In 4352 pregnancies in women with sickle-cell syndromes, pregnancy complication rates. Compared with controls, women with sickling disorders had a 63-percent rate of nondelivery related admissions. hey had a 1.8-fold greater incidence of hypertensive disorders-19 percent; a 2.9-fold higher rate of fetal-growth restriction-6 percent; and a 1.7-fold increased cesarean delivery rate-45 percent.
Prophylactic Red Cell Transfusions. Chronic transfusion therapy prevents strokes in high-risk children (DeBaun, 2014). During pregnancy, the most dramatic beneit of prophylactic transfusions has been on maternal morbidity rates (Benites, 2016). In an observational 10-year prospective study at Parkland Hospital, we ofered prophylactic transfusions to all pregnant women with sickle-cell syndromes. Transfusions were given throughout pregnancy to maintain the hematocrit above 25 volumes percent and the portion of hemoglobin S <60 percent (Cunningham, 1979). Maternal morbidity was minimal, and erythropoiesis suppression was not problematic. Their outcomes were compared with historical controls who were not routinely transfused. Overall, morbidity and hospitalization rates were signiicantly reduced in the transfused group (Asma, 2015; Cunningham, 1983; Grossetti, 2009). Still, adverse perinatal outcomes are prevalent (Ngo, 2010).
In a multicenter trial, Koshy and coworkers (1988) randomly assigned 72 pregnant women with sickle-cell syndromes to prophylactic or indicated transfusions. They reported a signiicant decline in the incidence of painful sickle-cell crises with prophylactic transfusions but no diferences in perinatal outcomes. Because of risks inherent with blood administration, they concluded that prophylactic transfusions were not indicated. A metaanalysis of 12 studies found prophylactic transfusions improved rates of some adverse maternal and neonatal outcomes, including maternal mortality, pulmonary complications, and perinatal mortality (Malinowski, 2015).
Undoubtedly, morbidity from multiple transfusions is significant. Up to 10 percent of women had a delayed hemolytic transfusion reaction, and infections are major concerns. Garratty (1997) reviewed 12 studies and found alloimmunization developed in a fourth of women. Finally, in liver biopsies in these women, we found no evidence of transfusion-related iron overload, hemochromatosis, or chronic hepatitis (Yeomans, 1990).
Because of what some consider marginal benefits, routine prophylactic transfusions during pregnancy remain controversial (American College of Obstetricians and Gynecologists, 2015; Okusayna, 2013). Current consensus is that their use should be individualized.
Fetal Assessment. Because of the high incidence offetal-growth restriction and perinatal mortality, serial fetal assessment with sonography and antepartum surveillance is recommended (American College of Obstetricians and Gynecologists, 2015).
Anyaegbunam and colleagues (1991) reported nonreactive stress tests during sickling crises, which resumed reactivity with crisis resolution. They concluded that transient efects of sicklecell crisis do not compromise umbilical blood flow.