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Alan S, Sharma D, Pecker LH. Prophylactic red cell transfusions for sickle cell disease pregnancy: increased use of therapy could transform outcomes. Curr Opin Hematol 2024; 31:285-293. [PMID: 39177058 PMCID: PMC11427169 DOI: 10.1097/moh.0000000000000837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
PURPOSE OF REVIEW Pregnancy for people with sickle cell disease (SCD) is high risk with persistently high rates of severe maternal and fetal mortality and morbidity. Transfusion therapy is the best-studied treatment for SCD in pregnancy; hydroxyurea is not usually used because of teratogenicity concerns. In high-resource settings, red cell transfusions are likely underutilized, while in low-resource settings, they may be altogether unavailable. RECENT FINDINGS A randomized controlled trial and meta-analysis, two of the strongest forms of clinical research, show transfusion significantly reduces maternal and fetal death, painful crisis, thrombosis, and acute respiratory failure. Downstream benefits of treatment are less well measured and may include improving maternal anemia, reducing opioid exposure, and avoiding hospitalization, which presents risk for additional complications. Alloimmunization is a particular transfusion risk in SCD. However, many strategies can mitigate this risk. Accordingly, the American Society of Hematology classifies chronic transfusion in pregnancy as low risk. SUMMARY Given the low risk classification, lack of alternative therapies, dismal, stagnant pregnancy outcomes and the potential for profound treatment benefit, wider use of chronic transfusion therapy for SCD pregnancy is likely indicated. This review discusses the benefits and potential risks of prophylactic transfusions for SCD pregnancy. Use of chronic transfusions during pregnancy is indicated to help urgently transform outcomes.
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Affiliation(s)
- Sheinei Alan
- INOVA Adult Sickle Cell Program, Inova Schar Cancer Institute, Fairfax, VA, USA
| | - Deva Sharma
- Division of Transfusion Medicine, Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville TN, USA
- Division of Hematology-Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lydia H. Pecker
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Gibson SMP, Hunter TA, Charles PE, Morgan MAC, Griffith-Anderson SKR, Cruickshank JK, Gossell-Williams MD, Johnson NA. Current obstetric outcomes in Jamaican women with sickle hemoglobinopathy - a balance of risks for aspirin? J Perinat Med 2024; 52:485-493. [PMID: 38629833 DOI: 10.1515/jpm-2023-0378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 02/29/2024] [Indexed: 06/02/2024]
Abstract
OBJECTIVES Sickle cell disease (SCD) occurs in 2.8 % of our Jamaican antenatal population with homozygous HbSS being most associated with adverse maternal and perinatal outcomes. METHODS A retrospective comparative analysis of HbSS, HbSC and HbSβThal pregnancy outcomes at the University Hospital of the West Indies (UHWI) between January 2012 and December 2022 was conducted. RESULTS Of 120 patients (138 pregnancies), obesity occurred in 36 % (20/56) of the 'non-HbSS' group, i.e. HbSβThal (55 %, 5/9) and HbSC (32 %, 15/47) combined vs. 9.7 % of the HbSS (8/82). HbSS patients had more crises requiring transfusions, acute chest syndrome (ACS), maternal 'near-misses' (OR=10.7, 95 % 3.5-32.3; p<0.001), hospitalizations (OR 7.6, 95 % CI 3.4-16.9; p<0.001), low birth weight (LBW) neonates (OR 3.1, 1.1-8.9; p=0.037) and preterm birth (OR=2.6, 1.2-5.8; p=0.018) compared to HbSC and HbSβThal. Low dose aspirin was prescribed in 43 %. Logistic regression showed those NOT on aspirin (n=76) had more miscarriages (22 v. 2 %), were LESS likely to have a live birth (75 v. 95 % (0.2, 0.04-0.57, p=0.005)), but surprisingly had fewer painful crises (28 v. 46 % (0.5, 0.03-0.9, p=0.03)). CONCLUSIONS HbSS women had a 10-fold excess of maternal near-misses. Additional research may further clarify the effects of aspirin on pregnancy outcomes as related to SCD genotypes.
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Affiliation(s)
- Shanea M P Gibson
- Department of Obstetrics and Gynaecology, 233759 University Hospital of the West Indies , Mona, Jamaica
| | - Tiffany A Hunter
- Department of Obstetrics and Gynaecology, 233759 University Hospital of the West Indies , Mona, Jamaica
- Department of Obstetrics and Gynaecology, 62707 University of the West Indies , Mona, Jamaica
| | - Phillip E Charles
- Department of Obstetrics and Gynaecology, 233759 University Hospital of the West Indies , Mona, Jamaica
- Department of Obstetrics and Gynaecology, 62707 University of the West Indies , Mona, Jamaica
| | - Melonie A C Morgan
- Department of Obstetrics and Gynaecology, 62707 University of the West Indies , Mona, Jamaica
| | - Shari K R Griffith-Anderson
- Department of Obstetrics and Gynaecology, 233759 University Hospital of the West Indies , Mona, Jamaica
- Department of Obstetrics and Gynaecology, 62707 University of the West Indies , Mona, Jamaica
| | | | | | - Nadine A Johnson
- Department of Obstetrics and Gynaecology, 233759 University Hospital of the West Indies , Mona, Jamaica
- Department of Obstetrics and Gynaecology, 62707 University of the West Indies , Mona, Jamaica
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Sikdar O, Ambulkar H, Jenkinson A, Hedley C, Johns J, Bhat R, Dassios T, Harris C, Greenough A. Maternal and infant outcomes in women with sickle cell disease: a matched cohort study. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2024-326848. [PMID: 38604649 DOI: 10.1136/archdischild-2024-326848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 03/25/2024] [Indexed: 04/13/2024]
Abstract
OBJECTIVE Women with sickle cell disease (SCD) have adverse maternal and infant outcomes. Our aim was to determine whether the outcomes of SCD mothers and their infants differed from African or Caribbean women not affected by SCD and whether there were differences between SCD individuals with the haemoglobin SS (HbSS) or haemoglobin SC (HbSC) genotypes. Furthermore, we wished to determine if any differences related to deprivation. DESIGN A matched cohort study. SETTING Tertiary perinatal centre in London PATIENTS: 4964 African or Caribbean women without SCD and 148 with SCD. MAIN OUTCOME MEASURES Mode of delivery, maternal exchange transfusion, birthweight, neonatal unit admission, neonatal death and deprivation indices RESULTS: SCD women were more likely to be delivered by caesarean section (p<0.001) and had babies of lower birthweight (p<0.001). Their infants were no more likely to be admitted to neonatal intensive care unit or suffer a neonatal death. There were no significant differences between the SCD women and those without SCD in their deprivation index or deprivation decile. The women with the HbSS genotype compared to those with the HbSC genotype were more anaemic (p<0.02), required more exchange transfusions (p<0.001) and were more likely to be delivered by caesarean section (p=0.008). The infant outcomes did not differ significantly between the genotypes. CONCLUSIONS Although, the SCD women, particularly those with the HbSS genotype, had greater morbidity, infant morbidity, and mortality was similar in mothers with the HbSS or HbSC genotypes and those without SCD.
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Affiliation(s)
- Oishi Sikdar
- Department of Women and Children's Health, King's College London, London, UK
| | - Hemant Ambulkar
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Allan Jenkinson
- Department of Women and Children's Health, King's College London, London, UK
| | - Catherine Hedley
- Department of Obstetrics and Gynaecology, King's College Hospital NHS Foundation Trust, London, UK
| | - Jemma Johns
- Department of Obstetrics and Gynaecology, King's College Hospital NHS Foundation Trust, London, UK
| | - Ravindra Bhat
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Theodore Dassios
- Department of Women and Children's Health, King's College London, London, UK
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Christopher Harris
- Department of Women and Children's Health, King's College London, London, UK
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, King's College London, London, UK
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4
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Joseph L, Driessen M. A comprehensive view of pregnancy in patients with sickle cell disease in high-income countries: the need for robust data and further decline in morbidity and mortality. Lancet Haematol 2024; 11:e75-e84. [PMID: 38135375 DOI: 10.1016/s2352-3026(23)00310-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 10/06/2023] [Accepted: 10/09/2023] [Indexed: 12/24/2023]
Abstract
Sickle cell disease is a major public health concern due to its prevalence and associated morbidities. In high-income countries, diagnosis and treatment advancements have extended patient's lives and enabled women to embrace motherhood. Although the provision of care in specialist centres has reduced maternal-fetal complication rates, the mortality rate among pregnant women with sickle cell disease remains disproportionately high. Complications arise from vaso-occlusive events, worsening organ damage, thrombotic risks, infections, and pregnancy-related issues, such as pre-eclampsia, premature birth, small-for-gestational-age, and pregnancy loss. Effective management during pregnancy includes preconception planning, genetic counselling, education, and collaborative care. There is no consensus on the overall approach to managing pregnant women with sickle cell disease; however, fostering a collaborative relationship between health-care professionals and researchers is crucial for advancing the understanding and management of this illness. The disparities in health-care outcomes associated with ethnicity and economic insecurity affect patients with sickle cell disease but have not been examined extensively. Hence, health-care personnel need sufficient training to address these issues alongside broader societal efforts to confront racism and discrimination. Comprehensive national and global action plans are required to address the multifaceted challenges of sickle cell disease.
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Affiliation(s)
- Laure Joseph
- Biotherapy Department, French National Sickle Cell Referral Centre, Biotherapy Clinical Investigation Centre, Hôpital Necker-Enfant Malades, Assistance-Publique Hôpitaux de Paris, Paris, France.
| | - Marine Driessen
- Department of Obstetrics and Fetal Medicine, Hôpital Necker-Enfant Malades, Assistance-Publique Hôpitaux de Paris, Paris, France
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Valentini CG, Pellegrino C, Ceglie S, Arena V, Di Landro F, Chiusolo P, Teofili L. Red Blood Cell Exchange as a Valid Therapeutic Approach for Pregnancy Management in Sickle Cell Disease: Three Explicative Cases and Systematic Review of Literature. J Clin Med 2023; 12:7123. [PMID: 38002735 PMCID: PMC10672461 DOI: 10.3390/jcm12227123] [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: 10/11/2023] [Revised: 11/08/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
Pregnancy in women with sickle cell disease (SCD) is a high-risk situation, especially during the third trimester of gestation and in the post-partum period, due to chronic hypoxia and vaso-occlusive phenomena occurring in the maternal-fetal microcirculation: as a result, unfavorable outcomes, such as intra-uterine growth restriction, prematurity or fetal loss are more frequent in SCD pregnancies. Therefore, there is a consensus on the need for a strict and multidisciplinary follow-up within specialized structures. Transfusion support remains the mainstay of treatment of SCD pregnancies, whereas more targeted modalities are still controversial: the benefit of prophylactic management, either by simple transfusions or by automated red blood cell exchange (aRBCX), is not unanimously recognized. We illustrate the cases of three SCD pregnant patients who underwent aRBCX procedures at our institution in different clinical scenarios. Moreover, we carried out a careful literature revision to investigate the management of pregnancy in SCD, with a particular focus on the viability of aRBCX. Our experience and the current literature support the use of aRBCX in pregnancy as a feasible and safe procedure, provided that specialized equipment and an experienced apheresis team is available. However, further research in this high-risk population, with appropriately powered prospective trials, is desirable to refine the indications and timing of aRBCX and to confirm the advantages of this approach on other transfusion modalities.
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Affiliation(s)
- Caterina Giovanna Valentini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Claudio Pellegrino
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Sara Ceglie
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Vincenzo Arena
- Sezione di Patologia, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Istituto di Anatomia Patologica, Università Cattolica Del Sacro Cuore, 00168 Rome, Italy
| | - Francesca Di Landro
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Patrizia Chiusolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Luciana Teofili
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Adesina OO, Brunson A, Fisch SC, Yu B, Mahajan A, Willen SM, Keegan THM, Wun T. Pregnancy outcomes in women with sickle cell disease in California. Am J Hematol 2023; 98:440-448. [PMID: 36594168 PMCID: PMC9942937 DOI: 10.1002/ajh.26818] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 11/28/2022] [Accepted: 12/06/2022] [Indexed: 01/04/2023]
Abstract
Adverse pregnancy outcomes occur frequently in women with sickle cell disease (SCD) across the globe. In the United States, Black women experience disproportionately worse maternal health outcomes than all other racial groups. To better understand how social determinants of health impact SCD maternal morbidity, we used California's Department of Health Care Access and Information data (1991-2019) to estimate the cumulative incidence of pregnancy outcomes in Black women with and without SCD-adjusted for age, insurance status, and Distressed Community Index (DCI) scores. Black pregnant women with SCD were more likely to deliver at a younger age, use government insurance, and live in at-risk or distressed neighborhoods, compared to those without SCD. They also experienced higher stillbirths (26.8, 95% confidence interval [CI]: 17.5-36.1 vs. 12.4 [CI: 12.1-12.7], per 1000 births) and inpatient maternal mortality (344.5 [CI: 337.6-682.2] vs. 6.1 [CI: 2.3-8.4], per 100 000 live births). Multivariate logistic regression models showed Black pregnant women with SCD had significantly higher odds ratios (OR) for sepsis (OR 14.89, CI: 10.81, 20.52), venous thromboembolism (OR 13.60, CI: 9.16, 20.20), and postpartum hemorrhage (OR 2.25, CI 1.79-2.82), with peak onset in the second trimester, third trimester, and six weeks postpartum, respectively. Despite adjusting for sociodemographic factors, Black women with SCD still experienced significantly worse pregnancy outcomes than those without SCD. We need additional studies to determine if early introduction to reproductive health education, continuation of SCD-modifying therapies during pregnancy, and increasing access to multidisciplinary perinatal care can reduce morbidity in pregnant women with SCD.
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Affiliation(s)
- Oyebimpe O. Adesina
- Center for Oncology Hematology Outcomes Research and Training, Division of Hematology Oncology, University of California Davis School of Medicine, Sacramento, CA
| | - Ann Brunson
- Center for Oncology Hematology Outcomes Research and Training, Division of Hematology Oncology, University of California Davis School of Medicine, Sacramento, CA
| | - Samantha C. Fisch
- University of California San Francisco School of Medicine, San Francisco, CA
| | - Bo Yu
- Department of Obstetrics & Gynecology, Stanford University School of Medicine; Stanford Maternal & Child Health Research Institute, Stanford, CA
| | - Anjlee Mahajan
- Center for Oncology Hematology Outcomes Research and Training, Division of Hematology Oncology, University of California Davis School of Medicine, Sacramento, CA
| | - Shaina M. Willen
- Center for Oncology Hematology Outcomes Research and Training, Division of Hematology Oncology, University of California Davis School of Medicine, Sacramento, CA
- Division of Pediatric Pulmonary and Sleep Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Theresa H. M. Keegan
- Center for Oncology Hematology Outcomes Research and Training, Division of Hematology Oncology, University of California Davis School of Medicine, Sacramento, CA
| | - Ted Wun
- Center for Oncology Hematology Outcomes Research and Training, Division of Hematology Oncology, University of California Davis School of Medicine, Sacramento, CA
- UC Davis Clinical and Translational Science Center, University of California, Davis, CA
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Early ML, Eke AC, Gemmill A, Lanzkron S, Pecker LH. Severe Maternal Morbidity and Mortality in Sickle Cell Disease in the National Inpatient Sample, 2012-2018. JAMA Netw Open 2023; 6:e2254552. [PMID: 36729452 PMCID: PMC9896307 DOI: 10.1001/jamanetworkopen.2022.54552] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
IMPORTANCE Pregnancy outcomes are historically poor among people with sickle cell disease (SCD) in the US, most of whom have Black race. Whether outcomes have improved is unknown. OBJECTIVE To tabulate adverse pregnancy outcomes among patients with SCD, comparing outcomes of deliveries among Black people with SCD with those of Black people without SCD and a control non-Black population, and to measure the association of racial disparities with adverse outcomes in SCD pregnancies. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study was a secondary analysis involving data from National Inpatient Sample, a nationally representative sample of 20% of acute hospital admissions in the US, between 2012 and 2018. The data set included all admissions with codes for delivery of a pregnancy among people aged 11 to 55 years. Data were analyzed from September 2021 to August 2022. EXPOSURES SCD, racial disparities. MAIN OUTCOMES AND MEASURES Severe maternal morbidity (SMM) as measured by the US Centers for Disease Control and Prevention's index alongside other outcomes; multiple logistic regression was used to compare the odds for adverse pregnancy outcomes. RESULTS The sample included 5 401 899 deliveries, including 3901 deliveries among people with SCD and 742 164 deliveries among people with Black race. Compared with the non-Black control group, patients with SCD and Black patients were younger (mean [SD] age: SCD, 27.2 [5.9] years; Black, 27.1 [6.1] years vs 28.7 [5.9] years) and more likely to have public insurance (SCD, 2609 deliveries [67.3%]; Black, 496 828 deliveries [65.4%] vs 1 880 198 deliveries [40.8%]). The maternal mortality rate in deliveries among people with SCD was 26 times greater than in the non-Black control group and more than 10 times greater than among Black pregnant people without SCD (Per 10 000 deliveries: SCD 13.3; 95% CI, 5.7-31.2; Black race, 1.2; 95% CI, 1.0-1.5; non-Black control 0.5; 95% CI, 0.5-0.6). Compared with the control group, SCD deliveries had higher odds of SMM (adjusted odds ratio [aOR], 7.22; 95% CI, 6.25-8.34; P < .001), especially cerebrovascular events (aOR, 22.00; 95% CI, 15.25-31.72; P < .001) and thromboembolism (aOR, 17.34; 95% CI, 11.55-26.03; P < .001). Racial disparities explained a median (IQR) 28.9% (21.2%-33.1%) of the increased risk in deliveries to people with SCD and between 40% and 50% of the increased risk for acute kidney failure (excess risk [ER], 56.9%; 95% CI, 54.3%-59.3%), intrauterine fetal demise (ER, 47.8%; 95% CI, 46.6%-49.1%), and eclampsia (ER, 42.1%; 95% CI, 37.9%-46.1%). CONCLUSIONS AND RELEVANCE In this large cross-sectional study of pregnancy outcomes in people with SCD, the risk for SMM was higher compared with deliveries among people without SCD, especially for thrombotic events, organ failure, and death. Racial disparities were associated with adverse outcomes. Our findings compel scientific, clinical, and political effort to improve outcomes for pregnant people with SCD.
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Affiliation(s)
- Macy L. Early
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ahizechukwu C. Eke
- Division of Maternal-Fetal Medicine & Clinical Pharmacology, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alison Gemmill
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sophie Lanzkron
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lydia H. Pecker
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Pecker LH, Nero A, Christianson M. No crystal stair: supporting fertility care and the pursuit of pregnancy in women with sickle cell disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:459-466. [PMID: 36485154 PMCID: PMC9821326 DOI: 10.1182/hematology.2022000381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Growing recognition that the ovary is an end organ in sickle cell disease (SCD), advances in SCD treatment and cure, and innovations in assisted reproductive technologies invite progressive challenges in fertility care for women with SCD. The reproductive life span of women with SCD may be reduced because ovarian reserve declines more rapidly in people with SCD compared to unaffected people. Some young women have diminished ovarian reserve, a risk factor for infertility. Referrals for fertility preservation may be offered and anticipatory guidance about when to seek infertility care provided. For a subset of people with SCD, this information is also applicable when pursuing in vitro fertilization with preimplantation genetic testing to avoid implantation of an embryo with SCD. Here we explore the dimensions of SCD-related fertility care illustrated by the case of a 28-year-old woman with hemoglobin SS disease who initially presented for a hematology consultation for preconception counseling. This case highlights the complexity of preconception SCD management and care and the need to partner with patients to help align pregnancy hopes with SCD treatment and the many associated uncertainties.
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Affiliation(s)
- Lydia H. Pecker
- Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD
- Division of Reproductive Endocrinology and Infertility, Johns Hopkins University School of Medicine, Baltimore, MD
- Correspondence Lydia H. Pecker, 720 Rutland Ave, Ross Bldg 1025, Johns Hopkins University School of Medicine, Baltimore, MD 21205; e-mail:
| | - Alecia Nero
- Division of Hematology-Oncology, UT Southwestern Medical Center, Dallas, TX
| | - Mindy Christianson
- Division of Reproductive Endocrinology and Infertility, Johns Hopkins University School of Medicine, Baltimore, MD
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9
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Oakley LL, Mitchell S, von Rege I, Hadebe R, Howard J, Robinson SE, Oteng-Ntim E. Perinatal outcomes in women with sickle cell disease: a matched cohort study from London, UK. Br J Haematol 2021; 196:1069-1075. [PMID: 34881428 DOI: 10.1111/bjh.17983] [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: 09/09/2021] [Revised: 11/01/2021] [Accepted: 11/19/2021] [Indexed: 11/29/2022]
Abstract
There are limited data on contemporary outcomes for women with sickle cell disease (SCD) in pregnancy. We conducted a single-site matched cohort study, comparing 131 pregnancies to women with SCD between 2007 and 2017 to a comparison group of 1310 pregnancies unaffected by SCD. Restricting our analysis to singleton pregnancies that reached 24 weeks of gestation, we used conditional Poisson regression to estimate adjusted risk ratios (aRRs) for perinatal outcomes. Infants born to mothers with SCD were more likely to be small for gestational age [aRR 1·69, 95% confidence interval (CI) 1·13-2·48], preterm (aRR 2·62, 95% CI 1·82-3·78) and require Neonatal Unit (NNU) admission (aRR 3·59, 95% CI 2·18-5·90). Pregnant women with SCD were at higher risk of pre-eclampsia/eclampsia (aRR 3·53, 95% CI 2·00-6·24), more likely to receive induction of labour (aRR 2·50, 95% CI 1·82-1·76) and caesarean birth (aRR 1·44, 95% CI 1·18-1·76). In analysis stratified by genotype, the risk of adverse outcomes was highest in haemoglobin SS (HbSS) pregnancies (n = 80). There was no strong evidence that haemoglobin SC (HbSC) pregnancies (n = 46) were at higher risk of preterm birth, caesarean delivery, or NNU admission. Pre-eclampsia/eclampsia was more frequently observed in HbSC pregnancies. Despite improvements in the care of pregnant women with SCD, the increased risk of adverse perinatal outcomes remains.
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Affiliation(s)
- Laura L Oakley
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Sian Mitchell
- Department of Women & Children's Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Inez von Rege
- Department of Women & Children's Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ruth Hadebe
- Department of Women & Children's Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jo Howard
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Susan E Robinson
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Eugene Oteng-Ntim
- Department of Women & Children's Health, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Cordier AG, Bouvier AS, Vibert F, Martinovic J, Couturier-Tarrade A, Lai-Kuen R, Curis E, Fournier T, Benachi A, Peoc'H K, Gil S. Preserved efficiency of sickle cell disease placentas despite altered morphology and function. Placenta 2020; 100:81-88. [PMID: 32871493 DOI: 10.1016/j.placenta.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 08/05/2020] [Accepted: 08/07/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Pregnant women with sickle cell disease (SCD) are at high risk for sickle cell-related complications, obstetrical complications, and perinatal morbidity. Chronic inflammation and the proangiogenic environment associated with SCD have been associated with endothelial damage. It is unknown whether SCD complications could be associated with placental dysfunction or abnormal placental morphology. Moreover, circulating angiogenic factors in pregnant women with SCD are unexplored. METHODS Clinical records, placental and blood samples were collected at term delivery for 21 pregnant patients with SCD and 19 HbAA pregnant controls with adapted to gestational age birth weight newborns. Histological and stereological analyses and scanning electron microscopy (SEM) of the placenta, and PlGF and sFlt1 measurements in blood were performed. RESULTS In the SCD group, the parenchyma-forming villi of placentas were thinner than in controls, and increased fibrinoid necrosis and an overabundance of syncytial knots were seen. SEM revealed elongated intermediate villous endings with a reduction in the number of terminal villi compared to controls, indicating a significant branching defect in SCD placentas. Finally, SCD patients had an imbalance in the angiogenic ratio of sFlt1/PlGF (p = 0.008) with a drop of PlGF concentrations. DISCUSSION We evidence for the first time both abnormal placenta morphology and altered sFlt1/PlGF ratio in SCD patients, uncorrelated with maintained placental efficiency and fetal growth.
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Affiliation(s)
- Anne-Gael Cordier
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie Obstétrique, Centre hospitalier universitaire Antoine Béclère, Université Paris-Sud, 92140, Clamart, France; Université de Paris, INSERM UMR-S1139 (3PHM), Sorbonne Paris Cité, Paris, F-75006, France; PremUp Foundation, Paris, F-75014, France; Centre de référence maladies rares. Syndromes drépanocytaires majeurs, thalassémies et autres pathologies rares du globule rouge et de l'érythropoïèse, Paris, France.
| | - Anne-Sophie Bouvier
- Université de Paris, INSERM UMR-S1139 (3PHM), Sorbonne Paris Cité, Paris, F-75006, France; PremUp Foundation, Paris, F-75014, France
| | - Francoise Vibert
- Université de Paris, INSERM UMR-S1139 (3PHM), Sorbonne Paris Cité, Paris, F-75006, France; PremUp Foundation, Paris, F-75014, France
| | - Jelena Martinovic
- Assistance Publique-Hôpitaux de Paris, Service de Fœtopathologie, Centre hospitalier universitaire Antoine Béclère, Université Paris-Sud, Clamart, France; INSERM, UMR, 1195, Université Paris Sud, Paris Saclay, France
| | | | - René Lai-Kuen
- Plateau technique Imagerie Cellulaire et Moléculaire (ICM), UMS, 3612, CNRS, US25 INSERM, Faculté de Pharmacie de Paris, Université Paris Descartes, Sorbonne Paris Cité, France
| | - Emmanuel Curis
- Service de biostatistiques et informatique médicale, Hôpital Saint-Louis, APHP, Paris, France; Laboratoire de biomathématiques, Faculté de pharmacie, Université Paris Descartes, France
| | - Thierry Fournier
- Université de Paris, INSERM UMR-S1139 (3PHM), Sorbonne Paris Cité, Paris, F-75006, France
| | - Alexandra Benachi
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie Obstétrique, Centre hospitalier universitaire Antoine Béclère, Université Paris-Sud, 92140, Clamart, France; Centre de référence maladies rares. Syndromes drépanocytaires majeurs, thalassémies et autres pathologies rares du globule rouge et de l'érythropoïèse, Paris, France
| | - Katell Peoc'H
- Université de Paris, INSERM UMR-S1139 (3PHM), Sorbonne Paris Cité, Paris, F-75006, France; Assistance Publique-Hôpitaux de Paris, Laboratoire de Biochimie Clinique, HUPNVS, Hôpital Beaujon, Clichy and Université de Paris, UFR de Médecine Xavier Bichat, Paris, France
| | - Sophie Gil
- Université de Paris, INSERM UMR-S1139 (3PHM), Sorbonne Paris Cité, Paris, F-75006, France; PremUp Foundation, Paris, F-75014, France
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