Obstetric History in Sickle Cell Disease Females

Obstetric and Gynecological History in Sickle Cell Disease
Soheir S. Adam, MD1, Jude Jonassaint,RN1, Mary R. Abrams,MPH1 ,Charles
Jonassaint2, MA1, Laura De Castro, MD1, Marilyn Telen, MD1
Department of Medicine, Duke University Medical Center, Durham, North Carolina,
27710, 2 Department of Psychiatry, Duke University, Durham, North Carolina, 27710
Pregnancy in sickle cell disease (SCD) has been associated with
complications and adverse outcomes for mother and child and thus warrants
specialized clinical care. There is bidirectional impact between pregnancy
and SCD. Only a small number of previous studies of pregnancy outcomes
in SCD patients have been published, and some have been based on
nationwide diagnosis queries rather than direct patient queries. An increased
incidence of spontaneous abortion, pregnancy-induced hypertension,
infections, pre-term labor, and low birth weight was noted in those reports.
The aim of the present study was to identify and describe the characteristics
and outcomes of pregnancy and other gynecological events in our current
patients with SCD. We hypothesized that these women experience a higher
frequency of pregnancy-related complications and earlier onset of
menopause than the general population. One hundred adult female SCD
patients from the Duke University Medical Center sickle cell clinic were
included in this study. Sixty five were homozygous for Hemoglobin (Hb)
SS, 22 had Hb SC and 13 had other Hb genotypes. A standard questionnaire
was developed, and patients were interviewed either personally or by
telephone after obtaining IRB-approved informed consent. Most of the data
reported here comes from patient interviews. Medical records were reviewed
only to confirm Hb genotype and age. The mean age of individuals included
in the study was 38.7+ 13 years (range 19 – 75 yr). Sixty-seven of 100
reported a history of regular menses. The median age at menopause was 45+
7 (range 27 to 58). Twenty-five percent of the patients were never pregnant,
92% of those (23 out of 25) stated they did so by choice. Seventy-five
patients reported a total of 158 pregnancies; there were 111 live births and 3
still-births. One tubal pregnancy was terminated. Patients reported a total of
43 abortions: 28 were spontaneous, and 15 were induced. Twenty-seven
(36%) patients have had at least one abortion. Of women with a history of
pregnancy, 57 (76%) reported unplanned pregnancies. Mean gestational age
was 35.9 + 5 weeks. Maternal complications evaluated included: thrombosis
in 6 patients (8%), five in the lower limb and one in the lungs; and
pregnancy-induced hypertension in 10 (13%) patients. The rate of live births
was 0.7. The prevalence of low birth weight was higher than in the AA
population (26.3% vs. 13.2%, respectively) and the mean birth weight was
lower than the AA population (2595.5 vs. 3089 g, respectively) (David et al,
NEJM. 1997). The mean birth weight for women who increased their use of
pain medications during pregnancy was lower than that for women who
continued on the same pain medication regimen, those who took less
medication, and those who did not use pain medication (2045, 2743, 2758,
and 2924 g, respectively, p < 0.02). The babies of patients in the first group
were more likely to stay longer in the hospital (p = 0.006). We conclude that
obstetrical and gynecological outcomes in SCD patients differ significantly
from and are in general worse than for the AA population, especially for
menstrual history, onset of menopause, prevalence of low birth weight and
mean birth weight. Moreover, increased use of pain medications in
pregnancy was associated with lower birth weight. This finding is
troublesome and deserves further study.