Guidelines for care of these women have been appropriately stressed by Rees and colleagues (2003). !vIarti-Carvajal and coworkers (2009) performed a Cochrane review and reported that no randomized trials have evaluated treatment during pregnancy. At minimum, intravenous luids are given, and opioids are administered promptly for severe pain. Oxygen via nasal cannula may decrease the intensity of sickling at the capillary level. We have found that red cell transfusions after the onset of severe pain do not dramatically improve pain intensity and may not shorten its duration. Conversely, as discussed later, prophylactic transfusions almost always prevent further vasoocclusive episodes and pain crises. Recent reports suggest benefits from epidural analgesia (Verstraete, 2012; Winder, 2011). Long term, afected women can become habituated to narcotics. his problem is highlighted by the increased rates of neonatal abstinence syndrome, which is a constellation of withdrawal symptoms (Shirel, 2016).
Rates of covert bacteriuria and acute pyelonephritis are elevated substantively, and screening and treatment for bacteriuria are essential. If pyelonephritis develops, sickle cells are extremely susceptible to bacterial endotoxin, which can cause dramatic and rapid red cell destruction while simultaneously suppressing erythropoiesis. Pneumonia, especially due to Streptococcus pneumoniae, is common. he Centers for Disease Control and Prevention recommends specific vaccination for those with sickle-cell disease and all asplenic patients (Kim, 2016). hese are polyvalent pneumococcal, Haemophilus inluenzae type B, and meningococcal vaccines, and administration guidelines are found in Table 9-7 (p. 172).
Pulmonary complications are frequent. Of these, acute chest syndrome is characterized by pleuritic chest pain, fever, cough, lung infiltrates, and hypoxia, and usually also by bone and joint pain (Vichinsky, 2000). In addition to symptoms, radiographs show a new pulmonary infiltrate. There are four precipitants: infection, marrow emboli, thromboembolism, and atelectasis (Medof, 2005). Bacterial or viral infection causes approximately half of cases. When acute chest syndrome develops, the mean duration of hospitalization is 10.5 days. Mechanical ventilation is required in approximately 15 percent, and the mortality rate approximates 3 percent (Gladwin, 2008). At least for nonpregnant adults, some recommend rapid simple or exchange transfusions to remove the "trigger" for acute chest syndromes (Gladwin, 2008). In a study of nonpregnant patients, Turner and colleagues (2009) reported that there were no increased beneits of exchange versus simple transfusions, and the former were associated with fourfold increased blood usage.
Women with sickle-cell disease usually have some degree of cardiac dysfunction from ventricular hypertrophy. Chronic hypertension worsens the dysfunction (Gandhi, 2000). During pregnancy, the basal hemodynamic state characterized by high cardiac output and increased blood volume is augmented (Veille, 1994). Although most women tolerate pregnancy with out problems, complications such as severe preeclampsia or ham, 1986). Heart failure caused by pulmonary hypertension must also be considered (Chakravarty, 2008).