Reproductive health issues in female patients with beta-thalassaemia major: a narrative literature review

Pregnancy, delivery, and neonatal outcomes among women with beta-thalassemia major: a population-based study of a large US database

PURPOSE

We explored the effect of beta-thalassemia major on pregnancy and delivery outcomes in non-endemic area, utilizing USA population database.

METHODS

This is a retrospective study utilizing data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample. A cohort of all deliveries between 2011 and 2014 was created using ICD-9 codes. The patients with beta-thalassemia major were identified and matched to patients without beta-thalassemia based on age, race, income quartile, and type of health insurance at a ratio of 1:20. The baseline characteristics were compared between the groups using Chi-square and Fischer's exact tests, as appropriate. The univariate and multivariate analyses were conducted for pregnancy, delivery and neonatal outcomes to estimate the unadjusted and adjusted odds ratio, respectively.

RESULTS

Out of 3,070,656 pregnancies over the study period, beta-thalassemia major complicated 445 pregnancies. The patients with beta-thalassemia were more likely to have thyroid disorders and previous C-section (p-value < 0.05). There were no differences in pregnancy outcomes such as gestational hypertension, preeclampsia, gestational diabetes, and placenta previa. C-section was 30% more likely to be the method of birth (aOR 1.30, 95%CI 1.03-1.63) and there was more than three-fold increase in rate of blood transfusion (aOR 4.69, 95% CI 3.02-7.28) among participants with beta-thalassemia major. Mothers with beta-thalassemia, almost, were 70% more likely to have a neonate small for gestational age (aOR 1.68, 95%CI 1.07-2.62).

CONCLUSIONS

Women with beta-thalassemia major are more likely to give birth by C-section, require blood transfusion and have small for gestational age neonates. Counseling patients with beta-thalassemia about these risks and increased antenatal surveillance is advised.

Reproductive Health in Women with Major β-Thalassemia: Evaluating Ovarian Reserve and Endocrine Complications

Thalassemia is an autosomal recessive hereditary chronic hemolytic anemia characterized by a partial or complete deficiency in the synthesis of alpha- or beta-globin chains, which are essential components of adult hemoglobin. Mutations in the globin genes lead to the production of unstable globin chains that precipitate within cells, causing hemolysis. This shortens the lifespan of mature red blood cells (RBCs) and results in the premature destruction of RBC precursors in the bone marrow. Regular red blood cell transfusions are the standard treatment for thalassemia. However, these transfusions can lead to increased iron overload, which can impair vital systems such as the liver, heart, ovaries, and endocrine system. Focusing on female reproductive endocrinology, recurrent blood transfusions can cause iron accumulation in the pituitary and hypothalamus, leading to hypogonadotropic hypogonadism (HH), the most common endocrinopathy in these patients, affecting 40-91% of women. Recurrent transfusions and the resulting iron overload can also lead to oxidative stress and ovarian damage in patients with beta-thalassemia major (BTM). Despite advancements in iron chelation therapy, hypothalamic-pituitary damage associated with HH contributes to subfertility and sexual dysfunction, often with little to no recovery. In women exposed to gonadotoxic drugs, particularly those with BTM, anti-Mullerian hormone (AMH)-a marker of ovarian reserve-is frequently used to assess ovarian damage. This review aims to explore the pathophysiology of β-thalassemia and its major clinical manifestations, with a focus on endocrine complications and their impact on ovarian reserve. It also investigates how metabolomics can provide insights into the disease's metabolic alterations and inform current and emerging therapeutic strategies to mitigate complications and optimize patient outcomes, potentially leading to more effective and personalized treatments.

Current status and trends in thalassemia burden across South, East and Southeast Asia, 1990-2021 a systematic analysis for the global burden of disease study 2021

OBJECTIVE

Thalassemia, an inherited hemoglobin synthesis disorder, imposes a significant health burden in Asian regions with high prevalence. Detailed patterns and trends of the disease across countries and territories within these regions remain underexplored. Our study focuses on the disease burden indices of thalassemia within the four GBD-defined Asian regions and the twenty-five included countries and territories. It provides insights into the gender-age distribution, temporal changes, and economic aspects of the thalassemia burden.

METHODS

Data on thalassemia prevalence, incidence, mortality, and Disability-Adjusted Life Years (DALYs) were extracted from the Global Burden of Disease (GBD) 2021 study for South, East, Southeast, and high-income Asia regions, encompassing the relevant countries and territories from 1990 to 2021. The Average Annual Percent Change (AAPC) in age-standardized rates of thalassemia was determined to assess temporal trends. Age-gender cohort proportions were considered. The economic aspect of the disease burden and frontier analysis were evaluated using the GBD Socio-Demographic Index and Global Health Expenditure data.

RESULTS

Southeast Asia exhibited notably high age-standardized mortality rate (ASMR), age-standardized prevalence rate (ASPR), and age-standardized DALYs rate among the four studied Asian regions in 2021. The East Asia region had recorded the highest age-standardized incidence rate (ASIR). A general decline in disease burden indices across the four regions from 1990 to 2021 was evident, with the exception of ASIR in Southeast Asia. The ASMR was highest among pediatric population under five years old, with a significant male preponderance. An unusual increase in ASMR was detected among females of childbearing age and the elderly within the studied region. Further analysis had identified six high-burden countries and territories, particularly those with low-middle Socio-Demographic Index (SDI) rankings and limited health expenditure.

CONCLUSION

Although the overall burden of thalassemia has decreased substantially, the disease burden was influenced by gender, age, geography, temporal trends, and economic factors in distinct manners. Based on the current SDI, many countries and regions still have greater improvement potential in the disease burden. There is a necessity for enhanced attention and resource allocation, particularly in low-middle and low SDI countries, with an emphasis on policies that promote early diagnosis and comprehensive care.

Ethical Challenges in Information Disclosure and Decision-making in Prenatal Testing: A Focus Group Study of Chinese Health Professionals in Maternal and Child Health Services

The international community has proposed a comprehensive strategy to prevent congenital abnormalities. And China, with a high incidence of congenital diseases, has implemented measures including prenatal screening and diagnosis to reduce the morbidity of congenital abnormalities. However, ethical challenges arise in the practice of prenatal screening and diagnosis among healthcare professionals. Five focus group discussions were conducted with twenty-four health professionals working in maternal and child health services in Hunan Province, China, to explore the ethical challenges they encountered in prenatal testing decision-making and information disclosure practices, as well as their views on these challenges. Participants were selected through purposive sampling, ensuring maximum demographic diversity. Three main themes were identified: 1) balancing between information disclosure and privacy protection; 2) patient-oriented decision-making and tensions within family-oriented decision-making; 3) the disparity between the limited help clinical ethics committees (CECs) can provide and professionals' need for CECs. Ethical norms for information disclosure and autonomous decision-making within prenatal screening and diagnostic institutions must be established. Utilizing CECs is crucial to guide professionals in delivering prenatal testing services while simultaneously focusing on targeted improvement of communication skills among these professionals.

Multidisciplinary Management of Oral Manifestations in Pregnant Women with Beta-Thalassemia Major: A Case Report

Introduction

Beta-thalassemia major is a blood disorder caused by impaired synthesis of hemoglobin beta chain. Oral manifestations of beta-thalassemia major in pregnancy have rarely been reported.

Objective

This study aimed to describe a case of oral manifestations in a pregnant woman with beta-thalassemia major for multidisciplinary management.

Case

A 27-year-old woman, suffering from beta thalassemia major who is undergoing therapy in the form of routine blood transfusions every month and taking anti-chelation drugs but is currently stopping this because she is pregnant, currently 16 weeks pregnant, complains complained of swollen gums, bleeding, and bad breath. Extraoral examination revealed dry, exfoliative lips. Intraoral examination revealed gingival hyperplasia with erythema, soft consistency, dark red rounded gingival margins, bleeding, true pockets and pain throughout the labial, buccal, palatal, and lingual. There was no history of systemic disease in this patient. Patient has never visited a dentist, either before or now, with complaints about her oral cavity. Hematological parameters showed abnormalities, and peripheral blood examination revealed an infection. The oral diagnoses included gingival enlargement and chronic periodontitis associated with pregnancy and β- thalassemia major.

Case Management

Dental management consisted of spooling with 3% hydrogen peroxide (H2O2) spooling, chlorine dioxide spray mouthwash, antibiotics, calculus removal, and oral hygiene instructions. Blood transfusions were administered once a month, and anti-chelation therapy was stopped during pregnancy. After three months of multidisciplinary management, the results were satisfactory.

Conclusion

Multidisciplinary, collaborative dental and medical management with non-surgical therapy of oral manifestations in pregnant women with beta-thalassemia major showed satisfactory results.

Development and psychometric properties evaluation of nurses' innovative behaviours inventory in Iran: protocol for a sequential exploratory mixed-method study

INTRODUCTION

Nurses' innovative behaviours play a crucial role in addressing the challenges including adapting to emerging technologies, resource limitations and social realities such as population ageing that are intricately tied to today's healthcare landscape. Innovative behaviours improve healthcare quality, patient safety and satisfaction. Organisational factors and individual attributes influence nurses' inclination to innovate. With the rise of artificial intelligence and novel technology, healthcare institutions are actively engaged in the pursuit of identifying nurses who demonstrate innovative qualities. Developing a comprehensive protocol to elucidate the various dimensions of nurses' innovative behaviours and constructing a valid measuring instrument, rooted in this protocol represents a significant step in operationalising this concept.

METHODS AND ANALYSIS

The study encompasses two phases: a qualitative study combined with a literature review, followed by the design and psychometric evaluation of the instrument. To ensure diversity, a maximum variation purposive sampling method will be used during the qualitative phase to select clinical nurses. In-depth semistructured interviews will be conducted and analysed using conventional content analysis. Additionally, a comprehensive literature review will supplement any missing features not captured in the qualitative phase, ensuring their inclusion in the primary tool. The subsequent quantitative phase will focus on evaluating the questionnaire's psychometric properties, including face, content and construct validity through exploratory factor analyses (including at least 300 samples) and confirmatory factor analyses (including at least 200 samples). Internal consistency (Cronbach's alpha), reliability (test-retest), responsiveness, interpretability and scoring will also be assessed.

ETHICS AND DISSEMINATION

This study originates from a doctoral dissertation in nursing. Permission and ethical approval from Semnan University of Medical Sciences has been obtained with reference code IR.SEMUMS.1401.226. The study's findings will ultimately be submitted as a research paper to a peer-reviewed journal.

Pregnancy and assisted reproductive technology use in Australian female transfusion-dependent haemoglobinopathy patients: a 20-year retrospective analysis

BACKGROUND

In the last few decades, the life expectancy of patients with transfusion-dependent thalassaemia (TDT) and sickle cell disease (SCD) has improved significantly, in part because of improved iron chelation. Fertility challenges and pregnancy complications have historically limited reproductive options in this group; however, improved multi-disciplinary care has made infertility a chronic disease complication requiring attention. Despite this, there are very few reports and no Australian data describing fertility and pregnancy outcomes in this population.

AIMS

To identify the rate of assisted reproductive technologies (ART) utilisation in our female transfusion-dependent haemoglobinopathy patients and to establish the nature of maternal and neonatal complications in this cohort.

METHODS

A 20-year retrospective analysis (1997-2017) at an Australian centre captured data on conception rates, use of assisted reproductive techniques (ART), and pregnancy and neonatal outcomes in female transfusion-dependent haemoglobinopathy patients.

RESULTS

Conception was attempted in 14 women (11 TDT and three SCD) during the study period. A total of 28 pregnancies resulting in 25 live births were recorded. ART supported 13 conceptions. A positive association was not identified between elevated mean serum ferritin and ART use; however, all patients with an established diagnosis of hypogonadotropic hypogonadism (HH) required ART. Maternal complications included gestational diabetes mellitus and post-partum haemorrhage. There were no cardiac complications. Two-thirds of women underwent lower segment caesarean section, with prematurity complicating 20% of births. There were no neonatal or maternal deaths.

CONCLUSION

Pregnancy is an achievable goal for women with transfusion-dependent haemoglobinopathies, although the support of ART may be required in a subset of patients.

Experiences of operating room nurses in disaster preparedness of a great disaster in Iran: a qualitative study

BACKGROUND

In recent years, Iran has encountered a growing frequency of earthquake disasters. Given that nurses constitute the largest group of healthcare providers, it is imperative that they possess adequate disaster preparedness skills, irrespective of the location or time. Despite the operating room nurses' roles in disasters, their experiences and challenges in disaster preparedness have been overlooked. Consequently, this study aimed to investigate the experiences, challenges, perspectives, and factors influencing the disaster preparedness of operating room nurses during the 2017 earthquake in Kermanshah, Iran.

METHODS

The present qualitative research was carried out in Iran In 2022 utilizing conventional content analysis. The study involved conducting semi-structured interviews with 16 operating room nurses who had participated in disaster preparedness during the Kermanshah earthquake. The participants were selected using a purposive sampling approach that aimed to achieve maximum diversity. The interviews were continued until the point of data saturation was reached, and the verbatim transcripts were analyzed using conventional content analysis in MAXQDA software. To ensure the rigor of the research, Guba and Lincoln's criteria were employed.

RESULTS

The study conducted data analysis to identify the main theme as "insufficient disaster preparedness due to a faded preparedness", along with six major categories and eighteen subcategories related to earthquake disaster preparedness. The major categories included: knowledge and perception of preparedness for disasters; educational and training programs for disaster preparedness; equipment preparedness for disasters; managerial-organizational preparedness for disasters; clinical skills for responding to disasters; and resilient ability in disaster response situations.

CONCLUSION

The findings of the study provide valuable insights into the dimensions of disaster preparedness in earthquake disasters among operating room nurses. Nursing managers can utilize these findings to develop effective strategies and provide support in areas such as improving knowledge and educational level, equipment preparedness, strengthening plans and managerial structures, enhancing skills, and explaining resilience strategies to improve the disaster preparedness of operating room nurses and medical organizations' disaster response teams.

Thrombosis in Pregnant Women with Hemolytic Anemia

Hemolytic anemias are a group of uncommon disorders affecting both genders, frequently occurring at the reproductive age. While a link between hemolysis and hypercoagulability has been suggested based on the elucidation of certain involved pathophysiological mechanisms, the extent of thrombotic risk in pregnant women with hemolytic anemia remains debatable. Due to the paucity of pregnancy-related data, risk assessment of gestations in women with hemolytic anemia is complicated. This review will highlight the latest advances in the diagnosis and management of these challenging disorders in pregnancy.

Ovarian tissue cryopreservation in the pediatric with rare diseases- experience from China's first and the largest ovarian tissue cryobank

Background

There is limited information about the efficacy of ovarian tissue cryopreservation (OTC) in children. In the present study, we report eight patients with rare diseases who underwent OTC in China's first and largest ovarian tissue cryobank.

Procedure

Data from girls with rare diseases who underwent OTC between September 2020 and November 2022 were retrospectively analyzed. We also compared the number of cryopreserved cortex pieces, follicle number, and AMH in those with rare diseases and age-matched children with non-rare diseases who also underwent OTC in our cryobank.

Results

The median age of the children was 5.88 ± 3.52 (range 2-13) years old. Unilateral oophorectomy was undertaken via laparoscopy in all of the children. The diseases in the 8 patients were: 4 mucopolysaccharidoses (MPS I two cases, IVA two cases), 1 Diamond-Blackfan anemia (DBA), 1 Fanconi anemia (FA), 1 hyperimmunoglobulin E syndrome (HIES), 1 Niemann-Pick disease. The number of cryopreserved cortex pieces was 17.13 ± 6.36, and the follicle count per 2 mm biopsy was 447.38 ± 524.35. No significant difference in age, the count of cryopreserved cortex pieces, follicle number per 2 mm biopsy, and AMH level was seen between the 20 children with non-rare diseases and those with rare diseases.

Conclusions

The reports help practitioners counsel girls with rare diseases about fertility preservation. The demand for OTC in pediatrics will likely grow as a standard of care.

New Entity-Thalassemic Endocrine Disease: Major Beta-Thalassemia and Endocrine Involvement

Beta-thalassemia (BTH), a recessively inherited haemoglobin (Hb) disorder, causes iron overload (IO), extra-medullary haematopoiesis and bone marrow expansion with major clinical impact. The main objective of this review is to address endocrine components (including aspects of reproductive health as fertility potential and pregnancy outcome) in major beta-thalassemia patients, a complex panel known as thalassemic endocrine disease (TED). We included English, full-text articles based on PubMed research (January 2017–June 2022). TED includes hypogonadism (hypoGn), anomalies of GH/IGF1 axes with growth retardation, hypothyroidism (hypoT), hypoparathyroidism (hypoPT), glucose profile anomalies, adrenal insufficiency, reduced bone mineral density (BMD), and deterioration of microarchitecture with increased fracture risk (FR). The prevalence of each ED varies with population, criteria of definition, etc. At least one out of every three to four children below the age of 12 y have one ED. ED correlates with ferritin and poor compliance to therapy, but not all studies agree. Up to 86% of the adult population is affected by an ED. Age is a positive linear predictor for ED. Low IGF1 is found in 95% of the population with GH deficiency (GHD), but also in 93.6% of persons without GHD. HypoT is mostly pituitary-related; it is not clinically manifested in the majority of cases, hence the importance of TSH/FT4 screening. HypoT is found at any age, with the prevalence varying between 8.3% and 30%. Non-compliance to chelation increases the risk of hypoT, yet not all studies confirmed the correlation with chelation history (reversible hypoT under chelation is reported). The pitfalls of TSH interpretation due to hypophyseal IO should be taken into consideration. HypoPT prevalence varies from 6.66% (below the age of 12) to a maximum of 40% (depending on the study). Serum ferritin might act as a stimulator of FGF23. Associated hypocalcaemia transitions from asymptomatic to severe manifestations. HypoPT is mostly found in association with growth retardation and hypoGn. TED-associated adrenal dysfunction is typically mild; an index of suspicion should be considered due to potential life-threatening complications. Periodic check-up by ACTH stimulation test is advised. Adrenal insufficiency/hypocortisolism status is the rarest ED (but some reported a prevalence of up to one third of patients). Significantly, many studies did not routinely perform a dynamic test. Atypical EM sites might be found in adrenals, mimicking an incidentaloma. Between 7.5–10% of children with major BTH have DM; screening starts by the age of 10, and ferritin correlated with glycaemia. Larger studies found DM in up to 34%of cases. Many studies do not take into consideration IGF, IGT, or do not routinely include OGTT. Glucose anomalies are time dependent. Emerging new markers represent promising alternatives, such as insulin secretion-sensitivity index-2. The pitfalls of glucose profile interpretation include the levels of HbA1c and the particular risk of gestational DM. Thalassemia bone disease (TBD) is related to hypoGn-related osteoporosis, renal function anomalies, DM, GHD, malnutrition, chronic hypoxia-induced calcium malabsorption, and transplant-associated protocols. Low BMD was identified in both paediatric and adult population; the prevalence of osteoporosis/TBD in major BTH patients varies; the highest rate is 40–72% depending on age, studied parameters, DXA evaluation and corrections, and screening thoracic–lumbar spine X-ray. Lower TBS and abnormal dynamics of bone turnover markers are reported. The largest cohorts on transfusion-dependent BTH identified the prevalence of hypoGn to be between 44.5% and 82%. Ferritin positively correlates with pubertal delay, and negatively with pituitary volume. Some authors appreciate hypoGn as the most frequent ED below the age of 15. Long-term untreated hypoGn induces a high cardiovascular risk and increased FR. Hormonal replacement therapy is necessary in addition to specific BTH therapy. Infertility underlines TED-related hormonal elements (primary and secondary hypoGn) and IO-induced gonadal toxicity. Males with BTH are at risk of infertility due to germ cell loss. IO induces an excessive amount of free radicals which impair the quality of sperm, iron being a local catalyser of ROS. Adequate chelation might improve fertility issues. Due to the advances in current therapies, the reproductive health of females with major BTH is improving; a low level of statistical significance reflects the pregnancy status in major BTH (limited data on spontaneous pregnancies and growing evidence of the induction of ovulation/assisted reproductive techniques). Pregnancy outcome also depends on TED approach, including factors such as DM control, adequate replacement of hypoT and hypoPT, and vitamin D supplementation for bone health. Asymptomatic TED elements such as subclinical hypothyroidism or IFG/IGT might become overt during pregnancy. Endocrine glands are particularly sensitive to iron deposits, hence TED includes a complicated puzzle of EDs which massively impacts on the overall picture, including the quality of life in major BTH. The BTH prognostic has registered progress in the last decades due to modern therapy, but the medical and social burden remains elevated. Genetic counselling represents a major step in approaching TH individuals, including as part of the pre-conception assessment. A multidisciplinary surveillance team is mandatory.

Ferroptosis and Its Emerging Role in Pre-Eclampsia

Iron is essential for cell survival, and iron deficiency is a known risk factor for many reproductive diseases. Paradoxically, such disorders are also more common in cases of iron overload. Here, we evaluated the role of ferroptosis in women's health, particularly focusing on pre-eclampsia (PE). PE is a multisystem disorder and is one of the leading causes of maternal and perinatal morbidity and mortality, especially when the condition is of early onset. Nevertheless, the exact etiological mechanism of PE remains unclear. Interestingly, ferroptosis, as a regulated iron-dependent cell death pathway, involves a lethal accumulation of lipid peroxides and shares some characteristics with PE pathophysiology. In this review, we comprehensively reviewed and summarized recent studies investigating the molecular mechanisms involved in the regulation and execution of ferroptosis, as well as ferroptosis mechanisms in the pathology of PE. We propose that ferroptosis not only plays an important role in PE, but may also become a novel therapeutic target for PE.

Association of Beta-Thalassaemia and Hypogonadotropic Hypogonadism

Thalassaemic syndromes are among the most common haemoglobinopathies and are associated with high morbidity and mortality. Because of the various treatments, a secondary endocrinopathy due to iron overload—haemosiderosis—can occur, causing hypopituitarism leading to hypogonadotropic hypogonadism (HH) and infertility. We present a case of secondary amenorrhoea in a patient with beta-thalassaemia and a history of multiple therapies in her adolescence, such as multiple transfusions, chemotherapy, and allogeneic bone marrow transplantation, who presented with HH and premature ovarian insufficiency.

Good Clinical Practice of the Italian Society of Thalassemia and Haemoglobinopathies (SITE) for the Management of Endocrine Complications in Patients with Haemoglobinopathies

Background: The treatment of endocrinopathies in haemoglobinopathies is a continually expanding research area; therefore, recommendations supporting the appropriateness of treatments are a pressing need for the medical community. Methods: The Management Committee of SITE selected and gathered a multidisciplinary and multi-professional team, including experts in haemoglobinopathies and experts in endocrinopathies, who have been flanked by experts with methodological and organizational expertise, in order to formulate recommendations based on the available scientific evidence integrated by personal clinical experience. The project followed the systematic approach for the production of clinical practice guidelines according to the methodology suggested by the National Center for Clinical Excellence, Quality and Safety of Care (CNEC). Results: Out of 14 topics, 100 clinical questions were addressed, and 206 recommendations were elaborated on. The strength of recommendations, panel agreement, a short general description of the topic, and the interpretation of evidence were reported. Conclusions: Good Practice Recommendations are the final outcome of translational research and allow one to transfer to the daily clinical practice of endocrine complications in haemoglobinopathies.

Consequences of β-Thalassemia or Sickle Cell Disease for Ovarian Follicle Number and Morphology in Girls Who Had Ovarian Tissue Cryopreserved

Women with β-thalassemia (BT) and sickle cell disease (SCD) have a high risk of infertility and premature ovarian insufficiency. Different fertility preserving strategies, including ovarian tissue cryopreservation (OTC) and oocyte cryopreservation has been considered, and healthy babies have been born after successful OTC and transplantation. We evaluated follicle number and follicle health in ovarian tissue from a cohort of BT and SCD patients who underwent OTC before the age of 18 years. Patients undergoing OTC from 2002 to 2019 were included. A total of 14 girls and adolescents with BT and four with SCD, aged 2.8-17.4 years at OTC were included together with a reference group of 43 girls and adolescents with non-anemia diseases considered to have normal ovaries aged 0.6-17.9 years at OTC. Ovarian follicle density was measured in cortex biopsies and compared to the reference group. Expression of proteins associated with follicular health was evaluated using immunohistochemistry. Follicles were detected in the ovarian cortex biopsies from all patients with BT and SCD. The follicle densities were within the 95% prediction interval of the reference group in all cases. A similar expression of six proteins essential for follicular health was detected using immunohistochemistry in BT, SCD, and references. OTC should be considered an option for young girls and adolescents with BT and SCD.