Thalassemia Effects on Pregnancy

Thalassemia Effects on PregnancyThalassemia is the most common hereditary disease in Iran and more than than 2 million carriers of the thalassaemia mutant gene are living in this country.Material methods In this retrospective, causal agency-control plain, all pregnancies occurred between 2006 and 2008 were included. Patients were dissever in two separates regarding the presence of - thalassemia. Patients in case and control classs were matched according to maternal age, gestational age and number of previous pregnancies. Cesarean delivery, hypertensive disorders, gestational diabetes mellitus, immature rupture of membranes and preterm labor were recorded in each group and were compared using the 2 or Fisher exact tests.Results Overall 510 -thalassemia subjects and 512 healthy controls were studied. cases with -thalassemia had significantly higher(prenominal) prevalence of oligohydramnios (P Conclusion -thalassemia does not influence the motherliness outcome in the negative w ay significantly.Keywords Minor -thalassemia, Pregnancy outcome, gestational diabetes mellitus OligohydramniosIntroductionThe prevalence and hardness of the thalassemia syndromes are population dependent.(1) Thalassemia tiddler results in a variable degree of the disease but, depending on the rate of -chain production, usually presents as asymptomatic anemia of mild degree(2)-thalassemia is the most common hereditary disease in Iran and more than 2 million carriers of the -thalassemia mutant gene are living in this country. About 110 mutant genes have been recognized all over the world of which 21 have been identified in the Iranian population. The mutant genes and their frequencies turn greatly in different parts of Iran Prevalence of thalassemia minor among Iranian is about 7%. (3)-thalassemia minor represents the heterozygous state. In general, a heterozygote for thalassemia is diagnosed owing to the patient presenting with a mild anemia ( haemoglobin A level 1 or 2 g below normal range), low inculpate cell volume, low mean corpuscular hemoglobin, elevated hemoglobin A2, and normal or elevated hemoglobin F. During maternalism, women with thalassemia minor will often return more significant anemia, which is often most prominent during the latter half of the second trimester and early tercet(4,5,6,7).Thalassemia syndromes constitute a group of inherited hemoglobinopathies that inquire close maternal and foetal surveillance during motherhood, including appropriate consultation with maternal fetal medicine and hematology specialists. Even for the women who are asymptomatic before pregnancy the added stresses of pregnancy on the hematopoietic system can cause deterioration of maternal status. Health guard providers must appreciate that the more severe the thalassemia syndrome the more significant the consequences for both woman and fetus.(4) The impaired globin synthesis impairs oxygen transport and delivery to tissues, placental bed, and fetus beca use of modified hemoglobin-oxygen binding. Furthermore, in more severe disease states, the accumulation of contract stores in vital maternal organ systems can lead to chronic organ dysfunction, such as cardiomyopathy and diabetes. These women must be monitored closely for worsening anemia and the development of pregnancy-associated complications (8).Because of high prevalence of -thalassemia in Iran and its possible effects on pregnancy outcome and limited study about this problem. we performed this retrospective case-control study to investigate pregnancy outcome of patients with minor -thalassemia referring to Hafez Hospital of Shiraz University of medical exam Sciences between 2006 and 2009. These results can alert health care providers to take more care about thalassemia and pregnancy.Methods and materialThis study was a case-control one which included all the pregnancies (7290) referring to Hafez Hospital of Shiraz University of Medical Sciences between 2006 and 2008. The patients were divided into two groups regarding the presence of -thalassemia. Patients in case and control groups were matched according to maternal age, gestational age and number of previous pregnancies. The study was approved by Shiraz University of Medical Sciences ethical committee and all the patients gave their written consents. The data was collected by a means of a questionnaire. Overall 510 -thalassemia subjects and 512 healthy controls were enrolled in the study. Only women with singleton pregnancy were included. Patient with recurrent abortions (2 or more consecutive pregnancies resulting in spontaneous abortion), tale of neural tube defect in previous pregnancies, history of infertility, history of any medical problem, undelivered in this center or mean follow-up visits slight than three times were excluded. Follow-up intervals in case and control groups were similar.Gestational age was calculated from the first day of last menstrual period or according to the sonogra phy which was performed in the first months of pregnancy. Anemia was nail downd on the basis of hemoglobin less than 10 mg/dl. Anemia evaluation was performed in all the cases. Complete blood count (CBC), Iron studies (iron, total iron binding capacity) were performed for excluding iron deficiency anemia and the anemia of chronic disorders. Thalassemia was diagnosed according to CBC and standard hemoglobin electrophoresis criteria in the first trimester an face lift of Hb A2 (equal or more than 3.5%) demonstrated by electrophoresis and column chromatography confirms the diagnosis of -thalassemia trait. Blood transfusions were given only when hemoglobin (Hb) dropped significantly (less than 7mg/dl)either due to pregnancy or any other causes. Hemoglobin increased at least to 10 mg/dl with transfusion.(According ACOG criteria(9) Folate supplement in each group (case control) was given 1mg orally daily.In the study period each patient was evaluated for maternal age, parity, gestation al age, maternal anemia during pregnancy (hemoglobin less than 10 g/dL) and put up weight. Poor pregnancy outcomes or complications included hypertensive disorders, gestational diabetes mellitus, premature rupture of membranes (rupture of membrane under 37 weeks gestational age ) and preterm labor.(labor annoying under 37 weaks of gestational age) Hydramnios ( amnic fluid index more than 24 cm), oligohydramnios (amniotic fluid index 5 cm or less) and intrauterine growth childbed (IUGR) (when intrauterine growth under 10% by serial sonography especially in third trimester of pregnancy)were also evaluated using sonography in the third trimester. Labor and perinatal outcome included placental breaking off, meconium-stained amniotic fluid, caesarean section delivery, Apgar score at 1 and 5 minutes less than 7, perinatal mortality, postpartum hemorrhage, and maternal packed-cell transfusions, neonatal ICU ad set downion.Statistical analysis was performed with the SPSS package. Stati stical significance was calculated by using the 2 or Fisher exact test. A multivariate logistic regression model, with backward elimination, was constructed to find independent risk factors associated with maternal -thalassemia minor. Odds ratios (ORs) and their 95% confidence intervals (CIs) were computed. A value of P less than 0.05 was considered statistically significant.ResultsWe recorded 510 alive-births and 7 (1.4 %) stillbirths in case and 512 alive births and 5 (1%) stillbirths in control group. The Hb A2 level in our cases usually was approximately 4-6%. service line characteristics of subjects in two study groups are shown in Table 1. There was no statistically significant difference between these groups regarding these baseline characteristics.There was no significant difference between these groups regarding pregnancy hypertension and gestational DM (Table 2). Polyhydramnios (AFI24cm) was observed in 1.4% of cases and 1.9% of control group while oligohydramnios was obse rved in 10.8% of case and 5.4% of control group (P=0.001, Table 2). Regarding the perinatal complications, 3.1% of case group and 1.5% of control group developed IUGR (P=0.073). Cesarean delivery was significantly more common in case group than control group (38.3% vs 26.5% P=0.001, Table 3). There was no significant difference between two groups regarding the Apgar score in initiative (P = 0.65) and 5th minute (P = 0.25), ICU admissions (P = 0.17) and placental abruption (P = 0.42).Using a multiple logistic regression model of risk factors for minor -thalassemia, oligohydramnios, placental abruption and meconium-stained amniotic fluid were significantly associated with cesarean delivery (Table 4).ConclusionThalassemia syndrome is very common in Iranian population. This case-control study was performed on patients with minor -thalassemia to determine the maternal and fetal outcomes and describe most risk factors associated with -thalassemia minor during pregnancy. This study consis ting 517 minor -thalassemia subjects is one of the biggest studies of its kind in Iran. Perinatal mortality (P=0.38) and Apgar score at 1min (P=0.65) and 5 min (P=0.25) after delivery were similar in patients with and without minor -thalassemia minor. This is consistent with previous studies (9-13).Thalassemia has been associated with an increased incidence of obstetrical complications (14). Adverse pregnancies outcomes spy in these case series, especially low birth weight (Wt Chronic maternal anemia during gestation might lead to fetal hypoxia, predisposing the fetus to IUGR (1,14). Thus, it was suggested that hemoglobin concentration should be maintained above 10 g/dL during these pregnancies (15). No significant association was found between hemoglobin levels and IUGR among thalassemic women in Eyal Sheiner and colleagues study and suggested that a different mechanism is responsible for IUGR in thalassemia minor patients (16).At least one study showed acute splenic infarct in t halassemia minor .(18).this mechanism may cause placental infarction but this theory needs further study to be approve.In other study all adhesion molecules and CRP (C-reactive protein) increased in patients with thalassemia intermediate (19) .so this molecules and inflammation may cause placental insufficiency in thalassemia minor but more study is needeSheiner and associates (2004) reported that oligohydramnios were increased twofold in 261 affected women. In our study oligohydramnios was found in 10.8% of case and 5.4% of control group (PWe found no statistically significant difference in the pregnancy outcome, preterm delivery, birth weight, growth restriction, pregnancy induced hypertension and gestational diabetes between thalassemic and non thalassemic patients. all(prenominal) studies investigating pregnancy outcome of patients with -thalassemia found higher rates of cesarean delivery (11,14,15,17). Likewise, in our study we found significantly higher rates of cesarean de livery.By using a multiple logistic regression model of risk factors for minor thalassemia, the following conditions were significantly associated with cesarean delivery oligohydramnios, abruption and meconium-stained amniotic fluid. However, IUGR was not statistically independent risk factor for cesarean delivery, unlike previous study that cesarean birth due to fetal distress colligate to fetal growth restriction (13).In conclusion, Hemoglobinopathies can be associated with a variety of effects on the mother, fetus or newborn. The effects range from absence seizure of clinical disease to severe morbidity and death. Through the obstetrician-gynecologists high index of suspicion based on clinical history and a close operative relationship with a consultant hematologist, pregnancy outcome in patients with these disorders can be improved.Since most hemoglobinopathies are inherited as autosomal recessive conditions, screening, counseling, and antepartum diagnosis are important compon ents of prenatal care for these women. Thalassemia syndrome, including minor -thalassemia during pregnancy can present unique management challenges and requires close maternal and fetal surveillance. The course of pregnancy of patients with -thalassemia minor, including perinatal outcomes, is favorable. In spite of an attempt to keep hemoglobin levels above 7.0g/dl, the incidence of fetal growth restriction and preterm birth has been relatively high, though maternal complications are rather not different from general. Care for such pregnancies should be multidisciplinary, incorporating a maternal-fetal medicine specialist, a genetic counselor, and a hematologist. However, since fetal growth restriction complicates more pregnancies with thalassemia syndrome, the need for close antenatal follow-up and frequent sonographic assessment of fetal growth can be overemphasized.Further prospective studies among high-risk populations for -thalassemia with larger sampling should investigate the efficacy of such surveillance programs. The American College of Obstetricians and Gynecologists recommends screening for -thalassemia in couples of Mediterranean ancestry.We might miss some pregnant ladies with minor thalassemia and normal hemoglobin who were included in control group.