Effect of active prenatal management on pregnancy outcome in sickle cell disease in an African setting

Abstract

Sickle cell disease (SCD) is associated with an increased risk of medical complications during pregnancy. In sub-Saharan Africa, fetal and maternal mortality rates are particularly high. This study evaluated the effect of an active prenatal management program on pregnancy outcome in patients with SCD in an African setting. Pregnant women with SCD attending the National Teaching Hospital in Cotonou (The Republic of Benin, West Africa) were recruited before the 28th week of gestation. Management was based on providing information and education about SCD and improving nutritional status, malaria prevention, early detection of bacterial infections, and restricted use of blood transfusion. Maternal and fetal mortality rates and SCD-related morbidity were the principal variables assessed. One hundred and eight patients (42 SS and 66 SC) with 111 fetuses were included in the study. Thirteen fetal deaths (from 9 SS and 4 SC mothers) were recorded and 2 deaths of SC mothers. The maternal mortality rate of 1.8% was comparable with the overall maternal mortality rate for this maternity unit (1.2%). Few SCD-related events were recorded. Plasmodium falciparum malaria infection was the major cause of morbidity. Sixty-three patients (19 SS and 44 SC) successfully completed their pregnancy (58.3%) without requiring transfusion. Providing pregnant SCD patients with relevant medical care based on simple cost-effective approaches can have a positive impact on SCD-associated morbidity and mortality in an otherwise difficult setting in Africa.

Malaria in pregnancy: the difficulties in measuring birthweight

“…The case reports did not contain sufficient details on the methodology used to measure birthweight and were excluded 10–12 . Forty‐three studies described in 59 publications were reviewed (Table S1, see Supporting information) 13–72 . Most (56%, 24/43) were studies on the prevention of malaria by intermittent preventive treatment (IPTp) or chemoprophylaxis in the African subcontinent (Table S1).…”

“…The remaining publications did not mention whether twins, stillborn infants or those with congenital abnormalities were included in the analysis. Congenital abnormalities were reported in 15 publications 13,14,17,22,23,29,43,45,46,50,54,60–62,72 . Eight studies (18%) reported the length of the infant at birth and, of these, four reported IUGR 41,50,64,72 …”

“… *Ultrasound‐derived gestational age assessment was used when menstrual dates were unknown (31%) or when the measurement of fetal size was more than two standard deviations above or below the mean for gestation calculated from the menstrual history (22%) 26 . Only women who could afford to pay had an ultrasound dating scan in Benin 62 …”

Implementation of multidisciplinary care reduces maternal mortality in women with sickle cell disease living in low‐resource setting

“…To our knowledge, the only other prospective cohort study describing improved management of pregnant women with SCD in Africa demonstrated that enhanced prenatal care specific for the region lowered maternal mortality from 26.7% to 1.8%, which was comparable to the 1.2% rate found in pregnant women without SCD in the same setting . Similar to our study, a multidisciplinary approach was used, but the study did not have a systematic evaluation of the deaths prior to the intervention, and was limited in describing reproducible protocols for management of SCD‐related complications, including vaso‐occlusive pain and acute chest syndrome …”

Pregnancy outcomes in women with sickle‐cell disease in low and high income countries: a systematic review and meta‐analysis

“…Given the lack of formal evidence to guide clinical practice, we believe that pregnant women with SCD should be managed by a multidisciplinary team including haematologists and obstetricians with experience in high‐risk pregnancy . The optimal approach of managing pregnancy complicated by SCD, that results in improved maternal and fetal outcomes, is yet to be identified.…”