Best Practice & Research Clinical Obstetrics & Gynaecology

Aims and Scope/Editorial Board

2012-02-01

Preface

Hassan Shehata — 2011-11-10

During the last 3 decades there have been major advances in the understanding and management of the haematological disorders associated with pregnancy. This edition aims to help update our management and knowledge of some of these conditions.

Anaemia in pregnancy

Malik Goonewardene, Mishkat Shehata, Asma Hamad — 2011-11-07

Anaemia in pregnancy, defined as a haemoglobin concentration (Hb) < 110 g/L, affects more than 56 million women globally, two thirds of them being from Asia. Multiple factors lead to anaemia in pregnancy, nutritional iron deficiency anaemia (IDA) being the commonest. Underlying inflammatory conditions, physiological haemodilution and several factors affecting Hb and iron status in pregnancy lead to difficulties in establishing a definitive diagnosis. IDA is associated with increased maternal and perinatal morbidity and mortality, and long-term adverse effects in the new born. Strategies to prevent anaemia in pregnancy and its adverse effects include treatment of underlying conditions, iron and folate supplementation given weekly for all menstruating women including adolescents and daily for women during pregnancy and the post partum period, and delayed clamping of the umbilical cord at delivery. Oral iron is preferable to intravenous therapy for treatment of IDA. B12 and folate deficiencies in pregnancy are rare and may be due to inadequate dietary intake with the latter being more common. These vitamins play an important role in embryo genesis and hence any relative deficiencies may result in congenital abnormalities. Finding the underlying cause are crucial to the management of these deficiencies. Haemolytic anaemias rare also rare in pregnancy, but may have life-threatening complications if the diagnosis is not made in good time and acted upon appropriately.

The obstetric management of sickle cell disease

Jo Howard, Eugene Oteng-Ntim — 2011-11-03

Sickle cell disease (SCD) is the most common inherited disease worldwide and is associated with anaemia and intermittent severe pain. Pregnant women who are affected have increased maternal and fetal mortality and morbidity. In view of this obstetricians should have an awareness of this condition and its complications, and pregnancies in women with SCD should be managed by a multidisciplinary team with experience of high risk pregnancies. Ideally women should be seen preconceptually for optimisation of their SCD and partner screening. Antenatal care should include regular outpatient visits with regular monitoring for pre-eclampsia and of fetal growth. Blood transfusion should be used for the treatment of acute anaemia, acute chest syndrome or acute stroke but there is not sufficient evidence currently to recommend its use prophylactically. There is an increased prevalence of sickle crisis during pregnancy and patients should be monitored carefully throughout this time.

Thalassaemia in pregnancy

Tak Yeung Leung, Terence T. Lao — 2011-11-04

Thalassaemia is the most common monogenetic disease worldwide. Antenatal screening is effective and simple, and accurate genetic prenatal diagnosis can be achieved in early gestation. Less invasive methods are feasible with ultrasound fetal assessment for alpha-thalassaemia, analysis of circulating fetal nucleic acid in maternal plasma, and pre-implantation genetic diagnosis. Women with thalassaemia major and intermedia are at risk of various maternal complications, such as cardiac failure, alloimmunisation, viral infection, thrombosis, endocrine and bone disturbances. Therefore, it is prudent to adhere to a standard management plan in this group of pregnant women. Close monitoring of the maternal and fetal condition during pregnancy is essential, and various treatments, such as blood transfusion or postpartum prophylaxis for thromboembolism, may be indicated. After birth, resumption of iron chelation and bisphosphonates treatment is needed, and counselling on breast feeding and contraception should be given.

Thromboembolic disorders in obstetrics

Gabriella Gray, Catherine Nelson-Piercy — 2011-11-09

Thromboembolic disorders remain a leading cause of maternal mortality in the developed world. The halving of the number of deaths from thromboembolic disorders in the last Confidential Enquiry provides further proof that they are largely preventable. A formal assessment of risk factors (e.g. previous thromboembolic disorders, thrombophilia, obesity) should be made at booking and at the time of delivery, or when intercurrent problems develop or the woman is admitted. Women with risk factors pre-dating pregnancy should be offered pre-pregnancy counselling and planning. Thromboprophylaxis should be instituted as soon as practical, bearing in mind that potentially fatal thromboembolic disorders may occur in the first trimester. All women presenting in pregnancy with new chest symptoms should be thoroughly investigated. Imaging is safe and should not be withheld. Treatment should be started empirically while the investigations are completed. Both prophylaxis and treatment doses should be carefully adjusted to take into account the weight of the woman.

Antiphospohlipid syndrome in obstetrics

Alvaro Danza, Guillermo Ruiz-Irastorza, Munther Khamashta — 2011-11-04

Antiphospholipid syndrome is characterised by a variety of clinical and immunological manifestations. The clinical hallmarks of this syndrome are thrombosis and poor obstetric outcomes, including miscarriages, fetal loss and severe pre-eclampsia. The main antiphospholipid antibodies include lupus anticoagulant, anticardiolipin and anti-β2-glycoprotein I. The combination of aspirin and heparin is considered the standard of care for women with antiphospholipid syndrome and embryo–fetal losses; however, aspirin in monotherapy may have a place in women with recurrent early miscarriage. A good benefit–risk ratio of low-molecular-weight heparin in pregnancy thrombosis treatment has been reported. Warfarin must be avoided if possible throughout the first trimester of pregnancy. Adequate pregnancy management of women with antiphospholipid syndrome should include co-ordinated medical-obstetrical care, a close follow-up protocol and a good neonatal unit. Close blood pressure control and early detection of proteinuria, together with Doppler studies of the utero–placental circulation should be included in the management protocol.

Massive obstetric haemorrhage with disseminated intravascular coagulopathy

Lin Lin Su, Yap Seng Chong — 2011-11-07

Massive obstetric haemorrhage is a major contributor towards maternal morbidity and mortality. The main causes are abruptio placentae, placenta praevia and postpartum haemorrhage. Clinicians managing pregnant women should be equipped with the knowledge and skills for managing massive obstetric haemorrhage to institute timely and appropriate life-saving treatment. Prompt resuscitation and reversal of coagulopathy are critical while definitive measures are carried out to arrest the bleeding. Massive antepartum haemorrhage necessitates deliveries whereas interventions for postpartum haemorrhage range from medical to surgical measures. Algorithms such as haemostasis are useful aids to the systematic and stepwise management of postpartum haemorrhage. Surgical measures used to avoid peripartum haemorrhage include uterine compression sutures, uterine balloon tamponade, uterine artery, and internal iliac artery ligation. Tranexamic acid and recombinant factor VII are more recent medical interventions in massive postpartum haemorrhage. Education, regular drills and adherence to guidelines and protocols are important to reduce haemorrhage-related maternal deaths.

Thrombophilia and early pregnancy loss

Kelly McNamee, Feroza Dawood, Roy G. Farquharson — 2011-11-03

Early pregnancy loss is the most common pregnancy complication. About 15% of pregnancies result in pregnancy loss and 1% of women experience recurrent miscarriage (more than three consecutive miscarriages). The influence of thrombophilia in pregnancy is a popular research topic in recurrent miscarriage. Both acquired and inherited thrombophilia are associated with a risk of pregnancy failure. Antiphospholipid syndrome is the only thrombophilia known to have a direct adverse effect on pregnancy. Historically, clinical research studying thrombophilia treatment in recurrent miscarriage has been of limited value owing to small participant numbers, poor study design and heterogeneity. The debate on the efficacy of aspirin and heparin has advanced with recently published randomised-controlled trials. Multi-centre collaboration is required to ascertain the effect of thrombophilia on early pregnancy loss and to establish an evidence-based treatment protocol.

Inherited bleeding disorders in pregnancy

Claudia Chi, Rezan A. Kadir — 2011-10-31

Women with inherited bleeding disorders may face several haemostatic challenges during pregnancy and childbirth. Pregnancy in these women requires specialised and individualised care. Prenatal diagnosis is primarily considered in families affected by severe bleeding disorder such as haemophilia. Non-invasive fetal sex determination by analysis of free fetal DNA in maternal blood offers carriers of haemophilia a means of avoiding invasive testing and its associated risks in female pregnancies. With the exception of fibrinogen and factor XIII deficiencies, it is currently unclear whether women with inherited bleeding disorders are at increased risk of miscarriage or antepartum haemorrhage. However, they are at increased risk of primary and secondary postpartum haemorrhage. The fetus, if severely affected, is at risk of cranial bleeding during labour and delivery. Appropriate haemostatic cover during labour and delivery, avoidance of prolonged labour and traumatic delivery, and active management of third stage of labour can minimise the risk of bleeding complications for the mother and her fetus.

Red-cell and platelet alloimmunisation in pregnancy

Michael Egbor, Peter Knott, Amarnath Bhide — 2011-11-11

The management of red-cell alloimmunisation has been revolutionised by the widespread use of anti-D administration for mothers who are rhesus negative, and the availability of non-invasive, ultrasound-based techniques for reliable detection of moderate-to-severe fetal anaemia. With reduced frequency of alloimmunisation to the D antigen, antibodies to c and Kell antigen are increasingly responsible for red-cell alloimmunisation. Ultrasound-based, non-invasive diagnosis is now so reliable that invasive techniques are sparingly used to detect significant fetal anaemia. Treatment of fetal anaemia using ultrasound-guided intravascular transfusions is highly successful. Advances in molecular biology have led to the successful determination of fetal blood group using free fetal DNA from maternal blood. This development is highly likely to allow use of anti-D in only those pregnant women carrying rhesus-positive fetuses. Sensitisation to non-D group antibodies continues to occur owing to the lack of available prophylaxis for other blood-group antigens.

Managing pregnancy with HIV, HELLP syndrome and low platelets

O.A. Onyangunga, J. Moodley — 2011-11-14

Management of pregnancies with human immunodeficiency virus, haemolytic anaemia, elevated liver enzymes, low platelets (HELLP) syndrome, and low platelets presents complexities in investigations and treatments, because these conditions and their treatment affect the mother and baby. Low platelets in severe pre-eclampsia, eclampsia and HELLP syndrome are relatively common, and should be detected early once the diagnosis of pre-eclampsia, HELLP syndrome, or both, are made. The mainstay of treatment is lowering of high blood pressure with rapid-acting antihypertensive agents, prevention of convulsions or further seizures with MgSO4, use of steroids for fetal lung maturity if necessary, followed by delivery of the baby. The use of high-dose steroids for the rapid recovery of maternal platelet counts is controversial, and should not be used routinely in women with HELLP syndrome. The use of platelet transfusion in women with severe pre-eclampsia, eclampsia and HELLP syndrome is a temporising measure, and should only be justified if the clinical circumstances warrant their use (e.g. before caesarean section when the woman has a low platelet count with evidence of bruising or bleeding from venepuncture sites). Low platelets may be an isolated finding in asymptomatic pregnant women and warrant the offer of a human immunodeficiency virus test, as it may be the first sign of this infection. Isolated low platelets may also indicate gestational thrombocytopaenia or idiothrombocytopaenic purpura. Gestational thrombocytopaenia is a benign condition and a diagnosis of exclusion. All clinicians should be aware that low platelets warrant further investigations because of the above-mentioned issues.

Management of haematological malignancy in pregnancy

Ihab El-Hemaidi, Susan E. Robinson — 2011-11-04

The incidence of haematological malignancies in pregnancy ranges from 1 in 1000 to 1 in 10,000. International prospective epidemiology, management and outcome data are important to gain further knowledge of haematological malignancies in pregnancy. The management of haematological malignancies in pregnancy is complex and requires a multidisciplinary approach. The clinician and mother need to address both maternal and fetal well-being. The mother should be provided with the necessary information and support to make informed decisions regarding the pregnancy and disease management. The haematological malignancies are a diverse group with varied presenting features, pathophysiology, treatment options, levels of urgency to commence treatment in pregnancy, effect on maternal and fetal outcome and overall prognosis. We have reviewed the published research in this area, and provide concise up-to-date guidance on the management of haematological malignancies in pregnancy.

Haematological Disorders in Pregnancy – Multiple Choice Questions for Vol. 26, No. 1

2011-12-16

If a pregnant woman has a Hb of 9.5 g/dL at eight weeks of gestation the flowing is/are true:

Sarcoma of the female genital tract – Answers to multiple choice questions for vol. 25, no. 6

2011-10-10

a) Fb) Fc) Td) Fe) F