PREGNANCY OUTCOMES IN WOMEN WITH SICKLE CELL DISEASE AT A TERTIARY HOSPITAL IN NIGERIA: A FIVE-YEAR RETROSPECTIVE STUDY

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T.A. Olukunle¹, O.O. Ogunbode², R.A. Abdus-salam²

1. Department of Obstetrics and Gynaecology, University College Hospital, Ibadan Nigeria.
2. Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Nigeria.

Abstract

Background: Sickle cell disease (SCD) in pregnancy constitutes a high-risk pregnancy, associated with increased risk of adverse outcomes. Objective: To describe the outcome of pregnancy in SCD women managed at the University College Hospital, Ibadan, Nigeria.

Materials and Methods: A retrospective review of the health records of sixty-three SCD pregnant women managed between January 1, 2016 and December 31, 2020. The information extracted included sociodemographic and obstetric characteristics, clinical presentations, mode of delivery, maternal and fetal outcomes. The data was analyzed using the IBM Statistical SPSS Statistics for Windows, version 23.0. Test of association was done using Chi-square and level of significance was p<0.05. Results: Prevalence of SCD in pregnant women was 0.65%. Mean age was 28.8±4.1years, 63.5% were haemoglobin SS while 36.5% were haemoglobin SC. Most of the women had tertiary education (61.8%) and booked for antenatal care (ANC) (60%). About 72.4% delivered at term while 46.1% had caesarean delivery. Most common complication was anaemia (79.4%) while vaso-occlusive crisis was the most common type of crisis (55.6%). Most of the women (92.5%) had livebirth with 15.2% of neonates requiring Neonatal Intensive Care Unit (NICU) admission. Maternal death rate was 6.3%. Good maternal and fetal outcomes occurred in 71.4% and 61.9% of participants respectively. Good maternal outcome was significantly associated with tertiary education(p=0.01). Good fetal outcome was associated with tertiary level of education(p=0.04) and multigravida status(p=0.03).

Conclusion: SCD pregnant women have good fetal-maternal outcomes, however not receiving ANC and lower level of education were associated with poor pregnancy outcomes. Health education, access to ANC, prompt diagnosis, treatment of complications and multi-disciplinary team management will improve the pregnancy outcomes.

Keywords: Fetal outcome, Maternal outcome, Haemoglobinopathy, Sickle cell disease in pregnancy

Introduction

Sickle cell disease (SCD) in a pregnant woman constitutes a high-risk pregnancy, with associated increased risk of adverse fetal and maternal outcomes. SCD is a single gene disorder with point mutation that affects the globin chain of the red blood cell.^1,2 SCD is most prevalent in malaria endemic areas in the tropics where outcomes are often poor due to resource constraints.³

Globally, an estimated 3.2 million people are living with SCD, and an additional 43 million are estimated to have sickle cell trait^.3,4 About 5-7% of the world
population carries an abnormal haemoglobin gene and SCD is found in one in every 500 Africans.⁵ A study done in Benin city, Nigeria, revealed a SCD prevalence of 2.39% and a carrier rate of about 23%.⁶ It is estimated that over 80% of over 300,000 annual births of children with SCD occur in sub-Saharan Africa, with largest burden from Central Republic of Congo.⁴ The term SCD comprises of a spectrum of disorders such as haemoglobin SS(HbSS), haemoglobin SC(HbSC) and haemoglobin S beta thalassemia (HbS betao or Hb S beta+). Haemoglobin AS (HbAS) or haemoglobin AC (HbAC), are benign conditions that have no specific antenatal sequelae.1 The polymerization of the abnormal haemoglobin in low-oxygen conditions in a SCD patient leads to the formation of rigid and fragile sickle-shaped red cells, and eventually resulting in myriads of clinical complications.^1,2

In Nigeria, the prevalence of SCD among pregnant women is 0.14-1.16%7 and in newborns about 20-30 per 1000 live births.6,8 Low- and middle-income countries (LMIC) are resource poor countries with documented high maternal and perinatal morbidity and mortality, which are also much higher in association with SCD. These have been attributed to the poor health seeking behaviors, low literacy rate, widespread poverty as well as poor infrastructure and dysfunctional health care service delivery.6,8

Pregnancy in SCD women is associated with increased risk and incidence of complications due to the stress posed by the pregnancy and the aggravated physiological changes of pregnancy. ^4,7 These complications may be maternal or fetal or both and could occur during the antenatal, intrapartum, or postpartum period. Commonly documented complications include anaemia, vaso-occlusive crisis, malaria infection, acute chest syndrome, pseudo-toxaemia, haemolytic crisis, aplastic crisis, pre eclampsia, miscarriage, intrauterine growth restriction (IUGR), low birth weight (LBW) infants, stillbirths, and increased risk of operative delivery among others.^7,9

With improved care of the individuals living with SCD, women with HbSS and HbSC constitute an increasing population of pregnant women attending antenatal care (ANC). These women now live longer than in time past due to improved knowledge of the disease, newer therapies and multi-disciplinary care, therefore periodic review to assess the presentation, risk factors or complications in pregnancy, outcomes in pregnancy and identification of areas for improvement is imperative. The University College Hospital (UCH), Ibadan, Nigeria, is a tertiary health facility, staffed with multi-disciplinary specialist and a referral centre for SCD patients including pregnant women.

This study was therefore designed to review the clinical presentation, complications, maternal and fetal outcomes in pregnant SCD women.