Third Trimester and Early Postpartum Period of Pregnancy have the Greatest Risk …

Asare EV, Olayemi E, Boafor T, Dei-Adomakoh Y, Mensah Dip E, Benjamin CH, Covert B, Kassim AA, James A, Rodeghier M, DeBaun MR, Oppong SA. Third trimester and early postpartum period of pregnancy have the greatest risk for ACS in women with SCD. Am J Hematol. 2019 Dec;94(12):E328-E331. doi: 10.1002/ajh.25643. Epub 2019 Oct 15. PMID: 31571271.

Pregnancy is a life-threatening occurrence in women with sickle cell disease (SCD), with increased odds of maternal and perinatal mortality compared to pregnant women without SCD.1 During pregnancy, women with SCD can also experience SCD related maternal morbidities, including acute vaso-occlusive pain episode, acute chest syndrome (ACS), and venous thromboembolism with expected increased incidence rates when compared to not being pregnant.2 We previously demonstrated in a case series that 87% of all maternal deaths were due to ACS, with almost 80% of episodes preceded by an acute pain event.3 In another prospective study, we demonstrated increased incidence rates of acute pain and ACS in pregnant women with SCD4 compared to historical non-pregnant women with SCD.5 As a planned follow-up to our prospective cohort study, we extended the outcome in our pre-existing cohort of pregnant women with SCD4 to determine the impact of pregnancy on acute pain events pre- and postpartum. We tested the hypothesis that pregnant women with SCD have higher incidence rates of acute pain requiring hospitalization and ACS during pregnancy compared to one-year postpartum.

This study received approval from the Ethical and Protocol Review Committee, University of Ghana, and Vanderbilt University Medical Center Institutional Review Board. Permission was obtained from the Ghana Institute of Clinical Genetics (GICG) and the Korle-Bu Teaching hospital (KBTH) where the study was conducted. The obstetric unit at KBTH conducts about 10 000 deliveries/year including ∼250 women with SCD. The adult SCD clinic at GICG provides day-care services with ∼10 000 patient visits/year. The study period was from April 2015 to November 2017. Participants were assessed over two time periods: a) pregnancy period: period from enrollment (irrespective of gestational age) to 6 weeks after delivery; and b) postpartum period: period between 6 weeks plus 1 day to 1-year (52 weeks) post-delivery.

The definition of acute pain episode as in our previous publications was maintained.3, 4, 6 During the postpartum period, “if the patient was able to judge whether the pain was of the type usually associated with crisis and reported such pain, this was considered appropriate evidence of an acute pain episode.5” The total number of acute pain episodes requiring hospitalization was confirmed with a chart review.

The definition of ACS as in our previous publications was maintained.3, 4, 6 The research obstetricians and hematologists adjudicated all participants admitted for suspected ACS events. A consensus agreement was reached to determine the diagnosis of ACS. Table S1 highlights the adjudication criteria used for ACS. The observers and adjudicators were separate individuals. During the pregnancy period, outpatient and inpatient care were provided by our multidisciplinary care team as previously described.

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