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i n P re g n a n c y : T h e
O b s t e t r i c i a n ’s
Perspective
Nicole A. Smith, MD, MPH*, Katherine E. Economy, MD, MPH
KEYWORDS
Pregnancy Hematology Delivery planning
The effect of hematologic disease on pregnancy varies by trimester. Most women with
medical conditions should be advised that they will have increased maternal and fetal
surveillance during their pregnancies. This may involve increased visits, laboratory
draws, or fetal evaluation. In addition, there may be extensive planning for labor and
delivery.
choose to pass early pregnancies at home, whereas others prefer to have surgical
evacuations by vacuum aspiration or dilation and curettage. Because they are at
increased risk of uncontrolled hemorrhage, women with bleeding disorders are typi-
cally best served by a surgical evacuation, which requires careful surgical planning.
Molar pregnancies are rare, occurring in approximately 0.1% of pregnancies.2
Bleeding is a hallmark of molar pregnancy, and surgical evacuation is required.
Placental abruption
Placental abruption is defined as a separation of the placental bed from the uterine
wall. An abruption may be characterized by light bleeding, or by major obstetric
hemorrhage requiring emergent delivery. Rates of abruption vary by population from
0.7%3 to 1.4%.4 The incidence is higher in women with risk factors such as smoking,
hypertension, or prior abruption. Bleeding disorders and anticoagulation may
substantially increase the risk to both mother and fetus in this setting. All pregnant
women with bleeding disorders should have a plan in place that outlines how to
manage unexpected bleeding.
Abnormal placentation
Placenta previa describes the situation in which the placenta is implanted close to, or
overlying, the uterine cervix, whereas placenta accreta describes invasion of the
placenta into the uterine wall. The risks of placenta previa and accreta increase with
greater numbers of cesarean deliveries or uterine surgeries. Previa is associated
with a risk of bleeding from unprotected placental vessels, which often leads to hospi-
talization and preterm birth. For most women without a prior cesarean delivery,
a placenta previa seen early in pregnancy spontaneously resolves as the uterus grows
during gestation. Placenta accreta almost universally necessitates hysterectomy at
the time of delivery.
Preterm labor
Preterm labor affects approximately 13% of the population, with more than 70% of
these babies born between 34 and 36 weeks’ gestation.5 Preterm contractions
without labor are even more common. The diagnosis of preterm labor is often
Hematologic Disease in Pregnancy 417
Anesthesia
Anesthesia is an important component of labor and delivery planning. Many women
undergoing spontaneous or induced labor request epidural anesthesia, and most
uncomplicated cesarean deliveries are performed under spinal anesthesia. There is
controversy in the anesthesia literature regarding safe platelet levels for regional anes-
thesia. Although some sources suggest platelets greater than 100,000 minimize the
risk of epidural hematoma,6 others7,8 report safe placement with platelets as low as
69,000. At our institution, platelets of 70,000 are required for both regional anesthesia
placement and removal of the epidural catheter.9 Additional options for pain control
during a vaginal birth include intravenous or intramuscular narcotics, and for cesarean
delivery, general anesthesia. General anesthesia increases the likelihood of need for
neonatal resuscitation, including intubation.
Postpartum hemorrhage
Postpartum hemorrhage (PPH) is defined as blood loss greater than 500 mL for a vaginal
delivery or 1000 mL for a cesarean delivery. Rates of PPH vary by study, but have been
reported to be as high as 19% in a low-risk European population.10,11 Many healthy
young women tolerate the increased blood loss well. Almost all hemorrhages occur
within 24 hours of delivery (early PPH), with a small minority occurring 24 hours to 6
weeks after delivery (late PPH). Bleeding may be brisk, because between 500 and
800 mL of blood pass through the term uterus each minute. Given the frequency of
PPH, the unique risks hemorrhage may hold for the patient with hematologic disease
need to be considered, as well as parameters for transfusion or medication therapy.
Fetal Concerns
An important consideration when caring for pregnant women with medical disease is
the risk that the fetus will either inherit the disease in question, or be affected by the
mother’s condition. Any woman with a potentially heritable disorder should be offered
genetic counseling before pregnancy or early in gestation, because genetic testing for
the fetus may be possible. Understanding fetal risk is also essential for delivery plan-
ning. If the fetus has a known or suspected bleeding disorder, or, as in ITP, there is
concern for neonatal thrombocytopenia, operative vaginal delivery (forceps or
vacuum-assisted delivery) is contraindicated, as is fetal monitoring using a scalp elec-
trode. In these infants, profound thrombocytopenia may develop in the first days of
life, therefore communication with the pediatric team is essential.
Pregnancy may impact medical disease in several ways. It may affect the ability to
diagnose or treat disease, or it may change the course of disease. The goal of medical
treatment in pregnancy should be to achieve the same level of care that would be seen
in the absence of pregnancy.
Diagnosis
Many diagnostic procedures are considered low risk, and should be used if they can
improve maternal outcomes. Nonionizing radiation is considered safe in pregnancy.
With regard to ionizing radiation, studies have shown that with exposure of less
than 5 rad at any point in pregnancy, noncancer health effects are not detectable.
Exposure of 5 to 50 rad before 15 weeks may be associated with an increased inci-
dence of major malformations and growth restriction, reduction in intelligence
quotient, and increase in severe mental retardation. These risks are seen with expo-
sure to more than 50 rad at any point in pregnancy.12,13
420 Smith & Economy
Ionizing radiation raises the risk of childhood cancers, and may increase the lifetime
risk for solid tumors. Exposure of less than 5 rad is associated with a 0.3% to 1% inci-
dence of childhood cancers, particularly leukemia, in comparison with a background
risk of 0.3%. The incidence of childhood cancers increases to 6% with exposure of
greater than 50 rad. Radiation exposure from a typical computed tomography (CT)
scan of the abdomen is less than 2.6 rad, whereas from a CT head it is less than
0.5 rad. Fetal radiation exposure in an abdominal radiograph is less than 0.3 rad.12,13
In practice, many obstetricians counsel patients that appropriately indicated radio-
logic studies should be performed, with an effort made to avoid ionizing radiation
exposure in the first trimester if possible.
Pregnant women can also safely undergo many procedures, including bone marrow
biopsies. Surgery such as splenectomy can be performed during gestation if neces-
sary, optimally in the second trimester.
Medication Use
Commonly used medications include steroids, anticoagulants, narcotics, erythropoi-
etin, DDAVP, and intravenous immunoglobulin (IVIG). In most cases, the benefits of
these medications outweigh the low risk to the fetus. Many chemotherapeutic agents
can also be used safely in pregnancy.
Medication use is most restricted in the first trimester because of concerns for tera-
togenicity and pregnancy loss. Many women with nausea and vomiting in the first
months of pregnancy find it difficult to tolerate pills and do best with intravenous or
per rectum administration. Later in gestation, some medications can be associated
with growth restriction of the fetus. In this case, we recommend serial ultrasound
surveillance of fetal growth. The specific risks of some commonly used medications
are outlined later.
A large number of medications are also compatible with lactation. Unlike guidelines
for medication use in pregnancy, those for use in lactation differ depending on the
reference used. The most current information can be obtained from a free National
Institutes of Health–sponsored Web site called LactMed (toxnet.nlm.nih.gov).
Heparin (category C) and low molecular weight heparins (category B): both
compatible with breastfeeding
Because of the large size of these molecules, heparin and low molecular weight hepa-
rins do not cross the placenta or enter breast milk.16
Hematologic Disease in Pregnancy 421
Iron dextran has been shown to be teratogenic and embryocidal to animals when
given in 3 times the maximum human dose. Studies regarding placental transfer
have been inconclusive. Some iron dextran does seem to reach the fetus, but it is
unknown in what form. In practice, iron dextran is given when indicated to pregnant
women. Neither iron sucrose nor sodium ferric gluconate have been shown to be tera-
togenic in animals, and no human studies exist.22–24
Traces of unmetabolized iron dextran are present in human milk. An oral agent may
be preferred because of limited experience in lactation. If this drug is required, breast-
feeding should not be discontinued. Iron sucrose does not appear to increase breast
milk iron. It is unknown whether sodium ferric gluconate is excreted in breast milk, but
use is considered compatible with breastfeeding.25–27
SUMMARY
ACKNOWLEDGMENTS
The authors wish to thank Bhavani Kodali, MD, Louise Wilkins-Haug, MD, PhD, and
Meaghan Muir, MLIS, for assistance in the preparation of this manuscript.
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