Abstract Introduction: Sickle cell disease (SCD) is an inherited hematologic disorder affecting around 100,000 Americans. Venous thromboembolism (VTE) risk is higher in those with SCD. Pregnancy is an additional risk factor for development in VTE in any patient. VTE risk has been described previously in several studies with risk of VTE in the pregnant SCD population being 7 -13%. While the risk of VTE has been well-documented in the pregnant SCD population, the risks and benefits of anticoagulation (AC) have not yet been described. Current clinical practice favors 6 weeks of postpartum prophylactic AC for pregnant patients with SCD as per the 2018 ASH guidelines for management of VTE in pregnancy though some institutions favor AC during pregnancy as well. This study seeks to evaluate the risks associated with prophylactic AC during pregnancy and in the postpartum setting. Methods: This was a single center retrospective chart review using ICD-10 codes to identify pregnant patients with SCD who sought care at Ohio State Wexner Medical Center (OSUWMC) from January 1, 2013 to December 31, 2023. Data were then gathered on patient VTE history, SCD pharmacologic and non-pharmacologic management, AC use and type, and potential complications of AC including heparin-induced thrombocytopenia (HIT), postpartum hemorrhage, unexpected transfusion, and admissions for bleeding. Generalized linear mixed model was applied for comparing categorical variables between two groups with clustered patient identification. Univariate (UVA) and multivariate analyses (MVA) were then applied to calculate odds ratios for the association between postpartum hemorrhage and patient characteristics. Results: There were 75 pregnancies identified amongst 59 patients during the study period and the median number of pregnancies was 2 (range 1 – 4). Median age at delivery was 28 years old (range 18 – 42). Of the 59 patients, 57 (97%) identified as Black or African American and 2 were Latina (3%). Of the 75 pregnancies, 39 were anticoagulated either during pregnancy and/or in the immediate postpartum period. There was no significant difference (p=0.63) between antiplatelet use among the AC group (n=18, 46.2%) and the non-AC group (n=14, 40.0%). Patients who had a history of VTE rates before pregnancy had a higher rate of receiving AC (n=18, 47.4%, p=0.01) than those with no VTE history. The rate of HIT was 3% (n=1) in the AC group as compared to 0% (n-0) in the non-AC group. Rates of postpartum hemorrhage in the AC versus non-AC groups were 10% (n=4) and 8% (n=3) respectively. VTE rates in the AC group were 10% (n=4) versus 0% (n=0) in the non-AC group. The VTE causes were: 1 case of postpartum line-associated deep vein thrombosis (DVT) in the setting of acute infection, 1 acute pulmonary embolism (PE) after emergency C-section, 1 acute PE in the postpartum setting after port placement, and 1 acute PE in the setting of HIT. Postpartum length of stay did not reach statistical significance with the AC group having a median length of stay of 5 days (range 2-37) as compared to 3 days (range 2-14) in the non-AC group (p=0.06). There were no maternal deaths in either group. While there was a statistically significant association between postpartum hemorrhage and unplanned transfusions in both the UVA (OR, 95% CI: 23.14, 2.12 – 252.40, p=0.01) and MVA (OR, 95% CI: 23.04, 2.08 – 255.21, p=0.01), there was no statistically significant difference between the patients who received prophylactic AC and those who did not. Conclusion: Prophylactic AC was not associated with a statistically significant increase in risk of postpartum hemorrhage, unexpected transfusion, postpartum length of stay, or an admission related to bleeding. While this may be due to the small number of patients identified, there were no major differences found in maternal outcomes between the AC and non-AC groups. The difference in VTE episodes between the groups all occurred in the setting of additional provoking factors in addition to SCD and pregnancy. The lack of significantly increased risks of AC adverse effects among the AC group further highlights the safety of prophylactic AC among pregnant people with SCD. These findings can pave the path for further exploration into prophylactic AC among pregnant and postpartum women with SCD. Limitations include changing clinical practices based on the 2018 ASH Guidelines during the study period as well as the small, retrospective nature of the study.
Roberta C. G. Azbell (Mon,) studied this question.