MDOCs) and the maternal early obstetric warning score (MEOWS). RESULTS Out of a total of 497 patients, 25 (5.5%) qualified to be included in the SCD group. MEOWS on admission was not different between patients with and without SCD and SCD patients had also less frequently reported MDOCs. Yet, crude HDU mortality in the SCD group was 36%, compared to 9.5% in the non SCD group (P < 0.01), with an independent association between SCD group exposure and mortality when accounting for severity on admission (hazard ratio 3.40; 95%CI 1.57-7.39; P = 0.002). Patients with SCD had a tendency to longer HDU length of stay. CONCLUSIONS One out of twenty patients accessing a HDU in Sierra Leone fulfilled criteria for SCD. Despite comparable severity on admission, mortality in SCD patients was four times higher than patients without SCD. Optimization of intermediate and intensive care for this group of patients should be prioritized in low-resource settings with high maternal mortality.
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Affiliation(s)
- Milena Mortara
- Department of Anesthesia and Intensive Care, University of Piemonte Orientale, Novara, Italy
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospitals Complex, Freetown, Sierra Leone
| | - Momoh Sitta Turay
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospitals Complex, Freetown, Sierra Leone
| | - Sonia Boyle
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospitals Complex, Freetown, Sierra Leone
| | - Claudia Caracciolo
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospitals Complex, Freetown, Sierra Leone
- Section of Operational Research, Doctors with Africa-Cuamm, Padova, Italy
| | - Sarjoh Bah
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospitals Complex, Freetown, Sierra Leone
| | - Henry Kargbo
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospitals Complex, Freetown, Sierra Leone
| | - Eva Hanciles
- Department of Anesthesia and Intensive Care, Connaught Hospital, University of Sierra Leone, Freetown, Sierra Leone
| | - Valerie John-Cole
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospitals Complex, Freetown, Sierra Leone
| | - Ester Scapini
- Anesthesia and Intensive Care Medicine, University of Bari, Bari, Italy
| | - Roberto Benoni
- Section of Operational Research, Doctors with Africa-Cuamm, Padova, Italy
| | - Vishmi Dissanayake
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Abi Beane
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Rashan Haniffa
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Adeniji O Adetunji
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospitals Complex, Freetown, Sierra Leone
| | - Williamson Taylor
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospitals Complex, Freetown, Sierra Leone
| | - Luigi Pisani
- Section of Operational Research, Doctors with Africa-Cuamm, Padova, Italy.
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.
- Intensive Care Unit, Miulli Regional Hospital, Acquaviva Delle Fonti, Italy.
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Boghossian NS, Greenberg LT, Saade GR, Rogowski J, Phibbs CS, Passarella M, Buzas JS, Lorch SA. Association of Sickle Cell Disease With Racial Disparities and Severe Maternal Morbidities in Black Individuals. JAMA Pediatr 2023; 177:808-817. [PMID: 37273202 PMCID: PMC10242511 DOI: 10.1001/jamapediatrics.2023.1580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 04/03/2023] [Indexed: 06/06/2023]
Abstract
Importance Little is known about the association between sickle cell disease (SCD) and severe maternal morbidity (SMM). Objective To examine the association of SCD with racial disparities in SMM and with SMM among Black individuals. Design, Setting, and Participants This cohort study was a retrospective population-based investigation of individuals with and without SCD in 5 states (California [2008-2018], Michigan [2008-2020], Missouri [2008-2014], Pennsylvania [2008-2014], and South Carolina [2008-2020]) delivering a fetal death or live birth. Data were analyzed between July and December 2022. Exposure Sickle cell disease identified during the delivery admission by using International Classification of Diseases, Ninth Revision and Tenth Revision codes. Main Outcomes and Measures The primary outcomes were SMM including and excluding blood transfusions during the delivery hospitalization. Modified Poisson regression was used to estimate risk ratios (RRs) adjusted for birth year, state, insurance type, education, maternal age, Adequacy of Prenatal Care Utilization Index, and obstetric comorbidity index. Results From a sample of 8 693 616 patients (mean [SD] age, 28.5 [6.1] years), 956 951 were Black individuals (11.0%), of whom 3586 (0.37%) had SCD. Black individuals with SCD vs Black individuals without SCD were more likely to have Medicaid insurance (70.2% vs 64.6%), to have a cesarean delivery (44.6% vs 34.0%), and to reside in South Carolina (25.2% vs 21.5%). Sickle cell disease accounted for 8.9% and for 14.3% of the Black-White disparity in SMM and nontransfusion SMM, respectively. Among Black individuals, SCD complicated 0.37% of the pregnancies but contributed to 4.3% of the SMM cases and to 6.9% of the nontransfusion SMM cases. Among Black individuals with SCD compared with those without, the crude RRs of SMM and nontransfusion SMM during the delivery hospitalization were 11.9 (95% CI, 11.3-12.5) and 19.8 (95% CI, 18.5-21.2), respectively, while the adjusted RRs were 3.8 (95% CI, 3.3-4.5) and 6.5 (95% CI, 5.3-8.0), respectively. The SMM indicators that incurred the highest adjusted RRs included air and thrombotic embolism (4.8; 95% CI, 2.9-7.8), puerperal cerebrovascular disorders (4.7; 95% CI, 3.0-7.4), and blood transfusion (3.7; 95% CI, 3.2-4.3). Conclusions and Relevance In this retrospective cohort study, SCD was found to be an important contributor to racial disparities in SMM and was associated with an elevated risk of SMM among Black individuals. Efforts from the research community, policy makers, and funding agencies are needed to advance care among individuals with SCD.
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Affiliation(s)
- Nansi S. Boghossian
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia
| | | | - George R. Saade
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk
| | - Jeannette Rogowski
- Department of Health Policy and Administration, The Pennsylvania State University, State College
| | - Ciaran S. Phibbs
- Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Health Care System, Menlo Park, California
- Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Molly Passarella
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jeffrey S. Buzas
- Department of Mathematics and Statistics, University of Vermont, Burlington
| | - Scott A. Lorch
- Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia
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Muacevic A, Adler JR, Mujalda A, Mujalda J, Yadav S, Kundal RK. The Effect of Sickle Cell Hemoglobinopathy on Pregnancy, Labor, Puerperium, and Fetal Outcome: A Retrospective Cohort Study From a Single Centre. Cureus 2023; 15:e34318. [PMID: 36865957 PMCID: PMC9971241 DOI: 10.7759/cureus.34318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 01/30/2023] Open
Abstract
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.
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Association of Sickle Cell Disease With Severe Maternal Morbidity. Obstet Gynecol 2023; 141:163-169. [PMID: 36701616 DOI: 10.1097/aog.0000000000004986] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/18/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate the association between sickle cell disease (SCD) and severe maternal morbidity (SMM) in a contemporary cohort of deliveries by non-Hispanic Black people. METHODS We retrospectively examined SMM by using electronic health record data on deliveries by non-Hispanic Black patients between 2011 and 2020 at a single tertiary, public institution. Sickle cell disease was identified during the delivery admission by using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. The primary outcome, SMM at delivery hospitalization, was ascertained using ICD-9-CM and ICD-10-CM codes and excluded sickle cell crisis as an indicator of SMM. We also constructed a secondary measure of SMM that excluded deliveries in which blood transfusion was the only indication of SMM. Poisson regression models were used to estimate risk ratios (RRs) and 95% CIs for the associations between SCD and SMM (overall and for individual indicators). Multivariable models adjusted for age, parity, insurance type, chronic conditions (chronic hypertension, diabetes mellitus, obesity), and multiple gestation. RESULTS Among 17,493 deliveries by non-Hispanic Black patients during the study period, 132 (0.8%) had a diagnosis of SCD. Of those patients, 87 (65.9%, 95% CI 57.2-73.9) with SCD and 2,035 (11.7%), 95% CI 11.2-12.2) without SCD had SMM. Sickle cell disease was associated with increased risk of SMM (87 vs 2,035, adjusted risk ratio [aRR] 5.4, 95% CI 4.6-6.3) and nontransfusion SMM (51 vs 1,057, aRR 6.0, 95% CI 4.6-8.0). Effect estimates were highest for cardiac arrest (3 vs 14, RR 28.2, 95% CI 3.8-209.3), air and thrombotic embolism (14 vs 72, RR 25.6, 95% CI 12.0-54.6), and puerperal cerebrovascular disorders (10 vs 53, RR 24.8, 95% CI 10.2-60.5). CONCLUSION Sickle cell disease was associated with a more than fivefold increased risk of SMM during the delivery hospitalization. Our data suggest cardiovascular morbidity as the driving major risk. The identification and monitoring of cardiovascular pathology in patients with SCD before and during pregnancy may reduce SMM.
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Ali EH, Alkindi S, Mohamed AO, Awadalla KE, Abdlgadir O, Adam G, Magdi M, Ibrahim AK, Ghebremeskel K. Adverse Pregnancy Outcomes in Sickle Cell Trait: a Prospective Cohort Study Evaluating Clinical and Haematological Parameters in Postpartum Mothers and Newborns. Mediterr J Hematol Infect Dis 2023; 15:e2023002. [PMID: 36660349 PMCID: PMC9833303 DOI: 10.4084/mjhid.2023.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 12/10/2022] [Indexed: 01/03/2023] Open
Abstract
Background Sickle cell trait (SCT) is a congenital condition caused by the inheritance of a single allele of the abnormal haemoglobin beta gene, HbS. Carriers of SCT are generally asymptomatic, and they do not manifest the clinical and haematological abnormalities of sickle cell anaemia (SCA). However, there is evidence that they display some symptoms in stressful situations. Pregnancy is a stressful physiological event, and it is not clear if SCT adversely affects pregnancy outcomes, particularly in those from developing countries where people regularly suffer from nutritional insufficiency. Objective This study aims to investigate pregnancy outcomes in Sudanese women with SCT. Subjects and methods: Pregnant women with (HbAS, n=34) and without (HbAA, n=60) SCT were recruited during their first trimester at El Obeid Hospital, Kordofan, Western Sudan. Following appropriate ethical approval and informed consent from the participants, detailed anthropometric, clinical, haematological, obstetric, and birth outcome data were registered. In addition, blood samples were collected at enrolment and at delivery. Results At enrolment in the first trimester, the SCT group did not manifest SCA symptoms, and there was no difference in the haematological parameters between the SCT and control groups. However, at delivery, the women with SCT, compared with the control group, had lower levels of hemoglobin (Hb, p=0.000), packed cell volume (PCV, p=0.000), mean corpuscular haemoglobin (MCH, p=0.002) and neutrophil counts (p=0.045) and higher mean corpuscular volume (MCV, p=0.000) and platelet counts (p=0.000). Similarly, at delivery, the babies of SCT women had lower birth weight (p=0.000), lower Hb (p=0.045), PCV (p=0.000), MCH (p=0.000), and higher neutrophil (p=0.004) and platelet counts (p=0.000) than the babies of the healthy control group. Additionally, there were more miscarriages, stillbirths, and admissions to the Special Care Baby Unit (SCBU) in the SCT group. Conclusions The study revealed that SCT is associated with adverse pregnancy outcomes, including maternal and neonatal anaemia, low birth weight, and increased risk of stillbirth, miscarriage, and admission to SCBU. Therefore, pregnant women with SCT should be given appropriate pre-conceptual advice and multidisciplinary antenatal and postnatal care.
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Affiliation(s)
- E H Ali
- Lipidomics and Nutrition Research Centre, School of Human Sciences, London Metropolitan University, UK
| | - S Alkindi
- Department of Haematology, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman
| | - A O Mohamed
- Department of Biochemistry, Faculty of Medicine, University of Khartoum, Sudan
| | | | - O Abdlgadir
- Sudan Sickle Cell Anaemia Centre, El Obeid - SUDAN
| | - G Adam
- Faculty of Education, Al Azhri University, Sudan
| | - M Magdi
- Directorate of Planning, Ministry of Health Oman, Muscat, Sultanate of Oman
| | - A K Ibrahim
- Sudan Sickle Cell Anaemia Centre, El Obeid - SUDAN
| | - K Ghebremeskel
- Lipidomics and Nutrition Research Centre, School of Human Sciences, London Metropolitan University, UK
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11
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Aghamolaei T, Pormehr-Yabandeh A, Hosseini Z, Roozbeh N, Arian M, Ghanbarnezhad A. Pregnancy in the Sickle Cell Disease and Fetomaternal Outcomes in Different Sickle cell Genotypes: A Systematic Review and Meta-Analysis. Ethiop J Health Sci 2022; 32:849-864. [PMID: 35950054 PMCID: PMC9341032 DOI: 10.4314/ejhs.v32i4.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/08/2022] [Indexed: 11/17/2022] Open
Abstract
Background Pregnancy is a major concern among women with the sickle cell disease (SCD), and it is associated with increased adverse outcomes. The aim of the present meta-analysis is to report the fetomaternal outcomes in different sickle cell genotypes. Methods In this systematic review and meta-analysis, a comprehensive search of databases and search engines such as PubMed, Scopus, Web of Science, ProQuest, Cochrane Library, Science Direct and Google Scholar were performed. Any observational studies that had compared at least one outcome such as maternal outcomes, fetal outcomes, and morbidity between two groups of pregnant women with different types of sickle cell genotypes and pregnant women without SCD were evaluated. Results A total number of 9,827 pregnant women with SCD were examined. The results showed that pregnancy in SCD increased the risk of adverse outcomes for the mothers (including postpartum hemorrhage, prematurity, pregnancy-induced hypertension, pre-eclampsia, eclampsia, cesarean section, lower segment cesareansection, maternal death), fetus (including live births, low birth weight, intrauterine growth restriction, APGAR score at 5 min <7, stillbirth, neonatal death, perinatal mortality, acute fetal distress, intrauterine fetal death) and morbidity among the SCD(severe anemia, urinary tract infection, blood transfusion, painful crisis, acute chest syndrome, vaso-occlusive crises). Conclusion According to the results of this meta-analysis, pregnancy in the SCD is associated with an increased risk of maternal outcomes, fetal outcomes, and morbidity among SCD patients with different genotypes. Pregnancy in sickle cell hemoglobinopathies needs careful multidisciplinary management and cautious caring so as to decrease maternal and fetal morbidity and mortality.
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Affiliation(s)
- Teamur Aghamolaei
- Cardiovascular Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Asiyeh Pormehr-Yabandeh
- PhD Student in Health Education and Promotion, Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Zahra Hosseini
- Social Determinants in Health Promotion Research Center, Hormozgan Health Institue, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Nasibeh Roozbeh
- Mother and Child Welfare Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Mahdieh Arian
- Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amin Ghanbarnezhad
- Social Determinants in Health Promotion Research Center, Hormozgan Health Institute, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
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12
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Figueira CO, Surita FG, Fertrin K, Nobrega GDM, Costa ML. Main Complications during Pregnancy and Recommendations for Adequate Antenatal Care in Sickle Cell Disease: A Literature Review. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:593-601. [PMID: 35139577 PMCID: PMC9948053 DOI: 10.1055/s-0042-1742314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Sickle cell disease (SCD) is the most common monogenic disease worldwide, with a variable prevalence in each continent. A single nucleotide substitution leads to an amino-acid change in the β-globin chain, altering the normal structure ofhemoglobin, which is then called hemoglobin S inherited in homozygosity (HbSS) or double heterozygosity (HbSC, HbSβ), and leads to chronic hemolysis, vaso-occlusion, inflammation, and endothelium activation. Pregnant women with SCD are at a higher risk of developing maternal and perinatal complications. We performed a narrative review of the literature considering SCD and pregnancy, the main clinical and obstetrical complications, the specific antenatal care, and the follow-up for maternal and fetal surveillance. Pregnant women with SCD are at a higher risk of developing clinical and obstetric complications such as pain episodes, pulmonary complications, infections, thromboembolic events, preeclampsia, and maternal death. Their newborns are also at an increased risk of developing neonatal complications: fetal growth restriction, preterm birth, stillbirth. Severe complications can occur in patients of any genotype. We concluded that SCD is a high-risk condition that increases maternal and perinatal morbidity and mortality. A multidisciplinary approach during pregnancy and the postpartum period is key to adequately diagnose and treat complications.
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Affiliation(s)
| | | | - Kleber Fertrin
- Division of Hematology, Department of Medicine, University of Washington, Seattle, Washington, United States
| | | | - Maria Laura Costa
- Department of Obstetrics and Gynecology, Universidade Estadual de Campinas, Campinas, SP, Brazil
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13
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McCaw-Binns A, Campbell L, Harris A, James LA, Asnani M. Maternal mortality among women with sickle cell disease in Jamaica over two decades (1998-2017). EClinicalMedicine 2022; 43:101238. [PMID: 34977515 PMCID: PMC8683691 DOI: 10.1016/j.eclinm.2021.101238] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Sickle cell disease (SCD) affects 2.8% of Jamaican antenatal women. Between 1998-2007 their maternal mortality ratio was 7-11 times higher than women without these disorders. We aim to determine if outcomes improved between 2008 and 17 amid declining fertility and changes in referral obstetric care. METHODS Maternal deaths in Jamaica's maternal mortality surveillance database (assembled since 1998) with SCD reported as underlying or associated cause of death were compared to those without known SCD, over two decades from 1998 to 2017. Social, demographic and health service variables were analysed using SPSS and EpiInfo Open. FINDINGS Over the two decades from 1998 to 2017, 806 (74%) of the 1082 pregnancy-associated deaths documented by the Jamaican Ministry of Health and Wellness were maternal deaths. The maternal mortality ratio (MMR) did not statistically change over the two periods for women with (p = 0.502) and without SCD (p = 0.629). The MMR among women with and without SCD in 2008-17 was 378.1 (n = 41) and 89.2/100,000 live births (n = 336) respectively, an odds ratio of 4.24 (95% CI: 3.07-5.87). When deaths due to their blood disorders were excluded, risk remained elevated at 2.17 (95% CI: 1.36-3.32). There was an upward trend in direct deaths over the two decades (p [trend]=0.051). INTERPRETATION MMRs were unchanged over two decades for Jamaicans with SCD. The high contribution to maternal mortality by women with SCD may explain some of the persistently higher mortality experience of women in the African diaspora. Multi-disciplinary evidence-based strategies need to be developed and tested which improve survival for women with SCD who want to have children. FUNDING No external funding was provided.
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Affiliation(s)
- Affette McCaw-Binns
- Department of Community Health & Psychiatry, Faculty of Medical Sciences, The University of the West Indies, Mona Campus, Kingston, Jamaica
| | - Leroy Campbell
- Victoria Jubilee Hospital, South-East Regional Health Authority, North Street, Kingston, Jamaica
| | - Ardene Harris
- Ministry of Health & Wellness, Epidemiology Unit, 10-16 Grenada Crescent, Kingston 5, Jamaica
| | - Lesley-Ann James
- Ministry of Health & Wellness, Epidemiology Unit, 10-16 Grenada Crescent, Kingston 5, Jamaica
| | - Monika Asnani
- Sickle Cell Unit, Caribbean Institute for Health Research, The University of the Indies, Mona Campus, Kingston 7, Jamaica
- Corresponding author at: Sickle Cell Unit, Caribbean Institute for Health Research, The University of the Indies, Mona Campus, Kingston 7, Jamaica.
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14
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Canelón SP, Butts S, Boland MR. Evaluation of Stillbirth Among Pregnant People With Sickle Cell Trait. JAMA Netw Open 2021; 4:e2134274. [PMID: 34817585 PMCID: PMC8613600 DOI: 10.1001/jamanetworkopen.2021.34274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/18/2021] [Indexed: 11/14/2022] Open
Abstract
Importance Relative to what is known about pregnancy complications and sickle cell disease (SCD), little is known about the risk of pregnancy complications among those with sickle cell trait (SCT). There is a lack of clinical research among sickle cell carriers largely due to low sample sizes and disparities in research funding. Objective To evaluate whether there is an association between SCT and a stillbirth outcome. Design, Setting, and Participants This retrospective cohort study included data on deliveries occurring between January 1, 2010, and August 15, 2017, at 4 quaternary academic medical centers within the Penn Medicine health system in Pennsylvania. The population included a total of 2482 deliveries from 1904 patients with SCT but not SCD, and 215 deliveries from 164 patients with SCD. Data were analyzed from May 3, 2019, to September 16, 2021. Exposures The primary exposure of interest was SCT, identified using clinical diagnosis codes recorded in the electronic health record. Main Outcomes and Measures A multivariate logistic regression model was constructed to assess the risk of stillbirth using the following risk factors: SCD, numbers of pain crises and blood transfusions before delivery, delivery episode (as a proxy for parity), prior cesarean delivery, multiple gestation, patient age, marital status, race and ethnicity, ABO blood type, Rhesus (Rh) factor, and year of delivery. Results This cohort study included 50 560 patients (63 334 deliveries), most of whom were aged 25 to 34 years (29 387 of 50 560 [58.1%]; mean [SD] age, 29.5 [6.1] years), were single at the time of delivery (28 186 [55.8%]), were Black or African American (23 777 [47.0%]), had ABO blood type O (22 879 [45.2%]), and were Rhesus factor positive (44 000 [87.0%]). From this general population, 2068 patients (4.1%) with a sickle cell gene variation were identified: 1904 patients (92.1%) with SCT (2482 deliveries) and 164 patients (7.9%) with SCD (215 deliveries). In the fully adjusted model, SCT was associated with an increased risk of stillbirth (adjusted odds ratio [aOR], 8.94; 95% CI, 1.05-75.79; P = .045) while adjusting for the risk factors of SCD (aOR, 26.40; 95% CI, 2.48-280.90; P = .007) and multiple gestation (aOR, 4.68; 95% CI, 3.48-6.29; P < .001). Conclusions and Relevance The results of this large, retrospective cohort study indicate an increased risk of stillbirth among pregnant people with SCT. These findings underscore the need for additional risk assessment during pregnancy for sickle cell carriers.
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Affiliation(s)
- Silvia P. Canelón
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia
| | - Samantha Butts
- Division of Reproductive Endocrinology and Infertility, Penn State College of Medicine and Penn State Health, Hershey, Pennsylvania
| | - Mary Regina Boland
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia
- Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia
- Center for Excellence in Environmental Toxicology, University of Pennsylvania, Philadelphia
- Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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15
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Boudhabhay I, Boutin E, Bartolucci P, Bornes MI, Habibi A, Lionnet F, Hertig A, Grimbert P, Stehlé T, El Karoui K, Sahali D, Fois E, Rémy P, Galacteros F, Haddad B, Canoui-Poitrine F, Lecarpentier E, Audard V. Impact of pre-eclampsia on renal outcome in sickle cell disease patients. Br J Haematol 2021; 194:1053-1062. [PMID: 34131893 DOI: 10.1111/bjh.17606] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 04/06/2021] [Indexed: 12/31/2022]
Abstract
The long-term consequences of pre-eclampsia (PrE) for renal function have never been determined in patients with sickle cell disease (SCD). Between 2008 and 2015, we screened 306 pregnancies in women with SCD and identified 40 with PrE (13%). The control group consisted of 65 pregnant SCD patients without PrE. In multivariable analysis, PrE events were associated with an increase of 1 log of lactate dehydrogenase level (adjusted odds ratio, aOR = 3·83, P = 0·05), a decrease of 10 g/l of haemoglobin levels (aOR = 2·48, P = 0·006) and one or more vaso-occlusive crisis during pregnancy (aOR = 16·68, P = 0·002). Estimated glomerular filtration rate (eGFR) was similar in the two groups at steady state but was significantly lower in the PrE group after one year of follow-up and at last follow-up (130 vs 148 ml/min/1·73 m2 , P < 0·001 and 120 vs 130 ml/min/1·73 m2 , P < 0·001, respectively). In multivariable analysis, eGFR had returned to steady-state levels one year after pregnancy in patients without PrE but continued to decrease in patients with PrE (β = -18·15 ml/min/1·73 m2 , P < 0·001). This decline was more marked at the end of follow-up (β = -31·15 ml/min, P < 0·001). In conclusion, PrE episodes are associated with a significant risk of subsequent renal function decline in SCD patients.
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Affiliation(s)
- Idris Boudhabhay
- Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Fédération Hospitalo-Universitaire Innovative Therapy for Immune Disorders, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Equipe 21, Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - Emmanuelle Boutin
- Unité de Recherche Clinique (URC Mondor), Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Service de Santé Publique, Assistance Publique Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Univ Paris Est Creteil, INSERM, IMRB, Equipe CEpiA (Clinical Epidemiology and Ageing), Créteil, France
| | - Pablo Bartolucci
- Centre de Référence des Syndromes Drépanocytaires Majeurs, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Univ Paris Est Créteil, Département Hospitalo-Universitaire Ageing-Thorax-Vessels-Blood, INSERM, IMRB, Equipe 2, Laboratoire d'excellence GRex, Créteil, France
| | - Marie-Isabelle Bornes
- Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Tenon, Paris, France
| | - Anoosha Habibi
- Centre de Référence des Syndromes Drépanocytaires Majeurs, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Univ Paris Est Créteil, Département Hospitalo-Universitaire Ageing-Thorax-Vessels-Blood, INSERM, IMRB, Equipe 2, Laboratoire d'excellence GRex, Créteil, France
| | - François Lionnet
- Service de Médecine Interne, Centre de Référence des Syndromes Drépanocytaires Majeurs, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Tenon, Sorbonne Université, Paris, France
| | - Alexandre Hertig
- Service de Transplantation Rénale, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital de la Pitié Salpétrière, Sorbonne Université, Paris, France
| | - Philippe Grimbert
- Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Fédération Hospitalo-Universitaire Innovative Therapy for Immune Disorders, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Equipe 21, Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - Thomas Stehlé
- Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Fédération Hospitalo-Universitaire Innovative Therapy for Immune Disorders, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Equipe 21, Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - Khalil El Karoui
- Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Fédération Hospitalo-Universitaire Innovative Therapy for Immune Disorders, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Equipe 21, Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - Dil Sahali
- Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Fédération Hospitalo-Universitaire Innovative Therapy for Immune Disorders, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Equipe 21, Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - Elena Fois
- Centre de Référence des Syndromes Drépanocytaires Majeurs, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Univ Paris Est Créteil, Département Hospitalo-Universitaire Ageing-Thorax-Vessels-Blood, INSERM, IMRB, Equipe 2, Laboratoire d'excellence GRex, Créteil, France
| | - Philippe Rémy
- Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Fédération Hospitalo-Universitaire Innovative Therapy for Immune Disorders, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Equipe 21, Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - Frédéric Galacteros
- Centre de Référence des Syndromes Drépanocytaires Majeurs, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Univ Paris Est Créteil, Département Hospitalo-Universitaire Ageing-Thorax-Vessels-Blood, INSERM, IMRB, Equipe 2, Laboratoire d'excellence GRex, Créteil, France
| | - Bassam Haddad
- Centre Hospitalier Inter-Communal de Créteil, Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Equipe Immunorégulation et Biothérapie (I-BIOT), Université Paris Est Créteil, Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor De Recherche Biomédicale (IMRB), Créteil, France
| | - Florence Canoui-Poitrine
- Unité de Recherche Clinique (URC Mondor), Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Service de Santé Publique, Assistance Publique Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Univ Paris Est Creteil, INSERM, IMRB, Equipe CEpiA (Clinical Epidemiology and Ageing), Créteil, France
| | - Edouard Lecarpentier
- Centre Hospitalier Inter-Communal de Créteil, Service de Gynécologie-Obstétrique et Médecine de la Reproduction, Equipe Immunorégulation et Biothérapie (I-BIOT), Université Paris Est Créteil, Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor De Recherche Biomédicale (IMRB), Créteil, France
| | - Vincent Audard
- Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Fédération Hospitalo-Universitaire Innovative Therapy for Immune Disorders, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France.,Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Equipe 21, Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
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16
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Malinowski AK, Kuo KHM, Tomlinson GA, Palcu P, Ward R, Shehata N. Distinct maternal and fetal pregnancy outcomes in women with sickle cell disease can be predicted using routine clinical and laboratory data. Br J Haematol 2021; 194:1063-1073. [PMID: 34124774 PMCID: PMC8518407 DOI: 10.1111/bjh.17607] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/06/2021] [Indexed: 12/01/2022]
Abstract
We aimed to identify risk factors for adverse outcomes in pregnancies of women with sickle cell disease (SCD) and develop risk prediction models. Models were derived from a retrospective cohort of pregnant women with SCD and constructed using generalised estimating equation logistic regression, with clustering by woman. Maternal event(s) consisted of acute anaemia; cardiac, pulmonary, hepatobiliary, musculoskeletal, skin, splenic, neurological or renal complications, multi‐organ failure, venous thromboembolism, admission‐requiring vaso‐occlusive events (VOE), red cell transfusion, mortality or hypertensive disorder of pregnancy. Fetal events included preterm birth, small‐for‐gestational‐age or perinatal mortality. Of 199 pregnancies, 71% and 45% resulted in adverse maternal and fetal outcomes respectively. Low first‐trimester haemoglobin, admission‐requiring VOE in the year before pregnancy, multiple transfusions before pregnancy, SCD genotype and previous cardiac complications predicted maternal risk. Younger age and SCD genotype allowed early prediction of fetal risk (model‐F1). Adding maternal event(s) and high lactate dehydrogenase enabled re‐assessment of fetal risk with advancing gestation (model‐F2). Models were well calibrated and moderately discriminative for maternal outcome (c‐statistic 0·81, cross‐validated value 0·79) and fetal outcome (model‐F1 c‐statistic 0·68, cross‐validated value 0·65; model‐F2 c‐statistic 0·72, cross‐validated value 0·68). The models will allow early identification of women with SCD at high risk of adverse events, permitting early targeted interventions and ongoing fetal risk re‐assessment enabling intensification of surveillance and optimisation of delivery timing.
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Affiliation(s)
- A Kinga Malinowski
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, Mount Sinai Hospital, Toronto, ON, Canada.,Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kevin H M Kuo
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Medical Oncology and Haematology, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - George A Tomlinson
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Patricia Palcu
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Richard Ward
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Medical Oncology and Haematology, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Nadine Shehata
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Medical Oncology and Haematology, Department of Medicine, University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Medicine, Division of Haematology, Mount Sinai Hospital, Toronto, ON, Canada
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17
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Abstract
PURPOSE OF REVIEW Pregnancy exacerbates sickle cell disease (SCD) and is associated with increased frequency and severity of complications resulting in high levels of maternal and fetal morbidity and mortality. We review recent recommendations for managing SCD in pregnancy. RECENT FINDINGS An updated pathobiological model of SCD now attributes the clinical picture to a vicious cycle of four major cellular disturbances. Management decisions should be guided by an understanding of this upgraded model. Red cell transfusions are a key therapeutic intervention used in managing several acute and chronic complications. Transfusion however has significant drawbacks. The American Society of Hematology recently published transfusion guidelines to support care providers. SUMMARY Patients should be managed by a multidisciplinary and experienced team. The perioperative episode is a recognized period of disease exacerbation and informed anesthetic management can contribute to improved patient outcomes.
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Affiliation(s)
- Ada Ezihe-Ejiofor
- Department of Anaesthesia, Guys & St Thomas's Hospital NHS Foundation Trust, London, UK
| | - Jaleesa Jackson
- Department of Anaesthesia, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Darlington F, Acha BM, Roshan T, Ikeanyionwu C, Kutse S, Abajue U, Osazuwa B, Gomez I, Spooner KK, Salemi JL, Dongarwar D, Olaleye OA, Salihu HM, Ndefo UA. Opioid-Related Disorders Among Pregnant Women with Sickle Cell Disease and Adverse Pregnancy Outcomes. PAIN MEDICINE 2021; 21:3087-3093. [PMID: 32710119 DOI: 10.1093/pm/pnaa188] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Opioid use during pregnancy has increased in recent years, parallel with the opioid epidemic in the general population. Opioids are commonly used as an analgesic for pain crisis, a hallmark symptom of sickle cell disease (SCD). With the amplified frequency and severity of SCD pain crisis during pregnancy, the use of opioids may increase concurrently. The aim of this study was to examine trends in opioid-related disorders (ORDs) among pregnant women with and without SCD, as well as assess the risk for preterm labor, maternal sepsis, and poor fetal growth among patients with SCD and ORD. METHODS We conducted a retrospective analysis of inpatient pregnancy- and childbirth-related hospital discharge data from the 2002-2014 National (Nationwide) Inpatient Sample database. The primary outcome was the risk of ORD in pregnant women with SCD and its impact on threatened preterm labor, fetal growth, and maternal sepsis. RESULTS Among the >57 million pregnancy-related hospitalizations examined, 9.6 per 10,000 had SCD. ORD in mothers with SCD was four times as prevalent as in those without SCD (2% vs 0.5%). A significant rise in ORD occurred throughout the study period and was associated with an increased risk of maternal sepsis, threatened preterm labor, and poor fetal growth. CONCLUSIONS Pregnant women with SCD have a fourfold increased risk of ORD compared with their non-SCD counterparts. The current opioid epidemic continues to worsen in both groups, warranting a tailored and effective public health response to reduce the resulting adverse pregnancy outcomes.
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Affiliation(s)
- Francis Darlington
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Benjamina Mbah Acha
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Tasha Roshan
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Charles Ikeanyionwu
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Seun Kutse
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Uzoamaka Abajue
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Billy Osazuwa
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Ian Gomez
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Kiara K Spooner
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas
| | - Jason L Salemi
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas
| | - Deepa Dongarwar
- Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, Houston, Texas, USA
| | - Omonike A Olaleye
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
| | - Hamisu M Salihu
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas.,Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, Houston, Texas, USA
| | - Uche Anadu Ndefo
- Department of Pharmaceutical and Environmental Health Sciences, College of Pharmacy and Health Sciences, Texas Southern University, Houston, Texas
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Yılmaz Baran Ş, Kozanoğlu İ, Korur A, Doğan Durdağ G, Kalaycı H, Alemdaroğlu S, Asma S, Kılıçdağ EB, Boğa C. Role of prophylactic and therapeutic red blood cell exchange in pregnancy with sickle cell disease: Maternal and perinatal outcomes. J Clin Apher 2020; 36:283-290. [PMID: 32797735 DOI: 10.1002/jca.21819] [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: 09/02/2019] [Revised: 06/22/2020] [Accepted: 07/13/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND AIM The incidence of fetomaternal complications during pregnancy is high for women with sickle cell disease (SCD), which is the most common hematologic genetic disorder worldwide. Prophylactic red blood cell exchange (pRBCX) has been shown to be efficient, safe, and feasible for preventing complications. The aim of this study was to observe maternal, perinatal, and neonatal outcomes of pregnancies in which pRBCX was. METHOD This was a single-center, retrospective, cross-sectional study, which recruited 46 consecutive adult pregnant women with SCD between January 2012 and June 2019. Obstetric features, SCD-related complications, and fetomaternal outcomes were compared between the 27 patients who received prophylactic exchange and the 19 who did not (therapeutic exchange was performed in 7 and was not performed in 12 cases). RESULTS Painful crises, preeclampsia, and preterm birth rates were significantly higher in the group that did not receive prophylactic exchange (control group; P = .001, P = .024, and P = .027, respectively). There was one maternal mortality in the control group (P = .41). Incidence of adverse fetal or maternal complications was significantly higher in the control group (P = .044 and P = .007, respectively). CONCLUSIONS Our center's experience over a 7.5-year period, as described above, demonstrates that pRBCX in SCD affects the course of pregnancy positively by ameliorating negative fetomaternal outcomes.
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Affiliation(s)
- Şafak Yılmaz Baran
- Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine Adana Dr Turgut Noyan Training and Research Center, Adana, Turkey
| | - İlknur Kozanoğlu
- Department of Physiology, Başkent University Faculty of Medicine Adana Dr Turgut Noyan Training and Research Center, Adana, Turkey.,Apheresis Unit, Başkent University Faculty of Medicine Adana Dr Turgut Noyan Training and Research Center, Adana, Turkey
| | - Aslı Korur
- Department of Family Medicine, Başkent University Faculty of Medicine Adana Dr Turgut Noyan Training and Research Center, Adana, Turkey
| | - Gülşen Doğan Durdağ
- Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine Adana Dr Turgut Noyan Training and Research Center, Adana, Turkey
| | - Hakan Kalaycı
- Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine Adana Dr Turgut Noyan Training and Research Center, Adana, Turkey
| | - Songül Alemdaroğlu
- Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine Adana Dr Turgut Noyan Training and Research Center, Adana, Turkey
| | - Süheyl Asma
- Department of Family Medicine, Başkent University Faculty of Medicine Adana Dr Turgut Noyan Training and Research Center, Adana, Turkey
| | - Esra Bulgan Kılıçdağ
- Department of Obstetrics and Gynecology, Başkent University Faculty of Medicine Adana Dr Turgut Noyan Training and Research Center, Adana, Turkey
| | - Can Boğa
- Department of Hematology, Başkent University Faculty of Medicine Adana Dr Turgut Noyan Training and Research Center, Adana, Turkey
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20
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Nkwabong E, Ngoundjou Dongmo P, Tayou C, Nana Njamen T. Outcome of pregnancies among women with sickle cell disease. J Matern Fetal Neonatal Med 2020; 35:1108-1112. [PMID: 32233705 DOI: 10.1080/14767058.2020.1743657] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Purpose: To evaluate the outcome of pregnancies among women affected by sickle cell disease (SCD).Material and methods: This retrospective comparative cohort study was carried out between 1 January 2014 and 31 December 2018. The files of pregnant women with and without SCD were analyzed. The main variables recorded included parity, diseases that occurred during pregnancy, maternal and gestational ages at delivery, mode of delivery, birthweight and Apgar score. Data were analyzed using SPSS 21.0. Fisher exact test and the t-test was used for comparison. p < .05 was considered statistically significant.Results: Our frequency of delivery of women with SCD was 0.1% (35/34,895). Significant complications associated with SCD were maternal anemia (RR = 17.00, 95%CI = 5.35-53.99), intra-uterine fetal demise (RR = 12.00, 95%CI = 1.39-103.22), low birthweight (RR = 2.52, 95%CI = 1.50-4.25), neonatal asphyxia (RR = 7.70, 95%CI = 2.57-22.99), transfer of newborn to the neonatal intensive care unit (RR = 3.42, 95%CI = 1.94-6.03), early neonatal death (RR = 4.56, 95%CI = 1.09-19.10), and maternal postpartum severe anemia (RR = 4.50, 95%CI = 1.36-14.87).Conclusions: Pregnancies amongst women with SCD are still associated with increased risk of maternal anemia as well as perinatal morbidity and mortality despite frequent blood transfusion. Therefore, new strategies should be explored to improve such pregnancies.
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Affiliation(s)
- Elie Nkwabong
- Department of Obstetrics and Gynecology, Faculty of Medicine and Biomedical Sciences, University Teaching Hospital, Yaoundé, Cameroon
| | | | - Claude Tayou
- Department of Hematology & Microbiology, Faculty of Medicine and Biomedical Sciences & University Teaching Hospital, Yaoundé, Cameroon
| | - Théophile Nana Njamen
- Department of Surgery, Obstetrics and Gynecology, Faculty of Health Sciences, Douala General Hospital, University of Buéa, Buéa, Cameroon
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21
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Sickle Cell Disease and Pregnancy. Mediterr J Hematol Infect Dis 2019; 11:e2019040. [PMID: 31308916 PMCID: PMC6613624 DOI: 10.4084/mjhid.2019.040] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 05/30/2019] [Indexed: 01/19/2023] Open
Abstract
Sickle cell disease (SCD) is the most common inherited hemoglobinopathy and is associated with increased risk of complications and early mortality. Nowadays, with improved health care facilities, antibiotic prophylaxis, vaccination, and availability of drugs like hydroxyurea, the life expectancy of SCD patients has improved. More women are reaching reproductive age group and are expressing their desire to reproduce. Though SCD adversely affects pregnancy, leading to increased incidence of maternal and perinatal complications like pre-eclampsia, preterm labor, IUGR, abortions etc., adequate care throughout pregnancy ensures a better outcome. Also, recent advancements in the fields of prenatal diagnosis and preimplantation genetic diagnosis, help couples suffering from SCD to have a healthy baby. This paper focuses on the effects of SCD on pregnancy outcomes and effective management of complications during pregnancy, also comparing maternal and perinatal outcomes in studies conducted in different countries. The second part of the paper summarizes pregnancy management in SCD for better maternal and fetal outcomes.
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22
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Houwing ME, de Pagter PJ, van Beers EJ, Biemond BJ, Rettenbacher E, Rijneveld AW, Schols EM, Philipsen JNJ, Tamminga RYJ, van Draat KF, Nur E, Cnossen MH. Sickle cell disease: Clinical presentation and management of a global health challenge. Blood Rev 2019; 37:100580. [PMID: 31128863 DOI: 10.1016/j.blre.2019.05.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 05/17/2019] [Accepted: 05/17/2019] [Indexed: 01/12/2023]
Abstract
Sickle cell disease is an autosomal recessive, multisystem disorder, characterised by chronic haemolytic anaemia, painful episodes of vaso-occlusion, progressive organ failure and a reduced life expectancy. Sickle cell disease is the most common monogenetic disease, with millions affected worldwide. In well-resourced countries, comprehensive care programs have increased life expectancy of sickle cell disease patients, with almost all infants surviving into adulthood. Therapeutic options for sickle cell disease patients are however, still scarce. Predictors of sickle cell disease severity and a better understanding of pathophysiology and (epi)genetic modifiers are warranted and could lead to more precise management and treatment. This review provides an extensive summary of the pathophysiology and management of sickle cell disease and encompasses the characteristics, complications and current and future treatment options of the disease.
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Affiliation(s)
- M E Houwing
- Department of Paediatric Haematology, Erasmus University Medical Center - Sophia Children's Hospital, Wytemaweg 80, 3015, CN, Rotterdam, the Netherlands.
| | - P J de Pagter
- Department of Paediatric Haematology, Erasmus University Medical Center - Sophia Children's Hospital, Wytemaweg 80, 3015, CN, Rotterdam, the Netherlands.
| | - E J van Beers
- Department of Internal Medicine and Dermatology, Van Creveldkliniek, University Medical Center Utrecht, Internal mail no C.01.412, 3508, GA, Utrecht, the Netherlands.
| | - B J Biemond
- Department of Internal Medicine and Clinical Haematology, Amsterdam University Medical Centers, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
| | - E Rettenbacher
- Department of Paediatric Haematology, Radboud University Medical Center - Amalia Children's Hospital, Geert Grooteplein Zuid 10, 6500, HB, Nijmegen, the Netherlands.
| | - A W Rijneveld
- Department of Haematology, Erasmus University Medical Center, Wytemaweg 80, 3015, CN, Rotterdam, the Netherlands.
| | - E M Schols
- Department of Haematology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525, GA, Nijmegen, the Netherlands.
| | - J N J Philipsen
- Department of Cell Biology, Erasmus University Medical Center, Wytemaweg 80, 3015, CN, Rotterdam, the Netherlands.
| | - R Y J Tamminga
- Department of Paediatric Oncology and Haematology, University Medical Center Groningen - Beatrix Children's Hospital, Postbus 30001, 9700, RB, Groningen, the Netherlands..
| | - K Fijn van Draat
- Department of Paediatric Haematology, Amsterdam University Medical Centers - Emma Children's Hospital, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Department of Plasma Proteins, Sanquin Research, the Netherlands.
| | - E Nur
- Department of Internal Medicine and Clinical Haematology, Amsterdam University Medical Centers, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
| | - M H Cnossen
- Department of Paediatric Haematology, Erasmus University Medical Center - Sophia Children's Hospital, Wytemaweg 80, 3015, CN, Rotterdam, the Netherlands.
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23
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Harrell KJ, Stanek J, Bonny AE, Christian-Rancy M, Creary SE, Desai P, O'Brien SH. A pilot study of hormonal contraceptive use and bone mineral density in young women with sickle cell disease. Pediatr Blood Cancer 2018; 65:e27398. [PMID: 30207046 DOI: 10.1002/pbc.27398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 07/16/2018] [Indexed: 11/08/2022]
Affiliation(s)
| | - Joseph Stanek
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio
| | - Andrea E Bonny
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Myra Christian-Rancy
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio
| | - Susan E Creary
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio
| | - Payal Desai
- Division of Hematology, The Ohio State University College of Medicine, Columbus, Ohio
| | - Sarah H O'Brien
- Division of Pediatric Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, Ohio
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24
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Cardosa D, Ridout A, Nanda S, Howard J, Robinson SE, Oteng-Ntim E. Maternal sickle cell disease and twin pregnancy: a case series and review of the literature. Hematology 2018; 24:148-158. [DOI: 10.1080/10245332.2018.1535534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Deyna Cardosa
- Department of Haematology, Southwark Wing, Guy’s Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Alexandra Ridout
- Women’s Health, St Thomas’ Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Surabhi Nanda
- Liverpool Women’s NHS Foundation Trust, University of Liverpool, Liverpool, UK
| | - Jo Howard
- Department of Haematology, Southwark Wing, Guy’s Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Susan E. Robinson
- Department of Haematology, Southwark Wing, Guy’s Hospital, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Eugene Oteng-Ntim
- Women’s Health, St. Thomas’ Hospital, King's Health Partners, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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25
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Differences in prenatal aneuploidy screening among African-American women with hemoglobin S variants. J Perinatol 2018; 38:797-803. [PMID: 29961762 DOI: 10.1038/s41372-018-0159-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 04/30/2018] [Accepted: 05/21/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE It has been shown that hemoglobinopathies increase the risk of pregnancy complications and placental dysfunction. This could alter the placental analytes examined during prenatal aneuploidy screening. Our objective was to determine whether there is a difference in maternal serum screening results for women with hemoglobin S variants (AS, SS, SC, S/beta thalassemia) compared with women with normal hemoglobin (AA). STUDY DESIGN This is a retrospective cohort study in African-American women receiving aneuploidy screening at MedStar Washington Hospital Center from 2008 to 2015. We evaluated 79 women with hemoglobin S variants (69 AS and 10 sickle cell disease (SCD)) and 79 controls. Descriptive statistics (means, medians, and frequencies) were calculated for each group. For the continuous variables, differences in the averages between the two groups were tested using the t test or Wilcoxon rank sum test. Differences in the averages between three or more groups were tested using the analysis of variance test or the Kruskal-Wallis test. RESULTS Demographics were similar between cases and controls. The overall screen positive rate for Down syndrome among patients with sickle cell trait (AS) was 3% (2/69). For patients with SCD, the overall screen positive rate was 10% (1/10). None of the women in the control population (AA) has a positive Down syndrome screening result (0/79). CONCLUSION As expected, the screen positive rate in patients with hemoglobin S variants was higher than controls, however, patients with sickle cell trait do not appear to be at an increased risk for false-positive results with serum aneuploidy screening compared with the general population. We did, however, find an increased risk of false-positive quad screen results in patients with sickle cell disease.
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26
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Current Evidence for the Use of Prophylactic Transfusion to Treat Sickle Cell Disease During Pregnancy. Transfus Med Rev 2018; 32:220-224. [PMID: 30029813 DOI: 10.1016/j.tmrv.2018.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/25/2018] [Accepted: 06/02/2018] [Indexed: 11/22/2022]
Abstract
The role of prophylactic transfusion therapy for the treatment of sickle cell disease during pregnancy is unclear. An analysis of the existing literature shows a limited number of publications that address this issue and specifically compare clinical outcomes in this population based on a treatment strategy of prophylactic transfusion versus transfusion only for clinical indications (on-demand transfusion). The existing studies show a wide variation in study design and outcomes measured. The results of this analysis suggest that there are insufficient data to support a clinically significant difference in morbidity and mortality outcomes based on transfusion strategy. Additional prospective clinical studies need to be performed to adequately address the risks and benefits of prophylactic transfusion and guide clinical decision making.
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27
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Holdt Somer SJ, Sinkey RG, Bryant AS. Epidemiology of racial/ethnic disparities in severe maternal morbidity and mortality. Semin Perinatol 2017; 41:258-265. [PMID: 28888263 DOI: 10.1053/j.semperi.2017.04.001] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The literature abounds with examples of racial/ethnic disparities in both obstetric outcomes and care. Disparities in maternal mortality are well documented with non-Hispanic blacks carrying the burden of the highest maternal mortality rates. Maternal deaths likely represent only the "tip of the iceberg" with respect to pregnancy complications, leading many to explore risk factors and disparities in severe maternal morbidity, a more common precursor to maternal mortality. This review article explores commonly cited indicators of severe maternal morbidity and includes a review of the epidemiological literature supporting or refuting disparities among each indicator.
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Affiliation(s)
- Sarah J Holdt Somer
- Department of Obstetrics and Gynecology, University of South Florida College of Medicine, Tampa, FL
| | - Rachel G Sinkey
- Department of Obstetrics and Gynecology, University of South Florida College of Medicine, Tampa, FL
| | - Allison S Bryant
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, 55 Fruit St, Founders 4, Boston, MA 02114.
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Desai G, Anand A, Shah P, Shah S, Dave K, Bhatt H, Desai S, Modi D. Sickle cell disease and pregnancy outcomes: a study of the community-based hospital in a tribal block of Gujarat, India. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2017; 36:3. [PMID: 28109314 PMCID: PMC5251338 DOI: 10.1186/s41043-017-0079-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 01/07/2017] [Indexed: 06/06/2023]
Abstract
BACKGROUND Sickle cell disease (SCD) is a hereditary blood disorder prevalent in tribal regions of India. SCD can increase complications during pregnancy and in turn negatively influence pregnancy outcomes. This study reports the analysis of tribal maternal admissions in the community-based hospital of SEWA Rural (Kasturba Maternity Hospital) in Jhagadia block, Gujarat. The objective of the study is to compare the pregnancy outcomes among SCD, sickle cell trait and non-SCD admissions. This study also estimated the risk of adverse pregnancy outcomes for SCD admissions. METHODS The data pertains to four and half years from March 2011 to September 2015. The total tribal maternal admissions were 14640, out of which 10519 admissions were deliveries. The admissions were classified as sickle cell disease, sickle cell trait and non-sickle cell disease. The selected pregnancy outcomes and maternal complications were abortion, stillbirth, Caesarean section, haemoglobin levels, blood transfusion, preterm pregnancy, newborn birth weight and other diagnosed morbidities (IUGR, PIH, eclampsia, preterm labour pain). The odds ratios for each risk factor were estimated for sickle cell patients. The odds ratios were adjusted for the respective years. RESULTS Overall, 1.2% (131 out of 10519) of tribal delivery admissions was sickle cell admissions. Another 15.6% (1645 out of 10519) of tribal delivery admissions have sickle cell trait. The percentage of stillbirth was 9.9% among sickle cell delivery admission compared to 4.2% among non-sickle cell deliveries admissions. Among sickle cell deliveries, 70.2% were low birth weight compared to 43.8% of non-sickle cell patient. Similarly, almost half of the sickle cell deliveries needed the blood transfusion. The 45.0% of sickle cell delivery admissions were pre-term births, compared to 17.3% in non-SCD deliveries. The odds ratio of severe anaemia, stillbirth, blood transfusion, Caesarean section, and low birth weight was significantly higher for sickle cell admissions compared to non-sickle cell admissions. CONCLUSIONS The study exhibited that there is a high risk of adverse pregnancy outcomes for women with SCD. It may also be associated with the poor maternal and neonatal health in these tribal regions. Thus, the study advocates the need for better management of SCD in tribal Gujarat.
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Affiliation(s)
- Gayatri Desai
- Kasturba Maternity Hospital, SEWA Rural, Bharuch, Gujarat India
| | - Ankit Anand
- Community Health Project, SEWA Rural, Bharuch, Gujarat India
- Population Research Centre, Institute for Social and Economic Change, Bangalore, India
| | - Pankaj Shah
- Kasturba Maternity Hospital, SEWA Rural, Bharuch, Gujarat India
- Community Health Project, SEWA Rural, Bharuch, Gujarat India
| | - Shobha Shah
- Women’s Health and Training, SEWA Rural, Bharuch, Gujarat India
| | - Kapilkumar Dave
- Community Health Project, SEWA Rural, Bharuch, Gujarat India
| | - Hardik Bhatt
- Community Health Project, SEWA Rural, Bharuch, Gujarat India
| | - Shrey Desai
- Community Health Project, SEWA Rural, Bharuch, Gujarat India
| | - Dhiren Modi
- Community Health Project, SEWA Rural, Bharuch, Gujarat India
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29
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Okusanya BO, Oladapo OT. Prophylactic versus selective blood transfusion for sickle cell disease in pregnancy. Cochrane Database Syst Rev 2016; 12:CD010378. [PMID: 28005272 PMCID: PMC6463955 DOI: 10.1002/14651858.cd010378.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Pregnant women with sickle cell disease (HbSS, HbSC and HbSβThal) may require blood transfusion to prevent severe anaemia or to manage potential medical complications. Preventive blood transfusion in the absence of complications starting from the early weeks of pregnancy or blood transfusion only for medical or obstetric indications have been used as management policies. There is currently no consensus on the blood transfusion policy that guarantees optimal clinical benefits with minimal risks for such women and their babies. This is an update of a Cochrane review that was published in 2013. OBJECTIVES To assess the benefits and harms of a policy of prophylactic versus selective blood transfusion in pregnant women with sickle cell disease. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 May 2016) and reference lists of retrieved studies. We did not apply any language or date restrictions. SELECTION CRITERIA Randomised controlled trials evaluating the effects of prophylactic versus selective (emergency) blood transfusion in pregnant women with sickle cell disease (SCD). Quasi-randomised trials and trials using a cluster-randomised design were eligible for inclusion but none were identified. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two review authors independently assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Out of six relevant reports identified by the search strategy, one trial involving 72 women with sickle cell anaemia (HbSS) met our inclusion criteria. The trial was at unclear risk of bias. Overall, there were few events for most of the reported outcomes and the results were generally imprecise. The included trial reported no maternal mortality occurring in women who received either prophylactic or selective blood transfusion. Very low-quality evidence indicated no clear differences in maternal mortality, perinatal mortality (risk ratio (RR) 2.85, 95% confidence interval (CI) 0.61 to 13.22; very low-quality evidence) or markers of severe maternal morbidity (pulmonary embolism (no events); congestive cardiac failure (RR 1.00, 95% CI 0.07 to 15.38; very low-quality evidence); acute chest syndrome (RR 0.67, 95% CI 0.12 to 3.75)) between the treatment groups (prophylactic blood transfusion versus selective blood transfusion). Low-quality evidence indicated that prophylactic blood transfusion reduced the risk of pain crisis compared with selective blood transfusion (RR 0.28, 95% CI 0.12 to 0.67, one trial, 72 women; low-quality evidence), and no differences in the occurrence of acute splenic sequestration (RR 0.33, 95% CI 0.01 to 7.92; low-quality evidence), haemolytic crises (RR 0.33, 95% CI 0.04 to 3.06) or delayed blood transfusion reaction (RR 2.00, 95% CI 0.54 to 7.39; very low-quality evidence) between the comparison groups.Other relevant maternal outcomes pre-specified for this review such as cumulative duration of hospital stay, postpartum haemorrhage and iron overload, and infant outcomes, admission to neonatal intensive care unit (NICU) and haemolytic disease of the newborn, were not reported by the trial. AUTHORS' CONCLUSIONS Evidence from one small trial of very low quality suggests that prophylactic blood transfusion to pregnant women with sickle cell anaemia (HbSS) confers no clear clinical benefits when compared with selective transfusion. Currently, there is no evidence from randomised or quasi-randomised trials to provide reliable advice on the optimal blood transfusion policy for women with other variants of sickle cell disease (i.e. HbSC and HbSβThal). The available data and quality of evidence on this subject are insufficient to advocate for a change in existing clinical practice and policy.
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Affiliation(s)
- Babasola O Okusanya
- Faculty of Clinical Sciences, College of Medicine, University of Lagos, Idi‐ArabaExperimental and Maternal Medicine Unit, Department of Obstetrics and GynaecologyLagosNigeria
| | - Olufemi T Oladapo
- World Health OrganizationUNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and ResearchAvenue Appia 20GenevaSwitzerlandCH‐1211
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Kuo K, Caughey AB. Contemporary outcomes of sickle cell disease in pregnancy. Am J Obstet Gynecol 2016; 215:505.e1-5. [PMID: 27242200 DOI: 10.1016/j.ajog.2016.05.032] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 05/10/2016] [Accepted: 05/20/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Data regarding pregnancy outcomes in sickle cell disease are conflicting. Previous studies are limited by small sample size, narrow geographic area, and a wide range of resource availability. OBJECTIVE The purpose of this study was to examine the association between maternal sickle cell disease and adverse pregnancy outcomes in a contemporary North American cohort. STUDY DESIGN We performed a retrospective cohort study of 2,027,323 women with singleton pregnancies delivered in California from 2005-2008. Deliveries at <24 or >42 6/7 weeks of gestation were excluded. Women with sickle cell disease were compared with control subjects. Maternal outcomes of interest included preeclampsia, preterm delivery, placental abruption, oligohydramnios, and cesarean delivery; neonatal outcomes included small for gestational age, anomalies, stillbirth, neonatal death, and infant death. RESULTS The prevalence of sickle cell disease was 0.017%. Compared with control subjects, women with sickle cell disease were more likely to have limited prenatal care (7.4 vs 3.8%; P=.001), underlying chronic hypertension (2.3% vs 1.1%; P=.038), and fetal anomalies (14.0 vs 6.4%; P<.001). The increased odds of fetal anomalies persisted after adjustment for multiple confounders (odds ratio, 1.73; 95% confidence interval, 1.26-2.38). Women with sickle cell disease also had higher odds of severe preeclampsia (odds ratio, 3.75; 95% confidence interval, 2.21-6.38), preterm delivery (odds ratio, 2.50; 95% confidence interval, 1.93-3.21), small for gestational age (odds ratio, 1.96; 95% confidence interval, 1.18-3.25), and cesarean delivery (odds ratio, 1.93; 95% confidence interval, 1.40-2.67). CONCLUSION Women with sickle cell disease are at high risk of maternal and neonatal morbidity. Low rates of fetal and neonatal death may reflect improved antenatal surveillance and management as compared with previous studies. The association between sickle cell disease and fetal anomalies warrants further investigation.
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Affiliation(s)
- Kelly Kuo
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR.
| | - Aaron B Caughey
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
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Chou ST, Fasano RM. Management of Patients with Sickle Cell Disease Using Transfusion Therapy. Hematol Oncol Clin North Am 2016; 30:591-608. [DOI: 10.1016/j.hoc.2016.01.011] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Boga C, Ozdogu H. Pregnancy and sickle cell disease: A review of the current literature. Crit Rev Oncol Hematol 2016; 98:364-74. [DOI: 10.1016/j.critrevonc.2015.11.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Revised: 09/22/2015] [Accepted: 11/24/2015] [Indexed: 12/20/2022] Open
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Boafor TK, Olayemi E, Galadanci N, Hayfron-Benjamin C, Dei-Adomakoh Y, Segbefia C, Kassim AA, Aliyu MH, Galadanci H, Tuuli MG, Rodeghier M, DeBaun MR, Oppong SA. Pregnancy outcomes in women with sickle-cell disease in low and high income countries: a systematic review and meta-analysis. BJOG 2015; 123:691-8. [DOI: 10.1111/1471-0528.13786] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2015] [Indexed: 11/26/2022]
Affiliation(s)
- TK Boafor
- Department of Obstetrics and Gynaecology; Korle-Bu Teaching Hospital; Accra Ghana
| | - E Olayemi
- Department of Haematology; University of Ghana Medical School; Accra Ghana
| | - N Galadanci
- Vanderbilt Center of Excellence in Sickle Cell Disease; Vanderbilt Children's Hospital and Vanderbilt University School of Medicine; Nashville TN USA
| | - C Hayfron-Benjamin
- Department of Physiology; University of Ghana Medical School; Accra Ghana
| | - Y Dei-Adomakoh
- Department of Haematology; University of Ghana Medical School; Accra Ghana
| | - C Segbefia
- Department of Child Health; University of Ghana Medical School; Accra Ghana
| | - AA Kassim
- Vanderbilt Center of Excellence in Sickle Cell Disease; Vanderbilt Children's Hospital and Vanderbilt University School of Medicine; Nashville TN USA
| | - MH Aliyu
- Vanderbilt Center of Excellence in Sickle Cell Disease; Vanderbilt Children's Hospital and Vanderbilt University School of Medicine; Nashville TN USA
| | | | - MG Tuuli
- Department of Obstetrics and Gynecology; Washington University in St Louis; St Louis MO USA
| | | | - Michael R DeBaun
- Vanderbilt Center of Excellence in Sickle Cell Disease; Vanderbilt Children's Hospital and Vanderbilt University School of Medicine; Nashville TN USA
| | - SA Oppong
- Department of Obstetrics and Gynaecology; University of Ghana Medical School; Accra Ghana
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Motivations of women with sickle cell disease for asking their partners to undergo genetic testing. Soc Sci Med 2015; 139:36-43. [DOI: 10.1016/j.socscimed.2015.06.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 06/16/2015] [Accepted: 06/24/2015] [Indexed: 01/16/2023]
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Adverse maternal and perinatal outcomes in pregnant women with sickle cell disease: systematic review and meta-analysis. Blood 2015; 125:3316-25. [DOI: 10.1182/blood-2014-11-607317] [Citation(s) in RCA: 126] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 02/10/2015] [Indexed: 12/27/2022] Open
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Mitra M, Parish SL, Clements KM, Cui X, Diop H. Pregnancy outcomes among women with intellectual and developmental disabilities. Am J Prev Med 2015; 48:300-8. [PMID: 25547927 DOI: 10.1016/j.amepre.2014.09.032] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 09/25/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND There is currently no population-based research on the maternal characteristics or birth outcomes of U.S. women with intellectual and developmental disabilities (IDDs). Findings from small-sample studies among non-U.S. women indicate that women with IDDs and their infants are at higher risk of adverse health outcomes. PURPOSE To describe the maternal characteristics and outcomes among deliveries to women with IDDs and compare them to women with diabetes and the general obstetric population. METHODS Data from the 1998-2010 Massachusetts Pregnancy to Early Life Longitudinal database were analyzed between November 2013 and May 2014 to identify in-state deliveries to Massachusetts women with IDDs. RESULTS Of the 916,032 deliveries in Massachusetts between 1998 and 2009, 703 (<0.1%) were to women with IDDs. Deliveries to women with IDDs were to those who were younger, less educated, more likely to be black and Hispanic, and less likely to be married. They were less likely to identify the father on the infant's birth certificate, more likely to smoke during pregnancy, and less likely to receive prenatal care during the first trimester compared to deliveries to women in the control groups (p<0.01). Deliveries to women with IDDs were associated with an increased risk of adverse outcomes, including preterm delivery, very low and low birth weight babies, and low Apgar scores. CONCLUSIONS Women with IDDs are at a heightened risk for adverse pregnancy outcomes. These findings highlight the need for a systematic investigation of the pregnancy-related risks, complications, costs, and outcomes of women with IDDs.
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Affiliation(s)
- Monika Mitra
- Department of Family Medicine and Community Health.
| | - Susan L Parish
- Lurie Institute for Disability Policy, Heller School for Social Policy and Management, Brandeis University, Waltham
| | - Karen M Clements
- Center for Health Policy and Research, University of Massachusetts Medical School, Shrewsbury
| | - Xiaohui Cui
- Bureau of Family Health and Nutrition, Massachusetts Department of Public Health, Boston, Massachusetts
| | - Hafsatou Diop
- Bureau of Family Health and Nutrition, Massachusetts Department of Public Health, Boston, Massachusetts
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Oteng-Ntim E, Ayensah B, Knight M, Howard J. Pregnancy outcome in patients with sickle cell disease in the UK - a national cohort study comparing sickle cell anaemia (HbSS) with HbSC disease. Br J Haematol 2014; 169:129-37. [DOI: 10.1111/bjh.13270] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 11/15/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Eugene Oteng-Ntim
- King's College London; London UK
- Directorate of Women's Health; Guy's and St Thomas' Foundation Trust; London UK
| | - Benjamin Ayensah
- Directorate of Women's Health; Guy's and St Thomas' Foundation Trust; London UK
| | - Marian Knight
- Perinatal Epidemiology Unit; University of Oxford; Oxford UK
| | - Jo Howard
- Department of Haematology; Guy's and St Thomas' NHS Foundation Trust; London UK
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Azonobi IC, Anderson BL, Byams VR, Grant AM, Schulkin J. Obstetrician-gynecologists' knowledge of sickle cell disease screening and management. BMC Pregnancy Childbirth 2014; 14:356. [PMID: 25311876 PMCID: PMC4287569 DOI: 10.1186/1471-2393-14-356] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 09/22/2014] [Indexed: 01/19/2023] Open
Abstract
Background Although obstetrician/gynecologists (OB/GYNs) play an important role in sickle cell disease (SCD) screening and patient care, there is little information on knowledge of SCD or sickle cell trait (SCT) or related practices in this provider group. Our objective was to assess SCD screening and prenatal management practices among OB/GYNs. Methods Twelve hundred Fellows and Junior Fellows of the American College of Obstetricians and Gynecologists (the College)a were invited to complete a mailed survey, of which half (n = 600) belonged to the Collaborative Ambulatory Research Network.b Participants answered questions regarding appropriate target patient groups for prenatal SCD screening, folic acid requirements, practice behaviors and adequacy of their medical school and residency training. Results A total of 338 CARN members (56.3%) and 165 non-CARN members (27.5%) returned a survey. Of the 503 responders, 382 provided obstetric services and were included in the analyses. Forty percent of these respondents (n = 153) reported seeing at least 1 patient with SCD in the last year. Of these, 97.4% reported regularly screening people of African descent for SCD or SCT, whereas 52.9% reported regularly screening people of Mediterranean descent and 30.1% reported regularly screening people of Asian descent. Only 56.2% knew the correct recommended daily dose of folic acid for pregnant women with SCD. The proportion of respondents that rated training on SCD screening, assessment and treatment as barely adequate or inadequate ranged from 19.7% to 39.3%. Conclusions The practice of many OB/GYNs who care for patients with SCD are not consistent with the College Practice Guidelines on the screening of certain target groups and on folic acid supplementation. There may be an opportunity to improve this knowledge gap through enhanced medical education.
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Affiliation(s)
| | | | | | | | - Jay Schulkin
- The American College of Obstetricians and Gynecologists, Washington, DC, USA.
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Asma S, Kozanoglu I, Tarım E, Sarıturk C, Gereklioglu C, Akdeniz A, Kasar M, Turgut NH, Yeral M, Kandemir F, Boga C, Ozdogu H. Prophylactic red blood cell exchange may be beneficial in the management of sickle cell disease in pregnancy. Transfusion 2014; 55:36-44. [DOI: 10.1111/trf.12780] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 05/28/2014] [Accepted: 05/28/2014] [Indexed: 02/06/2023]
Affiliation(s)
- Suheyl Asma
- Clinical Unit; Baskent University Adana Adult Bone Marrow Transplantation Center; Ankara Turkey
- Department of Family Medicine; Baskent University Medical Faculty; Ankara Turkey
| | - Ilknur Kozanoglu
- Cell Collecting and Therapeutic Apheresis Unit; Baskent University Adana Adult Bone Marrow Transplantation Center; Ankara Turkey
- Department of Physiology; Baskent University Medical Faculty; Ankara Turkey
| | - Ebru Tarım
- Department of Obstetrics and Gynecology; Baskent University Medical Faculty; Ankara Turkey
| | - Cagla Sarıturk
- Biostatistics Specialist; Baskent University Adana Hospital; Ankara Turkey
| | - Cigdem Gereklioglu
- Clinical Unit; Baskent University Adana Adult Bone Marrow Transplantation Center; Ankara Turkey
- Department of Family Medicine; Baskent University Medical Faculty; Ankara Turkey
| | - Aydan Akdeniz
- Department of Hematology; Mersin University Medical Faculty; Mersin Turkey
| | - Mutlu Kasar
- Clinical Unit; Baskent University Adana Adult Bone Marrow Transplantation Center; Ankara Turkey
| | - Nurhilal H. Turgut
- Clinical Unit; Baskent University Adana Adult Bone Marrow Transplantation Center; Ankara Turkey
| | - Mahmut Yeral
- Clinical Unit; Baskent University Adana Adult Bone Marrow Transplantation Center; Ankara Turkey
| | - Fatih Kandemir
- Department of Family Medicine; Baskent University Medical Faculty; Ankara Turkey
| | - Can Boga
- Clinical Unit; Baskent University Adana Adult Bone Marrow Transplantation Center; Ankara Turkey
| | - Hakan Ozdogu
- Clinical Unit; Baskent University Adana Adult Bone Marrow Transplantation Center; Ankara Turkey
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Abstract
Life expectancy in sickle cell disease (SCD) has increased substantially and thus women with SCD are almost universally reaching child-bearing age. Studies on potential complications during pregnancy have generated mixed data; however, it is generally accepted that women with SCD are at higher risk for adverse pregnancy outcomes and maternal mortality. It is therefore critical that their care be provided by a team that includes a hematologist and a maternal-fetal medicine specialist. Despite the published risks, women with SCD are capable of successful pregnancy outcomes with proper education and well-coordinated multidisciplinary care. Further investigation is needed to standardize management.
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Affiliation(s)
- Biree Andemariam
- Division of Hematology-Oncology, Lea Center for Hematologic Disorders, Adult Sickle Cell Clinical and Research Center, University of Connecticut Health Center, Farmington, CT 06030, USA.
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Natu N, Khandelwal S, Kumar R, Dave A. Maternal and Perinatal Outcome of Women With Sickle Cell Disease of a Tribal Population in Central India. Hemoglobin 2014; 38:91-4. [DOI: 10.3109/03630269.2013.869501] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Okusanya BO, Oladapo OT. Prophylactic versus selective blood transfusion for sickle cell disease in pregnancy. Cochrane Database Syst Rev 2013:CD010378. [PMID: 24297507 DOI: 10.1002/14651858.cd010378.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pregnant women with sickle cell disease (HbSS, HbSC and HbSβThal) may require blood transfusion to prevent severe anaemia or to manage potential medical complications. Preventive blood transfusion in the absence of complications starting from the early weeks of pregnancy or blood transfusion only for medical or obstetric indications have been used as management policies. There is currently no consensus on the blood transfusion policy that guarantees optimal clinical benefits with minimal risks for such women and their babies. The present review replaces and updates a Cochrane review that was withdrawn in 2006. OBJECTIVES To assess the benefits and harms of a policy of prophylactic versus selective blood transfusion in pregnant women with sickle cell disease. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2013) and reference lists of retrieved studies. We did not apply any language restrictions. SELECTION CRITERIA Randomised and quasi-randomised trials evaluating the effects of prophylactic versus selective (emergency) blood transfusion in pregnant women with sickle cell disease. Trials were considered for inclusion whether the unit of randomisation was at individual or cluster level, however, no cluster-randomised trials were identified. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion and assessed trial quality. Two review authors independently extracted data. Data were checked for accuracy. MAIN RESULTS Out of six relevant reports identified by the search strategy, two trials involving 98 women with sickle cell anaemia (HbSS) met our inclusion criteria. The two trials were at moderate risk of bias. Overall, there were few events for most of the reported outcomes and the results were generally imprecise. One trial (involving 72 women) reported no maternal mortality occurring in women who received either prophylactic or selective blood transfusion. The same trial (involving 72 women) indicated no clear differences in maternal mortality, perinatal mortality (risk ratio (RR) 2.85, 95% confidence interval (CI) 0.61 to 13.22) or markers of severe maternal morbidity [pulmonary embolism (no events); congestive cardiac failure (RR 1.00, 95% CI 0.07 to 15.38); acute chest syndrome (RR 0.67, 95% CI 0.12 to 3.75)] between the treatment groups (prophylactic blood transfusion versus selective blood transfusion). Prophylactic blood transfusion reduced the risk of pain crisis compared with selective blood transfusion (RR 0.42, 95% CI 0.17 to 0.99, two trials, 98 women); however, the margin of uncertainty around the effect estimate ranged from very small to substantial reduction. One trial (involving 72 women) indicated no differences in the occurrence of acute splenic sequestration (RR 0.33, 95% CI 0.01 to 7.92) and haemolytic crises (RR 0.33, 95% CI 0.04 to 3.06) and delayed blood transfusion reaction (RR 2.00, 95% CI 0.54 to 7.39) between the comparison groups. AUTHORS' CONCLUSIONS Evidence from two small trials of low quality suggests that prophylactic blood transfusion to pregnant women with sickle cell anaemia (HbSS) confers no clear clinical benefits when compared with selective transfusion. Currently, there is no evidence from randomised or quasi-randomised trials to provide reliable advice on the optimal blood transfusion policy for women with other variants of sickle cell disease (i.e. HbSC and HbSβThal). The available data and quality of evidence on this subject are insufficient to advocate for a change in existing clinical practice and policy.
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Affiliation(s)
- Babasola O Okusanya
- Experimental and Maternal Medicine Unit, Department of Obstetrics and Gynaecology, Faculty of Clinical Sciences, College of Medicine, University of Lagos, Idi-Araba, Lagos, Nigeria
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Okusanya BO, Oladapo OT. Prophylactic versus selective blood transfusion for sickle cell disease in pregnancy. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd010378] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Sickle cell disease in pregnancy: trend and pregnancy outcomes at a tertiary hospital in Tanzania. PLoS One 2013; 8:e56541. [PMID: 23418582 PMCID: PMC3572068 DOI: 10.1371/journal.pone.0056541] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 01/10/2013] [Indexed: 11/18/2022] Open
Abstract
SCD in pregnancy is associated with increased adverse fetal and maternal outcomes. In Tanzania where the frequency of sickle cell trait is 13% there has been scanty data on SCD in pregnancy. With progressive improvement in childhood survival the burden of SCD in pregnancy will increase. We analyzed all deliveries at Muhimbili National Hospital (MNH) from 1999 to 2011. Fetal and maternal outcomes of SCD deliveries were compared with non-SCD. Data were analyzed using IBM SPSS statistics version 19. Chi square and Fisher Exact tests were used to compare proportions and the independent t-test for continuous data. To predict risks of adverse effects, odds ratios were determined using multivariate logistic regression. A p-value<0.05 was considered significant. In total, 157,473 deliveries occurred at MNH during the study period, of which 149 were SCD (incidence of 95 SCD per 100,000 deliveries). The incidence of SCD had increased from 76 per 100,000 deliveries in the 1999–2002 period to over 100 per 100, 000 deliveries in recent years. The mean maternal age at delivery was lower in SCD (24.0±5.5 years) than in non-SCD deliveries (26.2±6.0 years), p<0.001. Compared with non-SCD (2.9±0.7 Kg), SCD deliveries had less mean birth-weight (2.6±0.6 Kg), p<0.001. SCD were more likely than non-SCD to deliver low APGAR score at 5 minutes (34.5% Vs 15.0%, OR = 3.0, 95%CI: 2.1–4.2), stillbirths (25.7% Vs 7.5%, OR = 4.0, 95%CI: 2.8–5.8). There was excessive risk of maternal deaths in SCD compared to non-SCD (11.4% Vs 0.4%, OR = 29, 95%CI: 17.3–48.1). The leading cause of deaths in SCD was infections in wholly 82% in contrast to only 32% in non-SCD. In conclusion SCD in pregnancy is an emerging problem at MNH with increased adverse fetal outcomes and excessive maternal mortality mainly due to infections.
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Boulet SL, Okoroh EM, Azonobi I, Grant A, Craig Hooper W. Sickle cell disease in pregnancy: maternal complications in a Medicaid-enrolled population. Matern Child Health J 2013; 17:200-7. [PMID: 23315242 PMCID: PMC4394367 DOI: 10.1007/s10995-012-1216-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Higher frequencies of pregnancy complications have been reported among women with sickle cell disease (SCD) compared with those without SCD; however, past studies are limited by small sample size, narrow geographic area, and use of hospital discharge data. We compared the prevalence of maternal complications among intrapartum and postpartum women with SCD to those without SCD in a large, geographically diverse sample. Data from the 2004-2010 Truven Health MarketScan(®) Multi-State Medicaid databases were used to assess the prevalence of maternal complications among intrapartum and postpartum women 15-44 years of age with and without SCD whose race was reported as black. The comparison group of women without SCD was further divided into those with chronic conditions associated with multi-organ failure and those without chronic conditions. Multivariable log-binomial regression models were used to calculate adjusted prevalence ratios for outcomes for women with SCD compared with women in the two comparison groups. Of the 335,348 black women with a delivery during 2004-2010, 1,526 had a diagnosis of SCD (0.5 %). Compared with women without SCD who had chronic conditions, women with SCD had higher prevalence of deep vein thrombosis, pulmonary embolism, obstetric shock, pneumonia, sepsis, postpartum infection, and transfusions. SCD was also positively associated with acute renal failure, cerebrovascular disorder, respiratory distress syndrome, eclampsia, postpartum hemorrhage, preterm birth, and ventilation when compared with women without SCD and chronic conditions. Overall, women with SCD have increased prevalence of pregnancy complications, even when compared with a group of women with similar risk for multi-organ failure.
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Affiliation(s)
- Sheree L Boulet
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, MS-K34, 30341, Atlanta, Georgia, USA.
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Wilson NO, Ceesay FK, Hibbert JM, Driss A, Obed SA, Adjei AA, Gyasi RK, Anderson WA, Stiles JK. Pregnancy outcomes among patients with sickle cell disease at Korle-Bu Teaching Hospital, Accra, Ghana: retrospective cohort study. Am J Trop Med Hyg 2012; 86:936-42. [PMID: 22665597 DOI: 10.4269/ajtmh.2012.11-0625] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Pregnancy in sickle cell disease (SCD) patients is associated with increased risk of maternal and fetal mortality. This study determines pregnancy outcomes among women with SCD delivering at Korle-Bu Teaching Hospital, Accra, Ghana. Nine hundred sixty (960) medical records of pregnant women (131 HbSS, 112 HbSC, and 717 comparison group) from 2007 to 2008 were reviewed. The HbSS women were at increased risk of eclampsia (adjusted odds ratio [AOR] = 10.56, 95% confidence interval [CI] = 3.60-30.96, P < 0.001), intrauterine growth restriction (AOR = 4.00, 95% CI = 1.38-11.64, P = 0.011), and placenta previa (AOR = 22.03, 95% CI = 9.87-49.14, P < 0.001) compared with the comparison group. The HbSC women had increased risk for intrauterine fetal death (AOR = 3.38, 95% CI = 1.15-9.96, P = 0.027) and decreased risk of delivering low birth weight babies (AOR = 0.21, 95% CI = 0.06-0.73, P = 0.014). Women with SCD in Ghana are at a greater risk of morbidity and mortality in pregnancy compared with women without hemoglobinopathies. Improved maternal and fetal outcomes in Ghanaian women with SCD can be achieved through effective intervention by health care providers with thorough knowledge about predisposing factors toward adverse outcomes.
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Affiliation(s)
- Nana O Wilson
- Morehouse School of Medicine, Department of Microbiology, Biochemistry and Immunology, Atlanta, GA 30310, USA.
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Excess risk of maternal death from sickle cell disease in Jamaica: 1998-2007. PLoS One 2011; 6:e26281. [PMID: 22039456 PMCID: PMC3200316 DOI: 10.1371/journal.pone.0026281] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 09/23/2011] [Indexed: 11/19/2022] Open
Abstract
Background Decreases in direct maternal deaths in Jamaica have been negated by growing indirect deaths. With sickle cell disease (SCD) a consistent underlying cause, we describe the epidemiology of maternal deaths in this population. Methods Demographic, service delivery and cause specific mortality rates were compared among women with (n = 42) and without SCD (n = 376), and between SCD women who died in 1998–2002 and 2003–7. Results Women with SCD had fewer viable pregnancies (p: 0.02) despite greater access to high risk antenatal care (p: 0.001), and more often died in an intensive care unit (p: 0.002). In the most recent period (2003–7) SCD women achieved more pregnancies (median 2 vs. 3; p: 0.009), made more antenatal visits (mean 3.3 vs. 7.3; p: 0.01) and were more often admitted antenatally (p:<0.0001). The maternal mortality ratio for SCD decedents was 7–11 times higher than the general population, with 41% of deaths attributable to their disorder. Cause specific mortality was higher for cardiovascular complications, gestational hypertension and haemorrhage. Respiratory failure was the leading immediate cause of death. Conclusions Women with SCD experience a significant excess risk of dying in pregnancy and childbirth [MMR: (SCD) 719/100,000, (non SCD) 78/100,000]. MDG5 cannot be realised without improving care for women with SCD. Tertiary services (e.g. ventilator support) are needed at regional centres to improve outcomes in this and other high risk populations. Universal SCD screening in pregnancy in populations of African and Mediterranean descent is needed as are guidelines for managing SCD pregnancies and educating families with SCD.
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Hoots WK. The registry and surveillance in hemoglobinopathies: improving the lives of individuals with hemoglobinopathies. Am J Prev Med 2010; 38:S510-1. [PMID: 20331951 DOI: 10.1016/j.amepre.2010.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 12/18/2009] [Accepted: 01/06/2010] [Indexed: 01/19/2023]
Affiliation(s)
- W Keith Hoots
- Division of Blood Diseases and Resources, National Heart, Lung, and Blood Institute, Bethesda, MD 20892-7950, USA.
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Lottenberg R. Nonmalignant blood disorders: time to establish a public health agenda. Am J Prev Med 2010; 38:S449-50. [PMID: 20331941 DOI: 10.1016/j.amepre.2010.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Revised: 01/11/2010] [Accepted: 01/15/2010] [Indexed: 10/19/2022]
Affiliation(s)
- Richard Lottenberg
- Division of Hematology and Oncology, Department of Medicine, University of Florida College of Medicine, Gainesville, FL 32610-0277, USA.
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