Maternal malnutrition during pregnancy among women with sickle cell disease

OBJECTIVE

The objective of this study was to compare the nutritional status and dietary intake of pregnant women with sickle cell disease (SS hemoglobinopathy and SC hemoglobinopathy) to healthy controls and report the maternal and perinatal outcomes.

METHODS

This is a prospective, longitudinal cohort study. Pregnant women with a diagnosis of sickle cell disease and control group were recruited in an outpatient clinic of a tertiary care hospital in São Paulo, Brazil. Maternal anthropometric data and dietary intake data were collected at the second and third trimesters.

RESULTS

A total of 49 pregnancies complicated by sickle cell disease were included. Prepregnancy body mass index was significantly lower in the SS hemoglobinopathy group (n=26, median 20.3 kg/m2) than the SC hemoglobinopathy group (n=23, 22.7 kg/m2) or control group (n=33, 23.2 kg/m2, p<0.05). The prepregnancy nutritional status revealed significantly more women classified as underweight in the SS hemoglobinopathy group (15.4%) than in the SC hemoglobinopathy group (4.4%) and control group (1.6%, p=0.009). In the second trimester, maternal protein intake was significantly lower in SS hemoglobinopathy (73.2 g/day) and SC hemoglobinopathy (68.8 g/day) than in the control group (95.7 g/day, p=0.004). In the third trimester, only SS hemoglobinopathy mothers showed dietary intake of protein significantly lower than that of the controls (67.5 g/day vs. 92.8 g/day, p=0.02). Vitamin A and E consumption was also reduced in the third trimester in the SS hemoglobinopathy group (p<0.05).

CONCLUSION

The nutritional status of pregnant women with SS hemoglobinopathy is characterized by a state of undernutrition. The lower protein intake in the second and third trimesters of pregnant women with SS hemoglobinopathy may contribute to this condition. Undernourishment is a serious complication of sickle cell disease, primarily during pregnancy, and it should be addressed during the prenatal period.

Effects of anti-Xa activity monitoring on the outcome of high-risk pregnancies treated with a prophylactic dose of low-molecular-weight heparin

OBJECTIVE

To evaluate if anti-Xa level monitoring and dose adjustment in women using a prophylactic dose of enoxaparin can decrease placenta-mediated pregnancy complications.

METHODS

This retrospective observational cohort study included pregnant women receiving enoxaparin prophylaxis, who were followed at the Thrombosis and Hemostasis Outpatient clinic between 2010 and 2017. The dose was adjusted according to enoxaparin anti-Xa levels in the study group or the weight of individuals in the control group.

RESULTS

Of 585 women surveyed, 110 met the inclusion criteria; 63 of them were included in the study group and 47 in the control group. Mean starting dose was 46 versus 43 mg (p = .25), mean final dose was 52 mg versus 45 mg (p = .03) and dose adjustment was required in 37% versus 11% (p = .002) in the study and control groups, respectively. Twenty-eight percent of anti-Xa measurements in the second trimester were beneath the prophylactic threshold, compared to 11% and 16% in the first and third trimesters, respectively (p = .02). Labors ended with live birth in 91% versus 94% of cases (p = .5), 85% versus 68% of pregnancies were term (p = .05), 11% versus 23% of newborns were low birth weight (p = .1) and placenta-mediated pregnancy complications were documented in 9% versus 19%, (p = .17) in the study group relative to controls, respectively.

CONCLUSIONS

The most prominent decrease in anti-Xa levels was observed in the second trimester. Monitored women had significantly more term deliveries and demonstrated a trend toward higher birth weight and fewer placenta-mediated pregnancy complications. Larger studies are needed to confirm improved pregnancy outcome in monitored women.

Association of Sickle Cell Disease With Racial Disparities and Severe Maternal Morbidities in Black Individuals

Importance

Little is known about the association between sickle cell disease (SCD) and severe maternal morbidity (SMM).

Objective

To examine the association of SCD with racial disparities in SMM and with SMM among Black individuals.

Design, Setting, and Participants

This cohort study was a retrospective population-based investigation of individuals with and without SCD in 5 states (California [2008-2018], Michigan [2008-2020], Missouri [2008-2014], Pennsylvania [2008-2014], and South Carolina [2008-2020]) delivering a fetal death or live birth. Data were analyzed between July and December 2022.

Exposure

Sickle cell disease identified during the delivery admission by using International Classification of Diseases, Ninth Revision and Tenth Revision codes.

Main Outcomes and Measures

The primary outcomes were SMM including and excluding blood transfusions during the delivery hospitalization. Modified Poisson regression was used to estimate risk ratios (RRs) adjusted for birth year, state, insurance type, education, maternal age, Adequacy of Prenatal Care Utilization Index, and obstetric comorbidity index.

Results

From a sample of 8 693 616 patients (mean [SD] age, 28.5 [6.1] years), 956 951 were Black individuals (11.0%), of whom 3586 (0.37%) had SCD. Black individuals with SCD vs Black individuals without SCD were more likely to have Medicaid insurance (70.2% vs 64.6%), to have a cesarean delivery (44.6% vs 34.0%), and to reside in South Carolina (25.2% vs 21.5%). Sickle cell disease accounted for 8.9% and for 14.3% of the Black-White disparity in SMM and nontransfusion SMM, respectively. Among Black individuals, SCD complicated 0.37% of the pregnancies but contributed to 4.3% of the SMM cases and to 6.9% of the nontransfusion SMM cases. Among Black individuals with SCD compared with those without, the crude RRs of SMM and nontransfusion SMM during the delivery hospitalization were 11.9 (95% CI, 11.3-12.5) and 19.8 (95% CI, 18.5-21.2), respectively, while the adjusted RRs were 3.8 (95% CI, 3.3-4.5) and 6.5 (95% CI, 5.3-8.0), respectively. The SMM indicators that incurred the highest adjusted RRs included air and thrombotic embolism (4.8; 95% CI, 2.9-7.8), puerperal cerebrovascular disorders (4.7; 95% CI, 3.0-7.4), and blood transfusion (3.7; 95% CI, 3.2-4.3).

Conclusions and Relevance

In this retrospective cohort study, SCD was found to be an important contributor to racial disparities in SMM and was associated with an elevated risk of SMM among Black individuals. Efforts from the research community, policy makers, and funding agencies are needed to advance care among individuals with SCD.

Maternal and foetal outcomes following natural vaginal versus caesarean section (c-section) delivery in women with bleeding disorders and carriers

BACKGROUND

Bleeding disorders are uncommon but may pose significant bleeding complications during pregnancy, labour and following delivery for both the woman and the foetus. While many bleeding disorders in women tend to improve in pregnancy, thus decreasing the haemorrhagic risk to the mother at the time of delivery, some do not correct or return quite quickly to their pre-pregnancy levels in the postpartum period. Therefore, specific measures to prevent maternal bleeding and foetal complications during childbirth, are required. The safest method of delivery to reduce morbidity and mortality in these women is controversial. This is an update of a previously published review.

OBJECTIVES

To assess the optimal mode of delivery in women with, or carriers of, bleeding disorders.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Coagulopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched the Cochrane Pregnancy and Childbirth Group's Trials Register as well as trials registries and the reference lists of relevant articles and reviews. Date of last search of the Group's Trials Registers: 21 June 2021.

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised controlled clinical trials investigating the optimal mode of delivery in women with, or carriers of, any type of bleeding disorder during pregnancy were eligible for the review.

DATA COLLECTION AND ANALYSIS

No trials matching the selection criteria were eligible for inclusion.

MAIN RESULTS

No trials matching the selection criteria were eligible for inclusion.

AUTHORS' CONCLUSIONS

The review did not identify any randomised controlled trials investigating the safest mode of delivery and associated maternal and foetal complications during delivery in women with, or carriers of, a bleeding disorder. In the absence of high quality evidence, clinicians need to use their clinical judgement and lower level evidence (e.g. from observational trials, case studies) to decide upon the optimal mode of delivery to ensure the safety of both mother and foetus. Given the ethical considerations, the rarity of the disorders and the low incidence of both maternal and foetal complications, future randomised controlled trials to find the optimal mode of delivery in this population are unlikely to be carried out. Other high quality controlled studies (such as risk allocation designs, sequential design, and parallel cohort design) are needed to investigate the risks and benefits of natural vaginal and caesarean section in this population or extrapolation from other clinical conditions that incur a haemorrhagic risk to the baby, such as platelet alloimmunisation.

Management and outcomes of newborns at risk for inherited antithrombin deficiency

BACKGROUND

As levels of antithrombin (AT) are low at birth, diagnosing inherited AT deficiency in newborns is challenging. In Stockholm, Sweden, pregnant women with known AT deficiency are referred to the Karolinska University Hospital, where local guidelines for management of newborns at risk of inherited AT deficiency have been established. Data on pregnancy, obstetric, and neonatal outcomes are recorded in a registry.

OBJECTIVES

We aimed to evaluate the current practice at the Karolinska University Hospital for managing delivery of newborns at risk for AT deficiency, the predictive value of AT levels at birth, and the neonatal outcomes of newborns with AT deficiency.

PATIENTS/METHODS

This was an observational, retrospective study. All children born to mothers with AT deficiency at the Karolinska University Hospital 2003-2018 were identified from the registry and included in the study. Data were collected from the medical records and the registry. AT activity was measured postnatally and after 6 months of age.

RESULTS

The total study cohort included 41 newborns. There was a significant association between low AT values postnatally and after 6 months of age (P = .001). Half (21/41) of the children were diagnosed with AT deficiency; two suffered from sinus thrombosis, which presented at 10 days of age. Both children with sinus thrombosis were delivered using vacuum extraction.

CONCLUSIONS

The current practice of testing newborns can in most cases predict inherited AT deficiency. The risk for thrombosis during the neonatal period is enhanced by the use of instrumental delivery.

Pregnancy in sickle cell trait: what we do and don't know

Sickle cell trait (SCT) is the carrier state for sickle cell disease that results from the HBB rs334 missense mutation (p.Glu6Val) in the β-globin chain of haemoglobin. While not associated with any impact on life expectancy, it has been established that SCT is associated with an increased risk of both venous thromboembolism (and in particular, pulmonary embolism) and chronic kidney disease. It is largely unknown what short- or long-term effect, if any, pregnancy has upon the risk or outcomes of these disorders. In addition, SCT has been linked with various adverse outcomes in pregnancy, ranging from maternal complications such as elevated risk of bacteriuria to potentially life-threatening entities such as pre-eclampsia and prematurity. In these scenarios also, no clear association with SCT has been established. Given the high worldwide prevalence of SCT, further studies addressing these issues are warranted.

Association between maternal anemia at admission for delivery and adverse perinatal outcomes

BACKGROUND

Maternal anemia is a risk factor for poor pregnancy outcomes and threatens maternal or fetal life. Anemia increases the risk of low birth weight and preterm birth. We aimed to determine the cutoff level of hemoglobin and risk factors for maternal anemia at admission for delivery and investigate the association between maternal anemia and adverse perinatal outcomes in contemporary Taiwanese women.

METHODS

About 32,234 women admitted to the Taipei Chang Gung Memorial Hospital from 2001 to 2016 were enrolled in this retrospective observational cohort study. The prevalence of pre-delivery maternal anemia in Taiwan and the maternal demographic and perinatal outcomes associated with maternal anemia was assessed.

RESULTS

The 10th and 5th percentile hemoglobin levels of the test cohort (2001-2008, n = 15,602) were 10.8 g/dL and 9.9 g/dL, respectively. In the study cohort (2009-2016, n = 13,026), women who were multiparous, who were aged >34 years, with history of cesarean delivery, and with history of uterine fibroids had higher prevalence of anemia. Anemic women were at increased risk of cesarean delivery, primary cesarean delivery, premature rupture of membranes, early preterm birth <34 weeks, having very low birth weight infants (<1,500 g), having large for gestational age infants, and neonatal intensive care center transfer, but at lower risk of having small for gestational age infants.

CONCLUSION

Maternal anemia at delivery is a risk factor for primary cesarean delivery and adverse maternal and neonatal outcomes. Furthermore, we hypothesize that maternal anemia might increase fetoplacental vasculogenesis and angiogenesis as an adaptive response.

The role of iron repletion in adult iron deficiency anemia and other diseases

Iron deficiency anemia (IDA) is the most prevalent and treatable form of anemia worldwide. The clinical management of patients with IDA requires a comprehensive understanding of the many etiologies that can lead to iron deficiency including pregnancy, blood loss, renal disease, heavy menstrual bleeding, inflammatory bowel disease, bariatric surgery, or extremely rare genetic disorders. The treatment landscape for many causes of IDA is currently shifting toward more abundant use of intravenous (IV) iron due to its effectiveness and improved formulations that decrease the likelihood of adverse effects. IV iron has found applications beyond treatment of IDA, and there is accruing data about its efficacy in patients with heart failure, restless leg syndrome, fatigue, and prevention of acute mountain sickness. This review provides a framework to diagnose, manage, and treat patients presenting with IDA and discusses other conditions that benefit from iron supplementation.

Severe thrombotic microangiopathy accompanied by liver rupture and multiorgan failure at week 26 of pregnancy

OBJECTIVE

Case of a primigravid woman who suffered from severe PTMS (postpartum thrombotic microangiopathy syndrome) in the 26th week of pregnancy.

DESIGN

Case report.

SETTING

Department of Gynecology and Obstetrics, Hospital Nový Ji&#269;ín; Department of Gynecology and Obstetrics, University Hospital Ostrava; Department of Hematooncology, University Hospital Ostrava; Department of Anaesthesiology and Resuscitation, University Hospital Ostrava.

RESULTS

A thirty-one-year old primigravid woman was admitted to a secondary level institution due to epigastric pain and spontaneous rupture of membranes at 26th week of pregnancy. On admission her blood pressure was 140/90 mm Hg and an intrauterine fetal death was confirmed. The patients condition deteriorated quickly, resulting in a hypertensive crisis (220/120 mm Hg), which did not respond to medication over a two hour period. Emergency caesarean section was performed, but the patients condition progressed to HELLP syndrome class I, DIC and MOF. She was transferred to the intensive care unit (ICU) of the district referral hospital 38 hours postpartum. On admission to ICU, liver rupture was diagnosed which was managed conservatively. Therapeutic plasma exchange (TPEX) was initiated on day 2 postpartum in response to falling platelets and continued for 6 days. Due to acute kidney injury (AKI), the patient required dialysis for 21 days. The patients condition improved gradually and at 28 days after admission to ICU she was transferred back to the referring hospital. The consensus reached by the treating teams was that PTMS was the most likely diagnosis.

CONCLUSION

This case demonstrates that PTMS improves (usually rapidly) after TPEX is initiated. It also emphasises the importance of maintaining a high index of suspicion for PTMS so that life-saving TPEX can be initiated, because it does not respond to classical treat-ment used in the management of HELLP syndrome. Other research suggests patients may also require a terminal complement blockade with the anti-C5 monoclonal antibody (eculizumab). Further research could focus on diagnostic tests to distinguish PTMS from HELLP to identify which patients would most benefit from these treatments.

Evans Syndrome and pregnancy: A case report with literature review

Evans syndrome is a rare autoimmune disease in which an individual's antibodies attacks the body's own red blood cells and platelets.1 There is a coexistence of Immune thrombocytopenia (ITP) with Autoimmune haemolytic anaemia (AIHA) and both of these events may occur simultaneously or one follows the other. 2 Association of Evans syndrome with pregnancy is very rare, and only a few cases have been published in medical literature. No definite treatment protocols are defined. Treatment options during pregnancy are further limited due to concerns of teratogenic effect of pharmacological agents. 3 Evans syndrome can be diagnosed with a full blood count film and a Coombs test. We describe here a rare case that was diagnosed as Evans syndrome during pregnancy that resulted in birth of stillborn twins after the case became complicated with the onset of Eclampsia. We have also briefly discussed the pathophysiology, the possible treatment options during pregnancy and prenatal outcome of Evans syndrome. This case was presented in June 2015 at the outpatient department of Obstetrics & Gynecology in Nishtar Medical College and Hospital, Multan.

Clinical Case of Parvovirus B19 Infection in Pregnant Woman with Β-Thalassemia in Bulgaria

A pregnant 30-year-old female in the 34th gestational week was admitted at University "Maichin Dom" Hospital prior to childbirth. The patient is diagnosed with β-thalassemia. During laboratory screening hemoglobin of 98 g/L was established. Blood smear shows mild microcytic hypochromic anemia: RBC 5.15 x 1012/L, HGB 98 g/L, MCV 65.8 fL, MCH 19.4 pg, MCHC 295 g/L. Serum iron concentration is 12.9 µmol/L and ferritin 17.5 µg/L. For the delivery process cesium was considered. Two days after procedure a rash presented on face, hands and breasts. Although the mother was positive for parvovirus B19 infection, the baby was negative. This was confirmed by se-rological and molecular investigations. We discovered only the mother's B19V IgG antibodies in the newborn. In connection to the main disease, namely β-thalassemia, acute virus infection could cause aplastic crisis. After consultation with a hematologist, serum hepcidin concentration (an iron homeostasis regulator) was quantified: 19.4 µg/L. ELISA test was used to prove B19V IgM antibodies in the mother. PCR analysis shows the presence of B19V DNA. During infection, inflammatory cytokines increase hepcidin secretion, leading to iron deposition into cells.

Pregnancy outcomes in women with non-transfusion dependent thalassaemia (NTDT): A haematology centre experience

INTRODUCTION

Non-transfusion dependent thalassaemia (NTDT) is a term used for thalassaemia patients who do not require lifelong regular transfusions for survival. Pregnancy in these women, whether spontaneous or through assisted reproductive technology, represents a challenge for the physician.

MATERIALS AND METHODS

The maternal and foetal outcomes of patients with NTDT followed up in a tertiary haematology centre over 6 months period were studied. A total of 36 pregnancies in 26 pregnant women with NTDT were analysed.

RESULTS

Among these women, all of the pregnancies resulted in successful delivery of singleton live-born neonates. There were four clinically distinct forms of NTDT among these women which include Hb E/β-thalassemia (mild and moderate forms), HbH disease, HbH-Constant Spring, and homozygous δβ-thalassemia. No blood transfusion was needed in 15 of the 36 pregnancies (41.6%). The lowest mean Hb level in which no blood transfusion was given was 8.21 g/dL. The mean of packed-cell units received during pregnancy was 6.95 units per pregnancy. There was no worsening of serum ferritin observed during pregnancy with mean serum ferritin pre- and post-pregnancy of 409.35 ug/L and 418.18 ug/L respectively. The mean gestational age at delivery was 38.6 weeks with no preterm delivery reported. The mean foetal birth weight was 2729 grams. There was no intrauterine growth restriction (IUGR) or congenital malformation. There was a case of small for gestational age (SGA) and a case of oligohydramnios.

CONCLUSION

This study showed that pregnancy was possible, safe and has a favourable outcome in patients with NTDT with multidisciplinary care.

Transfusion-related adverse events are decreased in pregnant women with sickle cell disease by a change in policy from systematic transfusion to prophylactic oxygen therapy at home: A retrospective survey by the international sickle cell disease observatory

Sickle cell disease (SCD) in pregnancy can be associated with adverse maternal and perinatal outcomes. Furthermore, complications of SCD can be aggravated by pregnancy. Optimal prenatal care aims to decrease the occurrence of maternal and fetal complications. A retrospective, French, two-center study compared two care strategies for pregnant women with SCD over two time periods. In the first study period (2005-2010), the women were systematically offered prophylactic transfusions. In the second study period (2011-2014), a targeted transfusion strategy was applied whenever possible, and home-based prophylactic nocturnal oxygen therapy was offered to all the pregnant women. The two periods did not differ significantly in terms of the incidence of vaso-occlusive events. Maternal mortality, perinatal mortality, and obstetric complication rates were also similar in the two periods, as was the incidence of post-transfusion complications (6.1% in 2005-2010 and 1.3% in 2011-2014, P = .15), although no de novo alloimmunizations or delayed hemolysis transfusion reactions were observed in the second period. The results of this preliminary, retrospective study indicate that targeted transfusion plus home-based prophylactic nocturnal oxygen therapy is safe and may decrease transfusion requirements and transfusion-associated complications.

Anesthetic Management of a Patient With Type 1 von Willebrand Disease and Uterine Placental Abruption: A Case Report

Von Willebrand disease is the most common inherited blood disorder, occurring in about 1% of the population. It results from a deficiency in the quality or quantity of von Willebrand factor, which is necessary for adequate hemostasis. An evidenced-based approach is prudent when this derangement is coupled with a potentially fatal obstetric complication. This article examines the anesthetic management of a parturient with a known diagnosis of von Willebrand disease who presented to the labor and delivery unit in active labor and with a suspected uterine placental abruption.

Antibody profile and clinical course in primary antiphospholipid syndrome with pregnancy morbidity

In women diagnosed as having category I primary obstetric antiphospholipid syndrome, clinical characteristics and the risk of subsequent thromboembolic events and further unsuccessful pregnancy has not been clearly documented. Women with unexplained obstetric complications and no definite autoimmune systemic diseases were tested for lupus anticoagulant (LA), IgG/ IgM anticardiolipin (aCL) and IgG/IgM anti-human β2-Glycoprotein I (aβ2GPI) antibodies and diagnosed as having primary antiphospholipid syndrome (APS) in classification category I on the basis of more than one laboratory criteria present in any combination. Characteristics at the time of diagnosis and risk factors for subsequent clinical events during a mean follow-up of 6.3 years were evaluated. Fifty-three of 600 women studied were found to fulfil obstetric criteria and had more than one positive laboratory test at the time of diagnosis. All the women were a CL and aβ2GPI positive, and 16 were also LA positive. This latter group (triple positivity) had distinct features and had more frequently experienced previous thromboembolism (OR= 122.5, 95% CI 16–957, p<0.001).They also had an increased rate of late pregnancy loss (OR=16.2, 95%CI 0.9–292, p=0.01), and a higher IgG aβ2GPI titer at diagnosis (median, 25th and 75th percentile were 118, 37–962, vs. 23, 18–32, respectively, p<0.0001). During follow-up, the rate of thromboembolic events was significantly higher in the group of women with triple positivity and/ or previous thromboembolism (OR=57.5, 95% CI 2.7–1160, p=0.0004) which were the only independent predictors of TE in the multivariate model. Recurrent pregnancy loss took place in seven out of 47 women who had a new pregnancy. Triple positivity and/or previous thromboembolism were again the only independent markers (OR=34.4, 95% CI 3.5–335.1, p=0.003) of an unsuccessful new pregnancy. In conclusion, in primary APS with pregnancy morbidity in classification category I, quite different groups of patients may be identified on the basis of laboratory tests. Triple positivity and/or a history of thromboembolism predict new TE events and new unsuccessful pregnancies.

Relapse of congenital thrombotic thrombocytopenic purpura, after spontaneous remission, in a second-trimester primigravida: case report and review of the literature

CONTEXT

Thrombotic microangiopathy syndrome or thrombotic thrombocytopenic purpura-hemolytic uremic syndrome (TTP-HUS) describes distinct diseases sharing common pathological features: microangiopathic hemolytic anemia and thrombocytopenia, without any other apparent cause.

CASE REPORT

An 18-year-old second-trimester primigravida presented with a history of fifteen days of intense weakness, followed by diarrhea over the past six days. She reported having had low platelets since childhood, but said that she had never had bleeding or menstrual abnormalities. Laboratory investigation showed anemia with schistocytes, thrombocytopenia and hypohaptoglobulinemia. Red blood cell concentrate and platelet transfusions were performed. The hypothesis of TTP or HUS was put forward and ADAMTS13 enzyme activity was investigated. The patient evolved with increasing platelet counts, even without specific treatment, and she was discharged. One month afterwards, she returned presenting weakness and swollen face and legs, which had developed one day earlier. The ADAMTS13 activity was less than 5%, without presence of autoantibodies. Regarding the two previous admissions (at 9 and 16 years of age), with similar clinical features, there was spontaneous remission on the first occasion and, on the second, the diagnosis of TTP was suspected and plasmapheresis was performed, but ADAMTS13 activity was not investigated.

CONCLUSION

To date, this is the only report of congenital TTP with two spontaneous remissions in the literature This report reveals the importance of suspicion of this condition in the presence of microangiopathic hemolytic anemia and thrombocytopenia without any other apparent cause.

Pregnancy in patients with thalassemia major: a cohort study and conclusions for an adequate care management approach

An improvement in quality of life and survival occurred among thalassemia major (TM) patients: pregnancy in such patients has become a reality. Safe pregnancy and delivery require efforts to ensure the best outcomes. Between 2007 and 2016, 30 TM patients had 37 pregnancies. We analyzed the hematological parameters before, during, and after pregnancies and in 19 patients a cardiovascular magnetic resonance (CMR) T2* was performed. The mean age at first pregnancy was 30 ± 4 years; the current mean age is 35 ± 5 years. Twenty-four patients (80%) had a single pregnancy, five patients (17%) had two pregnancies, and one patient (3%) became pregnant three times. Seventeen pregnancies (46%) were spontaneous, 20 (64%) needed gonadotrophin-induced ovulation and/or reproductive technologies. All pregnancies resulted in live births. Seven were twin pregnancies (19%). The mean gestational hemoglobin was 9.2 ± 0.5 g/dl, lower than pre- and postpregnancy (9.8 ± 1 g/dl, p = ns and 9.6 ± 1 g/dl, p = 0.02, respectively). Median ferritin levels increased progressively (1071, range 409-5724 ng/ml, before pregnancy vs 2231, range 836-6918 ng/ml, after pregnancy, p < 0.0001). CMR before pregnancy showed a normal cardiac T2* (mean 35.34 ± 8.90 ms) and a mean liver iron concentration (LIC) of 3.37 ± 2.11 mg/g dry weight (dw). After pregnancy, the mean cardiac T2* was 31.06 ± 13.26 ms and the mean LIC was significantly increased (9.06 ± 5.75 mg/g dw, p = 0.0001). Pregnancy is possible and safe in thalassemia major. During pregnancy, iron accumulates, especially in the liver; a prompt resumption of chelation after delivery is mandatory.

[Isolated thrombocytosis in chronic myeloid leukemia without significant leukocytosis]

Chronic myeloid leukemia (CML) typically causes leukocytosis rather than thrombocytosis. We encountered two women in their thirties with remarkable thrombocytosis, whose platelet counts were over 3,000×10³/µl, and without significant leukocytosis. Although their clinical findings resembled that of essential thrombocythemia (ET), they were diagnosed with CML because of the presence of Philadelphia chromosome. JAK2, CALR, and MPL were unmutated. On fluorescence in situ hybridization analysis, only 19.8% of granulocytes in case 2 were found to be BCR/ABL positive in peripheral blood (PB). We reviewed 11 CML cases whose platelet counts were over 2,000×10³/µl, but their WBC counts were not significantly elevated (<12,000/µl). Most of them were young females with a normal or a high neutrophil alkaline phosphatase score and without immature myeloid cells in PB. These findings suggested that there is a subgroup of CML patients with marked thrombocytosis and without significant leukocytosis, which may be misdiagnosed as ET.

The lowest surviving birth weight reported in a systemic lupus erythematosus patient: a review of the literature

The success rates for pregnancies in women with systemic lupus erythematosus(SLE) have improved over the years: however, pregnancy for women with active, serious, organ-threatening lupus continues to be a challenge. Preeclampsia and HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome may complicate pregnancy especially in the setting of advanced maternal age, underlying SLE and chronic renal disease.

We report the pregnancy course and outcome for a 35-year old woman with active lupus nephritis at the time of conception who developed severe preeclampsia and HELLP syndrome. The infant was delivered at 26-5/7 weeks gestation, which, associated with intrauterine growth retardation, led to a birth weight of only 470 g. We have reviewed the relevant literature for similar cases of prematurity, very low birth weight, and preeclampsia in the setting of underlying lupus in Medline between 1986 and 2006. This report represents the lowest birth weight pregnancy survival in a lupus patient and the first case of a survival in the second trimester with preeclampsia and HELLP syndrome.

Iron Deficiency and Other Types of Anemia in Infants and Children

Anemia, defined as a hemoglobin level two standard deviations below the mean for age, is prevalent in infants and children worldwide. The evaluation of a child with anemia should begin with a thorough history and risk assessment. Characterizing the anemia as microcytic, normocytic, or macrocytic based on the mean corpuscular volume will aid in the workup and management. Microcytic anemia due to iron deficiency is the most common type of anemia in children. The American Academy of Pediatrics and the World Health Organization recommend routine screening for anemia at 12 months of age; the U.S. Preventive Services Task Force found insufficient evidence to assess the benefits vs. harms of screening. Iron deficiency anemia, which can be associated with cognitive issues, is prevented and treated with iron supplements or increased intake of dietary iron. The U.S. Preventive Services Task Force found insufficient evidence to recommend screening or treating pregnant women for iron deficiency anemia to improve maternal or neonatal outcomes. Delayed cord clamping can improve iron status in infancy, especially for at-risk populations, such as those who are preterm or small for gestational age. Normocytic anemia may be caused by congenital membranopathies, hemoglobinopathies, enzymopathies, metabolic defects, and immune-mediated destruction. An initial reticulocyte count is needed to determine bone marrow function. Macrocytic anemia, which is uncommon in children, warrants subsequent evaluation for vitamin B12 and folate deficiencies, hypothyroidism, hepatic disease, and bone marrow disorders.

Cesarean delivery via a transverse uterine fundal incision for the successful management of a low-lying placenta and aplastic anemia

PURPOSE

To present a case report on the successful management of a low-lying placenta and aplastic anemia. Aplastic anemia is a rare but serious disorder that is often characterized by severe pancytopenia. Because of the rarity of aplastic anemia, a pregnancy complicated by it is rarely encountered by obstetricians. Moreover, placenta previa (low-lying placenta) complicated by aplastic anemia has not been previously reported.

MATERIALS AND METHODS

The authors present the first reported case of placenta previa with aplastic anemia in a patient who had undergone a previous cesarean delivery.

RESULTS

They successfully managed this case by making a transverse uterine fundal incision during an elective cesarean delivery. This incision minimized blood loss and enabled good visualization of the source of bleeding in the lower uterine segment. Bleeding was stemmed by suturing the source of bleeding.

CONCLUSION

The authors propose that this procedure should be considered for patients with low platelet counts and abnormal placentation.

Determination of optimal timing of serial in-utero transfusions in red-cell alloimmunization

OBJECTIVES

To assess the performance of middle cerebral artery peak systolic velocity (MCA-PSV) and of the expected daily decrease in fetal hemoglobin in determining the timing of serial in-utero transfusions (IUT) in red-cell alloimmunization.

METHODS

This was a retrospective study of a continuous series of suspected anemic fetuses undergoing IUT between June 2003 and December 2012. Doppler measurement of MCA-PSV and pre- and post-transfusion hemoglobin levels were recorded at the time of the first, second and third IUT. Receiver-operating characteristics (ROC) curves and negative and positive predictive values of MCA-PSV in the prediction of severe fetal anemia were calculated. The daily decrease of fetal hemoglobin (Hb) between IUTs was calculated. Regression analysis was used to assess the correlation between pretransfusion fetal hemoglobin and MCA-PSV, and between observed and expected (by projection of daily decreases) pretransfusion fetal hemoglobin levels.

RESULTS

One hundred and eleven fetuses required an IUT, of which 96 and 67 received a second and third IUT, respectively. The area under the ROC curve for MCA-PSV in the prediction of severe fetal anemia was not different for each rank of transfusion. The positive predictive value of MCA-PSV decreased from 75.3% at the first IUT, to 46.7% and 48.8% at the second and third IUTs, respectively, while the negative predictive value for a 1.5-MoM threshold remained high (88.9% at the second and 91.7% at the third IUT). The mean daily decrease in hemoglobin following each transfusion was 0.45, 0.35 and 0.32 g/dL, respectively. There was a persistent linear correlation between fetal hemoglobin and MCA-PSV and between observed and expected fetal hemoglobin levels.

CONCLUSIONS

Both MCA-PSV and projection of daily decrease in hemoglobin are reliable means of diagnosing fetal anemia following previous IUTs. The high negative predictive value of MCA-PSV could allow subsequent IUTs to be postponed in selected cases.

THE RISK OF HYPERCOAGULABILITY IN OVARIAN HYPERSTIMULATION SYNDROME

Ovarian hyperstimulation syndrome (OHSS) is a rare and potentially life-threatening complication of infertility treatment occurring during either the luteal phase or early pregnancy. An increasing number of thromboembolic complications associated with the increased use of assisted reproductive techniques have been reported in the literature. Identification of the risk factors is crucial for prevention of thromboembolic events in OHSS patients. Alterations in the hemostatic system cause hypercoagulability in women affected by severe OHSS. Coexistence of inherited hypercoagulable conditions increases the risk of thromboembolism. The role of clinical parameters that can help predict development of thrombosis is controversial. Patients with a personal or family history of thrombosis undergoing infertility treatment should be considered for thrombophilia screening, while routine examination of inherited thrombophilic mutations is not indicated in infertile patients. Antithrombotic primary prevention is not indicated in healthy women undergoing assisted reproductive procedures or in women with thrombophilia. Anticoagulant therapy is indicted if there is clinical evidence of thrombosis or laboratory evidence of hypercoagulability. In this review, the risks of hypercoagulability in the OHSS are discussed.

NON-INVASIVE MONITORING OF FOETAL ANAEMIA IN KELL SENSITIZED PREGNANCY

We report a case of Kell sensitized pregnancy with good neonatal outcome. Anti-K antibodies were detected in maternal serum in early pregnancy as a part of routine antibody screening test. The middle cerebral artery doppler monitoring and serial titers were carried out to screen for foetal anaemia. Despite of rising antibody titers, serial middle cerebral artery doppler was normal and did not showed foetal anaemia. The pregnancy was carried out till term and patient delivered at 37 weeks of pregnancy with no evidence of foetal anaemia. This case underlines the need of general screening on rare antibodies in all pregnant women and that non-invasive monitoring of foetal anaemia can be done with anti-k titers and middle cerebral artery Doppler.

Current therapies and their indications for the Philadelphia-negative myeloproliferative neoplasms

The groundbreaking discovery of the Janus-associated kinase 2 (JAK2) V617F mutation 10 years ago resulted in an unprecedented intensive basic and clinical research in Philadelphia-negative myeloproliferative neoplasms (MPNs). During these years, many new potential targets for therapy were identified that opened the era of targeted therapy for these diseases. However, only one new drug (ruxolitinib) has been approved during the past 40 years, and, although promising new therapies are evaluated, the armamentarium to treat MPN still relies on conventional drugs, like cytotoxic agents and anagrelide. The exact role of interferon (IFN) alfa still needs to be clarified in randomized studies, although it has been shown to be effective in MPNs for more than 25 years. The current therapeutic strategy for MPNs is based on the risk of vascular complication, which is the main cause of mortality and mortality in the medium term. However, the long-term outcome may be different, with an increasing risk of transformation to myelodysplastic syndrome or acute leukemia during follow-up times. Medicines able to change this natural history have not been clearly identified yet, and allogeneic stem cell transplantation currently remains the unique curative approach, which is only justified for patients with high-risk myelofibrosis or for patients with MPNs that have transformed to myelodysplasia or acute leukemia.

Syndromes of thrombotic microangiopathy associated with pregnancy

When a pregnant or postpartum woman presents with sudden and severe microangiopathic hemolytic anemia (MAHA) and thrombocytopenia, three syndromes that require urgent care must be considered: (1) preeclampsia with severe features/hemolysis, elevated liver function tests, low platelets (PE/HELLP) syndrome; (2) thrombotic thrombocytopenic purpura (TTP); and (3) complement-mediated thrombotic microangiopathy (C-TMA; also referred to as atypical hemolytic-uremic syndrome). The distinction among these three syndromes is often unclear because they share multiple clinical features. Overlap between PE/HELLP syndrome and the other two syndromes is also apparent from the fact that pregnancy can be a trigger for both TTP and C-TMA both before and after delivery and also the increased frequency of PE/HELLP syndrome in women who have recovered from TTP. When diagnostic criteria for PE/HELLP syndrome are present, management of hypertension and delivery is curative. Absence of improvement or actual progression of MAHA, thrombocytopenia, and kidney function abnormalities after delivery requires consideration of TTP and C-TMA. Minimal kidney involvement with severe thrombocytopenia suggests TTP and the need for treatment with plasma exchange; progressive kidney injury (in the absence of a cause for acute tubular necrosis) suggests C-TMA and the need for anti-complement treatment. We describe how we use these criteria to evaluate and manage pregnant/postpartum women with MAHA and thrombocytopenia.

Sickle cell disease and pregnancy outcomes: population-based study on 8.8 million births

OBJECTIVE

To estimate the prevalence of sickle cell disease (SCD) in pregnancy, and to measure risk factors, morbidity, and mortality among women with SCD with and without crisis at the time of birth.

METHODS

We conducted a population-based, retrospective cohort study on all births in the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) from 1999 to 2008. Births to SCD with and without crisis were identified using ICD-9 codes. Adjusted effects of risk factors and outcomes were estimated using logistic regression analyses. Effect of hemoglobin variants among women with SCD was analyzed as a predictor of crisis.

RESULTS

There were 4262 births to women with SCD for an overall prevalence of 4.83 per 10,000 deliveries. 28.5% of women with SCD developed crisis at the time of delivery. The maternal mortality rate was 1.6 per 1000 deliveries in women with SCD, compared to 0.1 per 1000 in women without SCD. Pregnant women with SCD had a higher risk of developing preeclampsia, eclampsia, venous thromboembolism, cardiomyopathy, intrauterine fetal demise, and intrauterine growth restriction. Cesarean delivery rates were higher in women with SCD. Among the 1898 SCD women with identified hemoglobin variants, homozygous SS was the greatest risk factor for sickle cell crisis, accounting for 89.8% of all women who developed crisis.

CONCLUSION

Pregnant women with SCD have a high risk of morbidity and mortality. Developing acute sickle cell crisis worsened perinatal outcomes.

[Thrombotic microangiopathy in pregnancy complicated by acute hemorrhagic-necrotic pancreatitis during early puerperium]

OBJECTIVE

Authors in the article describe a case of a patient with thrombotic thrombocytopenic purpurain 37 weeks gestation complicated by acute severe hemorrhagic-necrotic pancreatitis during the early puerperium.

DESIGN

Case report.

SETTING

Ist Department of gynaecology and obstetrics of the Comenius University Bratislava.

CASE-REPORT

33-years-old patient in the 37 weeks gestation was admitted to our department with the signs of HELLP syndrome (hemolysis, elevated liver enzymes, low platelets). Due to the worsening clinical status, we have performed caesarean section. After the transient stabilization of the patient's clinical status, the hemolysis with severe thrombocytopenia reappeared. Based on the clinical signs of abdominal pain and computer tomography, the diagnosis of acute hemorrhagic-necrotic pancreatitis was set. The primary diagnosis was thrombotic thrombocytopenic purpura. Therefore, therapeutic plasma exchange was performed with consequent improvement of the patients clinical state. Normalization of the platelet count was achieved after 4.plasma exchanges. Consequently 5 plasma exchanges were performed. However, one month later, the disease relapsed. Therapeutic plasma exchanges were needed again (4x), with anti CD 20 administration. This therapy had good clinical outcome, without the need for further plasma exchanges.

CONCLUSION

Thrombotic thrombocytopenic purpura is highly lethal disease. Early diagnosis, treatment, and multidisciplinary approach are essential.

Peripartum anesthetic management of patients with Factor XI deficiency

INTRODUCTION

Factor XI deficiency is predominantly found in the Ashkenazi Jewish population with a prevalence of 9%, but also seen in other ethnicities. Little information is available on obstetric anesthesia management in women with Factor XI deficiency. Therefore, we undertook a study to evaluate obstetric, anesthetic and perinatal outcomes in parturients with Factor XI deficiency.

METHODS

A retrospective study was conducted with chart reviews from 1996 to 2011 resulted in 74 women with Factor XI level deficiency. We compared anesthetic and obstetric management in parturients with low (≤30%) level of Factor XI to those with higher levels.

RESULTS

Ninety-one pregnancy outcomes were reviewed in these 74 women with Factor XI deficiency. Forty-three women had levels ≤30% in 46 labors while 31 women had levels >30% in 45 labors. Women with low levels of Factor XI were significantly more likely to receive FFP and less likely to receive neuroaxial anesthesia. There were no anesthetic complications and no difference in mode of delivery or neonatal outcomes.

DISCUSSION

This study is the first step in building a national database for anesthetic cases and outcomes of parturients with Factor XI deficiency. Further efforts must be made to provide safe analgesia for these women.

Influence of maternal anemia during pregnancy on placenta and newborns

INTRODUCTION

Sideropenic anemia is a common pregnancy disorder. Depending on severity, maternal anemia can significantly influence morphometric characteristic of placental tissue, pregnancy course and outcome.

OBJECTIVES

to estimate if maternal anemia a) results with significant placental changes; b) influence on newborn weight, length and vitality.

PATIENTS, MATERIAL AND METHODS

Research included 100 women and their newborns, 50 anemic, and 50 women in the control group. Sixty placentas were collected, placental mass and volume was determined, and blood vessels of terminal villi were stereologically analyzed. Newborns mass and body length, and Apgar scores within 1 and 5 minutes after delivery were recorded.

THE RESULTS

Placentas of anemic pregnant women showed significant increase of terminal villi blood vessels (224.18 vs. 197.00 cm3; p < 0.0001), but total placental mass and volume did not differ significantly. Anemic mothers' newborns were significantly shorter (51.76 vs. 55.54 cm; p < 0.0001), smaller body mass (3048.00 vs. 3615.60 g; p < 0.0001) and delivered one week early (38.2 vs. 39.2 GW; p < 0.0001), but not significantly poorer vitality (p > 0.05) comparing with the control group.

CONCLUSION

Sideropenic anemia increase placental maturity, that could be a possible cause of earlier spontaneous delivery among anemic women. The anemic mothers' newborns are shorter and lower body mass, but not poorer vitality index.

[Occurence, etiology and clinical significance of trombocytopenia in pregnancy]

OBJECTIVE

The principal objective of the study is to compare results from the experimental group of pregnant women suffering from thrombocytopenia in pregnancy with results from the control group of pregnant women with normal physiologic blood platelet count.

SETTING

Department of Obstetrics and Gynaecology of the Tomas Bata Regional Hospital Zlín, Obstetrics and Gynaecology Clinic, Haematology and Oncology Clinic of the Palacky University Teaching Hospital and Medical School in Olomouc, Obstetrics and Gynaecology Clinic of the Ostrava Teaching Hospital.

METHODOLOGY

A group of 200 pregnant women suffering from thrombocytopenia underwent thorough medical tests. The level of platelets, presence of anti-platelets agents, liver function (LFT), anti-phospholipid antibodies, complete blood count with differential, specific antibodies for hepatitis B and C, Lyme borreliosis and cytomegalovirus were determined from venous blood using the EIA, ELISA methods.

RESULTS

Medical articles and books about thrombocytopenia divide the causes for thrombocytopenia as follows: 79.5% benign gestational thrombocytopenia, 16% preeclampsia, 2.5% HELLP syndrome, 1% immune thrombocytopenia, 1% HVC. The number of women who developed physiological anaemia in pregnancy and were overweight is identical in the experimental group of pregnant women suffering from thrombocytopenia and in the control group of pregnant women with normal physiologic blood platelet count, and the proportion of the different age groups in the two groups of pregnant women is also identical.

CONCLUSION

32% of pregnancies in the experimental group ended in a caesarean section, of which 13.5% in a group of 127 pregnant women suffering from mild thrombocytopenia, 17.5% in a group of 71 pregnant women suffering from moderate thrombocytopenia and 1% in a group of 2 pregnant women suffering from severe thrombocytopenia. 20.5% pregnancies in the control group ended in caesarean section.

Mild iron deficiency anaemia during pregnancy and lactation in guinea pigs alters amplitudes and auditory nerve velocity, but not brainstem transmission times in the offspring's auditory brainstem response

OBJECTIVES

It is well known that postnatal/early childhood iron deficiency (ID) anaemia (IDA) adversely affects infants' cognitive development and neurophysiology. However, the effects of IDA during gestation and lactation on the offspring are largely unknown. To address this health issue, the impact of mild IDA during gestation and lactation on the offsprings' neural maturation was studied in the guinea pig, using auditory brainstem responses (ABRs) latencies and amplitudes.

METHODS

Female guinea pigs (n = 10/group) were fed an iron sufficient (ISD) or deficient diet (IDD) (144 and 11.7 mg iron/kg) during the gestation and lactation periods. From postnatal day (PNd) 9 onward, the ISD was given to both groups of weaned offspring. The offsprings' ABRs were collected on PNd24 using a broad range of stimulus intensities in response to 2, 4, 8, 16, and 32 kHz tone pips.

RESULTS

Although the IDA siblings (n = 8) did not differ in brainstem transmission times (BTTs) compared to the IS siblings (n = 8), they showed significant delayed peak I latency at 100 and 80 dB, respectively. Additionally, significantly higher ABR wave amplitudes were observed in the IDA female offspring between 35 and 50 dB (4 kHz), a phenomenon suggestive of a neural hyperactivity (hyperacusis).

DISCUSSION

In support to our previous findings, the present results indicate that a mild IDA during gestation and lactation can have detrimental effects on early development of the offsprings' hearing and nervous systems, particularly on neural synchrony and auditory nerve conduction velocity, but not on BTT.

[Anesthetic management of emergency cesarean section in a patient with acquired von Willebrand syndrome]

Acquired von Willebrand syndrome (AvWS) is generic name of bleeding disorders caused by acquired decrease of von Willebrand factor. A 25-year-old woman with AvWS underwent emergent cesarean section under combined spinal and epidural anesthesia. Before operation, her APTT was within normal ranges. Platelet count was about 80,000 and factor VIII and von Willebrand factor's activities were 37% and 21%, respectively. Therefore, we administered 10 units of platelet concentrate and 2,000 units of factor VIII concentrate intravenously before the operation. The emergent operation was done without any bleeding complications. Factor VIII concentrate was administered until 11 days after the operation. Epidural catheter was removed just after administration of factor VIII concentrate 3 days after operation. The perioperative course was uneventful and the patient was discharged 11 days after the operation. It is important to co-operate with other related departments in managing the perioperative coagulation status in a patient with AvWS.

[Pregnancy and Fallot tetralogy without surgical correction: report of a case]

Tetralogy of Fallot is the most common cyanotic congenital heart disease. Women with this condition may become pregnant, and it is important to detect the disease to prevent cardiovascular complications and to reduce maternal and fetal death. The purpose of this paper is to report the case of a pregnant patient with no previous diagnosis of uncorrected tetralogy of Fallot, who reached the end of pregnancy with added diagnoses of severe preeclampsia and HELLP syndrome. For accurate information about the natural history of tetralogy of Fallot it is necessary to review the literature of the past 30 years because there is no recently published series. It is common for patients with tetralogy of Fallot and pregnancy to suffer a gradual increase in the severity of pulmonary stenosis, with exacerbation of symptoms and increased cyanosis. The long-term prognosis is extremely poor in the absence of correction, with a mortality of 10%.

Comparison of pregnancy outcomes in women with sickle cell disease and trait

OBJECTIVE

To compare the pregnancy and neonatal outcome in sickle cell disease and trait women.

METHOD

The retrospective comparative study was conducted at Abha General Hospital, Abha, Saudi Arabia, from January 2009 to December 2011. The records of women having sickle cell disease and trait were reviewed for antenatal and postnatal complications. Pregnancy and foetal outcome was also compared in both the groups. Chi-square, Fisher's Exact and Student's t tests were used for statistical analysis.

RESULTS

Out of 112 women, 57 (50.89%) had sickle cell disease and 55 (40.10%) had sickle cell trait. The mean gravidity and parity in the latter group (5.05+/-3.51 and 3.2+/-2.74 respectively) was more than double in the former group (2.89+/-1.36 and 1.66+/-0.96 respectively). There were significant differences in antenatal complications. In the disease group, anaemia was in 55 (96.5%) cases compared to 35 (63.6%) in the trait group. Significant number of women in the first group (n=41; 71.9%) experienced painful crisis in pregnancy compared to 4 (7.27%) in the second group. Mean haemoglobin in the disease group was 8.35g/dl, while it was 9.96 g/dl in the other (p <0.01). The requirement of blood transfusion was higher in the former, 28 (38.6%) than in the latter 3 (5.54%). Frequency of preterm delivery was only slightly higher in the disease group, 14 (28.57%) than in the trait women, 13(23.63%). The mean birth weight of babies of women with the disease and the trait was 2380 and 2480 grams. This 100 grams difference, however, was statistically insignificant.

CONCLUSION

Patients with sickle cell disease had more antenatal complications than those with sickle cell trait, without affecting the foetal outcome. Though the trait is generally considered a benign disease, women need special care and attention during a stressful situation like pregnancy.

Clinical and obstetrical management of pregnant women with autoimmune hepatitis complicated by moderate or severe thrombocytopenia

OBJECTIVE

To describe the management of prenatal care and delivery in patients bearing autoimmune hepatitis associated with moderate or severe thrombocytopenia.

METHODS

This study was performed in a tertiary level university hospital. Thirteen pregnancies in ten patients diagnosed with autoimmune hepatitis, complicated by thrombocytopenia, were retrospectively analyzed. The inclusion criteria were as follows: clinical diagnosis of autoimmune hepatitis, moderate or severe thrombocytopenia (platelet count < 100 x 103/mm3), gestational age at birth over 22 weeks, and patient followed-up by a specialized team at the institution. The variables studied were: maternal age, parity, treatment regimen, platelet count, examinations for investigation of hepatic function, type of delivery, weight at birth, and gestational age at the time of delivery.

RESULTS

The average maternal age was 24.5 years (SD = 5.3) and six (50%) occurred in nulliparous women. During pregnancy, monotherapy with prednisone was adopted in 11 cases (92%). According to the autoantibody profiles, seven pregnancies (58%) had the autoimmune hepatitis type I diagnosis, two pregnancies had type II (17%), and three pregnancies (25%) had cryptogenic chronic hepatitis (undetectable titers of autoantibodies). Portal hypertension was featured in 11 pregnancies (92%). The average gestational age at delivery was 36.9 weeks (SD = 1.5 weeks), with an average weight at birth of 2,446 g (SD = 655 g). Eight infants (67%) were small for gestational age. At the time of delivery, severe thrombocytopenia was featured in four cases (33%) and cesarean surgery was performed in seven cases (58%). Complications at delivery occurred in three cases (25%), one patient presented uterine atony, and two patients presented perineal bruising. There was no perinatal or maternal death.

CONCLUSION

The complications of thrombocytopenic patients with autoimmune hepatitis are elevated; nevertheless, with appropriate attention and care, they can be resolved. The association between two severe pathologies appears to increase the risk of prematurity and fetal growth restriction, demanding specialized prenatal care, as well as surveillance of newborn well-being.

[Bleeding disorders in pregnancy]

Bleeding disorders in pregnancy represent heterogenous and often serious group of diseases. Solving of this problems and proper treatment of the patiens requires close cooperation between obstetricians and hematologists. There are disorders specific for pregnancy (HELLP syndrom) and disorders occurring independently in pregnancy, but these can be modified in pregnancy as well. Bleeding and postpartum haemorrhage still remain the leading cause of maternal mortality.

KEYWORDS

bleeding - pregnancy - thrombocytopenia - coagulopathy.