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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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2
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Asare EV. Acute pain episodes, acute chest syndrome, and pulmonary thromboembolism in pregnancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:388-407. [PMID: 36485167 PMCID: PMC9821602 DOI: 10.1182/hematology.2022000376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Pregnancy in women with sickle cell disease (SCD) is a life-threatening condition. In both high- and low-income countries, there is an 11-fold increased risk of maternal death and a 4-fold increased risk of perinatal death. We highlight the epidemiology of SCD-specific and obstetric complications commonly seen during pregnancy in SCD and propose definitions for acute pain and acute chest syndrome (ACS) episodes during pregnancy. We conducted a systematic review of the recent obstetric and hematology literature using full research articles published within the last 5 years that reported outcomes in pregnant women with SCD. The prevalence of acute pain episodes during pregnancy ranged between 4% and 75%. The prevalence of ACS episodes during pregnancy ranged between 4% and 13%. The estimated prevalence of pulmonary thromboembolism in women with SCD during pregnancy is approximately 0.5 to 1%. ACS is the most common cause of death and is often preceded by acute pain episodes. The most crucial time to develop these complications in pregnancy is during the third trimester and postpartum period. In a pooled analysis from studies in low- and middle-income settings, maternal death in women with SCD is approximately 2393 and 4300 deaths per 100 000 live births with and without multidisciplinary care, respectively. In comparison, in the US and northern Europe, the general maternal mortality rate is approximately 23.8 and 8 deaths per 100 000 live births, respectively. A multidisciplinary SCD obstetrics care approach reduces maternal and perinatal morbidity and mortality in low- and middle-income countries.
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Affiliation(s)
- Eugenia Vicky Asare
- Ghana Institute of Clinical Genetics, Korle-Bu, Accra, Ghana
- Department of Haematology, Korle-Bu Teaching Hospital, Accra, Ghana
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3
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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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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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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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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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Sorrentino F, Maffei L, Caprari P, Cassetta R, Dell'Anna D, Materazzi S, Risoluti R. Pregnancy in Thalassemia and Sickle Cell Disease: The Experience of an Italian Thalassemia Center. Front Mol Biosci 2020; 7:16. [PMID: 32118041 PMCID: PMC7033579 DOI: 10.3389/fmolb.2020.00016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 01/28/2020] [Indexed: 12/16/2022] Open
Abstract
The life expectancy of thalassemia patients has increased significantly in recent years being the most "elderly" patients approaching or are over 50 years old. Consequently, patients' perspectives have changed, leading them to longer-term planning with a consequent increase in their reproductive potential and desire to have children. Crucial points in the management of pregnancy in thalassemia are the iron chelation therapy before and during pregnancy, the antithrombotic prophylaxis, the management of transfusion therapy according to the modified transfusion requirement, a cardiologic monitoring for hemodynamic changes that expose an increased risk of heart failure. Pregnancy in women with sickle cell disease is still associated with increased rates of maternal and fetal mortality and adverse outcomes. Maternal morbidity may be due to acute sickling crises, thromboembolism, infection, and chronic end-organ dysfunction, while neonatal outcomes may be intrauterine growth retardation, preterm delivery, small infants for gestational age, stillbirth, and neonatal death. The management of pregnancy in thalassemia and sickle cell disease requires to be approached by a multidisciplinary team and followed from the pre-conception phase until the post-partum period with a close monitoring of the maternal and fetal conditions, in order to ensure optimal outcome. This approach requires the application of well-defined protocols that cover all the critical aspects of pregnancies in women affected by these pathologies. We describe our experience of spontaneous and non-spontaneous pregnancies in patients with thalassemia major and intermedia and sickle cell disease followed between 1992 and 2018 at the Thalassemia Unit of S. Eugenio Hospital of Rome.
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Affiliation(s)
| | - Laura Maffei
- Thalassemia Unit, S. Eugenio Hospital, Rome, Italy
| | - Patrizia Caprari
- National Centre for the Control and Evaluation of Medicines, Istituto Superiore di Sanità, Rome, Italy
| | | | | | | | - Roberta Risoluti
- Department of Chemistry, Sapienza University of Rome, Rome, Italy
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