Sacha Choupa is a student and researcher at Georgetown University School of Medicine, where she focuses on health disparities, particularly in sickle cell disease (SCD).
Sickle cell disease (SCD) is a globally prevalent, inherited hemoglobinopathy that poses substantial clinical challenges across the lifespan.1 Among its many complications, venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, remains underrecognized, particularly in pregnant individuals, despite its strong association with adverse maternal outcomes.
People with SCD experience a chronic hypercoagulable state driven by hemolysis, endothelial dysfunction, inflammation, and recurrent vaso-occlusive episodes.2 This physiology places them at a fourfold to sixfold risk of VTE compared to the general population.3 A recent analysis of U.S. Medicaid data showed that pregnant individuals with SCD had an 11.3% incidence of VTE and a 5.2% incidence of arterial thromboembolism, compared to 1.2% and 0.6%, respectively, among pregnant individuals without SCD.4 This translates to nearly a tenfold increase in risk, underscoring the urgency of preventive strategies (Figure).
Venous thromboembolism incidence in pregnancies with sickle cell disease
Adapted from Agarwal, et al.4
Venous thromboembolism incidence in pregnancies with sickle cell disease
Adapted from Agarwal, et al.4
Clinical data further show that VTE during pregnancy in individuals with SCD is strongly associated with prior thrombotic events, acute chest syndrome, and painful vaso-occlusive episodes requiring acute care.5 A binational retrospective cohort study reviewed 290 pregnancies in individuals with SCD and reported a 7% VTE occurrence.5 Risk factors included previous VTE, hydroxyurea use before conception, and intrapartum complications. Notably, VTE was linked to earlier deliveries and higher cesarean section rates, emphasizing the impact on maternal-fetal outcomes.5
National trends echo these concerns. A recent analysis of the National Inpatient Sample from 2012 to 2018 found that deliveries among individuals with SCD had significantly higher odds of severe maternal morbidity compared to deliveries without SCD. This included thrombotic complications such as cerebrovascular events and VTE.6 These data reinforce the need for standardized protocols, multidisciplinary care, and policy-level advocacy.
Despite these risks, clear guidelines for anticoagulation during pregnancies of those with SCD remain lacking. While anticoagulation may reduce thrombotic events, it must be weighed against bleeding risks. Some institutions provide postpartum prophylaxis universally, while others reserve it for patients with a prior history of VTE. This lack of standardization leaves clinicians navigating uncertainty, often with limited data to support decision-making.
Addressing these gaps requires both research and reform. First, we must invest in prospective studies focused on the safety and efficacy of anticoagulation in pregnant individuals with SCD. Second, multidisciplinary care teams, which bring together hematologists, obstetricians, and vascular specialists, are essential for proactive, individualized care. Finally, policies must evolve to support equitable access to specialized services and evidence-based thromboprophylaxis.
Recognizing VTE in pregnant individuals living with SCD is not only a matter of clinical precision, but also a matter of justice. Patients living with SCD deserve care that anticipates complications, not just responds to them. We can close the gap and improve outcomes for this vulnerable population through research, structural reform, and collaborative care.
Disclosure Statement
Dr. Choupa indicated no relevant conflicts of interest.
