Aplastic anemia during pregnancy: a review of obstetric and anesthetic considerations

Diagnosis and management of acquired aplastic anemia in childhood. Guidelines from the Marrow Failure Study Group of the Pediatric Haemato-Oncology Italian Association (AIEOP)

Acquired aplastic anemia (AA) is a rare heterogeneous disorder characterized by pancytopenia and hypoplastic bone marrow. The incidence is 2-3 per million population per year in the Western world, but 3 times higher in East Asia. Survival in severe aplastic anemia (SAA) has improved significantly due to advances in hematopoietic stem cell transplantation (HSCT), immunosuppressive therapy, biologic agents, and supportive care. In SAA, HSCT from a matched sibling donor (MSD) is the first-line treatment. If a MSD is not available, options include immunosuppressive therapy (IST), matched unrelated donor, or haploidentical HSCT. The purpose of this guideline is to provide health care professionals with clear guidance on the diagnosis and management of pediatric patients with AA. A preliminary evidence-based document prepared by a group of pediatric hematologists of the Bone Marrow Failure Study Group of the Italian Association of Pediatric Hemato-Oncology (AIEOP) was discussed, modified and approved during a series of consensus conferences that started online during COVID 19 and continued in the following years, according to procedures previously validated by the AIEOP Board of Directors.

Aplastic Anaemia in Pregnancy: A Case-Based Comprehensive Review of the Literature

Aplastic anaemia (AA) is a rare and life-threatening haematologic disorder characterised by pancytopenia and bone marrow failure. Its occurrence during pregnancy is exceedingly rare, posing significant risks and management challenges for both the mother and the foetus. We present here the case of a 23-year-old female, six months pregnant, diagnosed with severe aplastic anaemia (AA), aiming to highlight the diagnostic challenges and management considerations of AA in pregnancy. Our case underscores the critical nature of considering aplastic anaemia in differential diagnosis for pregnant patients presenting with unexplained pancytopenia. Based on that, we performed a comprehensive literature review of the past 20 years of papers published in the English language identified through searches in PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase and the Cochrane Library, to provide an in-depth analysis of the current understanding of AA in pregnancy. We emphasise the necessity for cautious yet thorough investigation in such cases to avoid complications in both maternal and foetal health, focusing attention on the need for further research into safe and effective treatment protocols for managing AA in pregnancy, given the complexities introduced by the condition and its treatment on pregnancy outcomes.

Guidelines for the diagnosis and management of adult aplastic anaemia: A British Society for Haematology Guideline

Pancytopenia with hypocellular bone marrow is the hallmark of aplastic anaemia (AA) and the diagnosis is confirmed after careful evaluation, following exclusion of alternate diagnosis including hypoplastic myelodysplastic syndromes. Emerging use of molecular cyto-genomics is helpful in delineating immune mediated AA from inherited bone marrow failures (IBMF). Camitta criteria is used to assess disease severity, which along with age and availability of human leucocyte antigen compatible donor are determinants for therapeutic decisions. Supportive care with blood and platelet transfusion support, along with anti-microbial prophylaxis and prompt management of opportunistic infections remain key throughout the disease course. The standard first-line treatment for newly diagnosed acquired severe/very severe AA patients is horse anti-thymocyte globulin and ciclosporin-based immunosuppressive therapy (IST) with eltrombopag or allogeneic haemopoietic stem cell transplant (HSCT) from a matched sibling donor. Unrelated donor HSCT in adults should be considered after lack of response to IST, and up front for young adults with severe infections and a readily available matched unrelated donor. Management of IBMF, AA in pregnancy and in elderly require special attention. In view of the rarity of AA and complexity of management, appropriate discussion in multidisciplinary meetings and involvement of expert centres is strongly recommended to improve patient outcomes.

Neonatal outcomes and related risk factors of 30 cases with aplastic anemia in pregnancy: A retrospective study

OBJECTIVE

To analyze the neonatal outcomes of pregnancies complicated by aplastic anemia (AA) and to investigate the underlying risk factors.

METHODS

A single-center retrospective study was performed. Thirty singleton gravidas with AA (AA group) and another thirty singleton gravidas (control group) without immune or blood system disorders who gave birth around the same time were selected. Neonatal outcomes were compared between the two groups. Meanwhile, multivariable analyses were utilized to investigate the association between underlying risk factors and adverse neonatal events.

RESULTS

No neonatal deaths occurred. Compared to the control group, the offspring of women with AA had a smaller gestational age (36 ± 1.9 vs. 39.1 ± 0.9 weeks; P < 0.001) and birth weight (2683.7 ± 479.9 vs. 3324.3 ± 394.1 g; P < 0.001). Newborns of women with AA had a higher risk of premature delivery (53.3 % vs. 3.3 %; P < 0.001), low birth weight (23.3 % vs. 0 %; P < 0.001) and NICU admission (53.3 % vs. 16.7 %; P = 0.003). Multivariate analysis showed neutropenia, anemia and thrombocytopenia as risk factors for premature delivery and admission to NICU. Anemia was independently associated with low birth weight (OR 0.94, 95 % CI 0.9-0.98, P = 0.01).

CONCLUSIONS

Neonatal complications such as premature delivery, low birth weight and NICU admission are more common in pregnant women with AA. Newborn babies' s hematopoietic system did not appear to have been affected. Maintaining a certain level of neutrophils, hemoglobin, and platelets in the mother can improve newborn outcomes.

Importance of the Third Trimester Complete Blood Count: A Case Report on Aplastic Anemia in Pregnancy

Aplastic anemia (AA) poses a significant threat to maternal and fetal health throughout the perinatal period. Diagnosis is based on complete blood count (CBC) and bone marrow biopsy with treatment varying based on severity of disease. This report highlights a case of AA incidentally identified by the third trimester CBC drawn in the outpatient office. Patient was referred for inpatient management to mobilize a multidisciplinary team of healthcare professionals including obstetricians, hematologists, and anesthesiologists to optimize maternal and fetal outcome. The patient received blood and platelet transfusions prior to delivering a healthy liveborn infant by cesarean section. This case highlights the importance for routine third trimester CBC screening to identify potential complications and decrease maternal and fetal morbidity and mortality.

A case of Fanconi anaemia in pregnancy

Fanconi anaemia is a rare autosomal recessive chromosomal instability syndrome characterised by progressive bone marrow failure, skeletal defects, reduced fertility and increased susceptibility to malignancy. Successful pregnancy in both transplanted and non-transplanted patients have been recorded. In this paper, we present a woman diagnosed with Fanconi anaemia and who had a spontaneous conception at the age of 25 years with an uneventful delivery at 38 weeks of pregnancy.

Aplastic Anemia Treated with Eltrombopag during Pregnancy

Aplastic anemia is a rare blood disorder characterized by pancytopenia and hypocellular bone marrow. In patients with aplastic anemia, pancytopenia sometimes worsens during pregnancy, and relapse of aplastic anemia in pregnancy is common. Nevertheless, only supportive care with blood products is the mainstay of treatment of aplastic anemia in pregnancy. Thus, the obstetric management and treatment of aplastic anemia in pregnancy is extremely challenging. We herein report the first case of a pregnant woman complicated with aplastic anemia who was successfully treated with eltrombopag, a thrombopoietin receptor agonist. A 27-year-old primigravida woman who had a history of aplastic anemia refractory to immunosuppressive therapy and was treated with eltrombopag became pregnant. Eltrombopag treatment was continued after weighing the benefits and potential risks. Throughout pregnancy, the woman's pancytopenia did not progress, and she delivered a 2336 g baby vaginally at 38 weeks of gestation. Her postpartum outcome was uneventful, and the neonate did not develop thrombocytosis. Since the efficacy and safety of eltrombopag in pregnancy has not yet been established, its routine use should be avoided. However, if limited to refractory cases and with adequate maternal and fetal monitoring, including neonatal blood examinations, the use of eltrombopag for patients with aplastic anemia during pregnancy may be acceptable and result in favorable maternal and fetal outcomes.

Pregnancy-associated aplastic anemia: a case-based review

Introduction: Pregnancy-associated aplastic anemia (pAA) occurs when aplastic anemia (AA) is diagnosed for the first time during pregnancy and it is a rare but serious condition leading to severe maternal and fetal complications. It is unknown whether pregnancy triggers bone marrow failure or if this state is unrelated to the pathogenesis of pAA.Areas covered: In this review, three new cases of pAA are presented and its controversial etiologic relationship with pregnancy, its atypical presentation, and management are also discussed. Furthermore, a literature review of pAA cases between 1975 and 2020 was performed in PubMed, accessed via the National Library of Medicine PubMed interface. Keywords included 'aplastic anemia' AND 'pregnancy'. We found 54 cases reported in the literature with a clear diagnosis of pAA.Expert opinion: The diagnosis of pAA is challenging since pregnancy is associated with physiologic hematological changes in the complete blood count which can mask the disease. Meticulous monitoring and adequate support therapy given by a trained multidisciplinary team have the potential to improve outcomes for women and their neonates. All women should receive frequent assessments to optimize their care during pregnancy and after delivery, definitive treatment should be offered.

Self-limiting pregnancy-associated pure red cell aplasia developing in two consecutive pregnancies: case report and literature review

Pregnancy-associated primary red cell aplasia (pPRCA) is a rare disorder that may occur at various time points during pregnancy. Unlike pregnancy-associated aplastic anemia, pPRCA is usually reversible, and no maternal deaths attributable to pPRCA have been reported. Herein, we report a woman diagnosed with pPRCA in two consecutive pregnancies. Corticosteroids were found to be ineffective, and she required a large number of red blood cell transfusions during both pregnancies. Despite severe anemia developing in both pregnancies, two healthy babies were vaginally born and spontaneous remission of pPRCA was seen after delivery. Interestingly, in both events of pPRCA described here, a transient rise of reticulocytes was observed precedent to the authentic recovery phase of reticulocytes and remission of pPRCA, which is a novel finding that has not been reported. The significance of this phenomenon has yet to be elucidated. Along with this case report, we review all 15 cases with 21 events of pPRCA in the literature, including the present case.