Management recommendations for pregnant women with SCD
| Trimester . |
|---|
| First trimester/initial visit |
| General recommendations |
| Identify and establish a communication plan with members of multidisciplinary team, including a specialist in SCD and high-risk obstetrical care |
| Establish frequency of routine visits throughout pregnancy |
| Test for and treat iron deficiency |
| Start folic acid supplementation—5 mg daily |
| Discuss need for penicillin prophylaxis, particularly in women with a past history of pneumococcal sepsis |
| Vaccinate for encapsulated organisms and hepatitis B if not administered previously; administer influenza vaccine |
| Discuss low-dose aspirin therapy—consider starting aspirin 75-81 mg daily at 12 wk gestation; for patients with prior preeclampsia, renal disease, or hypertension, discuss higher doses of daily aspirin |
| Discuss VTE prophylaxis—compression stocking use daily and low-molecular weight heparin prophylaxis during hospitalizations; for patients with permanent venous catheters, discuss daily low-molecular weight heparin |
| Close monitoring for hypertension—establish baseline blood pressure and monitor blood pressure frequently |
| Regular monitoring of fetal growth by ultrasound |
| Routine screening for bacteriuria |
| Establish steady-state values |
| Pulse oximetry |
| Blood pressure |
| Hemoglobin phenotype/genotype |
| Hemoglobin and reticulocyte count ranges |
| Red cell antigen phenotype or genotype |
| Red cell antibodies—both present and transient |
| End-organ damage assessment |
| Echocardiogram |
| Urine protein assessment |
| Pulmonary function tests |
| Ophthalmologic examination |
| Evaluation for iron overload |
| Screen for red cell alloimmunization |
| Medication evaluation |
| Discontinue hydroxyurea, warfarin, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers; chelation therapies; and consider substitute therapies; chelation therapies |
| Genetic counseling and patient education |
| Hemoglobin electrophoresis on patient’s partner/father of child |
| In-person meeting to discuss test results and educate on potential outcomes of pregnancy for mother and child, including both positive and negative events |
| Develop plans for pain management, end-organ damage and blood pressure monitoring, red cell transfusions, and fetal monitoring |
| Pain management |
| Analgesics to be used according to trimesters |
| Identification of hospital team to manage pain and hospital unit location |
| Monitoring of fetus during inpatient stays |
| Use of anticoagulation for VTE prophylaxis |
| End-organ damage and blood pressure monitoring |
| Urinalysis, glomerular filtration rate, and proteinuria assessments monthly |
| Establish, document, and communicate systolic and diastolic steady-state ranges for patient before pregnancy |
| Blood pressure monitoring during pregnancy every 2-4 wk |
| Red cell transfusions |
| Establish hemoglobin goals at steady state and during inpatient admissions |
| Monitor complete blood count and reticulocyte count every 2-3 mo |
| Establish indications for intermittent red cell transfusions |
| Establish indications for chronic/prophylactic transfusions |
| Communicate appropriate red cell antigen matching—at minimum ABO, D, C, E, Kell; consider further extended antigen matching based on red cell alloimmunization and history of delayed hemolytic transfusion reactions |
| Establish posttransfusion hemoglobin and hemoglobin S percentage goals |
| Fetal monitoring |
| Fetal ultrasound at 7-9 wk; recommend every 4 wk through 24 wk and then, every 2 wk to monitor fetal growth |
| Biophysical profile during inpatient stays |
| Second trimester |
| Revise first trimester management plans if necessary |
| Develop a plan for delivery, including plan for Cesarean section |
| Educate mother and her support system about complications that may occur during and after delivery as well as possible need for neonatal intensive care unit stay for infant |
| Communicate plans to members of multidisciplinary team |
| Revise frequency of routine visits |
| Test for and treat iron deficiency |
| Third trimester |
| Include neonatologist in discussions about fetal growth, plans for delivery, mother’s alloimmunization status, and use of opioids throughout pregnancy |
| Revise first/second trimester management plan if necessary |
| Revise plan for delivery, including plan for Cesarean section and whether transfusion before delivery is required |
| Discuss pain management postpartum and need for initiating/restarting prepregnancy disease-modifying therapies; plans may need modification according to whether the patient plans to breastfeed |
| Develop plan for VTE prophylaxis postdelivery |
| Develop plan for screening infant for neonatal abstinence and hemolytic disease of the newborn |
| Communicate plans to members of multidisciplinary team |
| Revise frequency of routine visits |
| Test for and treat iron deficiency |
| Trimester . |
|---|
| First trimester/initial visit |
| General recommendations |
| Identify and establish a communication plan with members of multidisciplinary team, including a specialist in SCD and high-risk obstetrical care |
| Establish frequency of routine visits throughout pregnancy |
| Test for and treat iron deficiency |
| Start folic acid supplementation—5 mg daily |
| Discuss need for penicillin prophylaxis, particularly in women with a past history of pneumococcal sepsis |
| Vaccinate for encapsulated organisms and hepatitis B if not administered previously; administer influenza vaccine |
| Discuss low-dose aspirin therapy—consider starting aspirin 75-81 mg daily at 12 wk gestation; for patients with prior preeclampsia, renal disease, or hypertension, discuss higher doses of daily aspirin |
| Discuss VTE prophylaxis—compression stocking use daily and low-molecular weight heparin prophylaxis during hospitalizations; for patients with permanent venous catheters, discuss daily low-molecular weight heparin |
| Close monitoring for hypertension—establish baseline blood pressure and monitor blood pressure frequently |
| Regular monitoring of fetal growth by ultrasound |
| Routine screening for bacteriuria |
| Establish steady-state values |
| Pulse oximetry |
| Blood pressure |
| Hemoglobin phenotype/genotype |
| Hemoglobin and reticulocyte count ranges |
| Red cell antigen phenotype or genotype |
| Red cell antibodies—both present and transient |
| End-organ damage assessment |
| Echocardiogram |
| Urine protein assessment |
| Pulmonary function tests |
| Ophthalmologic examination |
| Evaluation for iron overload |
| Screen for red cell alloimmunization |
| Medication evaluation |
| Discontinue hydroxyurea, warfarin, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers; chelation therapies; and consider substitute therapies; chelation therapies |
| Genetic counseling and patient education |
| Hemoglobin electrophoresis on patient’s partner/father of child |
| In-person meeting to discuss test results and educate on potential outcomes of pregnancy for mother and child, including both positive and negative events |
| Develop plans for pain management, end-organ damage and blood pressure monitoring, red cell transfusions, and fetal monitoring |
| Pain management |
| Analgesics to be used according to trimesters |
| Identification of hospital team to manage pain and hospital unit location |
| Monitoring of fetus during inpatient stays |
| Use of anticoagulation for VTE prophylaxis |
| End-organ damage and blood pressure monitoring |
| Urinalysis, glomerular filtration rate, and proteinuria assessments monthly |
| Establish, document, and communicate systolic and diastolic steady-state ranges for patient before pregnancy |
| Blood pressure monitoring during pregnancy every 2-4 wk |
| Red cell transfusions |
| Establish hemoglobin goals at steady state and during inpatient admissions |
| Monitor complete blood count and reticulocyte count every 2-3 mo |
| Establish indications for intermittent red cell transfusions |
| Establish indications for chronic/prophylactic transfusions |
| Communicate appropriate red cell antigen matching—at minimum ABO, D, C, E, Kell; consider further extended antigen matching based on red cell alloimmunization and history of delayed hemolytic transfusion reactions |
| Establish posttransfusion hemoglobin and hemoglobin S percentage goals |
| Fetal monitoring |
| Fetal ultrasound at 7-9 wk; recommend every 4 wk through 24 wk and then, every 2 wk to monitor fetal growth |
| Biophysical profile during inpatient stays |
| Second trimester |
| Revise first trimester management plans if necessary |
| Develop a plan for delivery, including plan for Cesarean section |
| Educate mother and her support system about complications that may occur during and after delivery as well as possible need for neonatal intensive care unit stay for infant |
| Communicate plans to members of multidisciplinary team |
| Revise frequency of routine visits |
| Test for and treat iron deficiency |
| Third trimester |
| Include neonatologist in discussions about fetal growth, plans for delivery, mother’s alloimmunization status, and use of opioids throughout pregnancy |
| Revise first/second trimester management plan if necessary |
| Revise plan for delivery, including plan for Cesarean section and whether transfusion before delivery is required |
| Discuss pain management postpartum and need for initiating/restarting prepregnancy disease-modifying therapies; plans may need modification according to whether the patient plans to breastfeed |
| Develop plan for VTE prophylaxis postdelivery |
| Develop plan for screening infant for neonatal abstinence and hemolytic disease of the newborn |
| Communicate plans to members of multidisciplinary team |
| Revise frequency of routine visits |
| Test for and treat iron deficiency |