To address the unmet needs of pregnant women with blood disorders, last fall Duke Health opened two specialty clinics staffed by an obstetrician and hematologist who work together to treat these patients.
“Obstetricians are frequently unaware of the hematological issues involved in pregnancy and hematologists often don’t know about changes imposed by pregnancy,” says Andra H. James, MD, MPH, maternal-fetal medicine specialist, who staffs the clinics along with Laura E. Talamo, MD, hematologist. “By having an obstetrician and hematologist work together, they can provide optimal care of pregnant women with blood disorders.”
The team cares for pregnant women with immune thrombocytopenia (ITP), platelet disorders, clotting disorders, bleeding disorders, and sickle cell disease (along with the Adult Sickle Cell Center). “We provide consultation regarding hormonal use, preconception consultation, prenatal consultation, and ongoing care,” she says.
“Dr. Talamo recommends the optimal hematological treatment and I review any proposed treatment and evaluate its safety for the mother and unborn infant,” James says. “I also monitor unborn infants and plan for the delivery.”
In the past, Duke had a clinic to address the needs of women requiring anticoagulation during pregnancy, but the new joint clinics’ scope is much broader.
Advances in Treatment
For women with a history of venous thromboembolism, stroke, myocardial infarction, or peripheral arterial disease, Duke has developed protocols for safe anticoagulation during pregnancy using low molecular weight heparin. The protocols also specify that a patient should be scheduled for delivery, usually at 39 weeks gestation. Low molecular weight heparin shouldn’t be given 24 hours before the delivery process is started, and then it’s restarted 12 to 24 hours after birth depending on the delivery mode.
For pregnant women with a history of venous thromboembolism, Duke physicians follow the recently developed American Society of Hematology guidelines, which James co-authored. The guidelines recommend against converting patients to unfractionated heparin in anticipation of delivery. Duke has been preferentially maintaining patients on low molecular weight heparin in anticipation of delivery for more than five years.
For women with bleeding disorders, including inherited bleeding disorders such as von Willebrand disease or carrying the gene for hemophilia, Duke physicians not only prepare for the bleeding challenges of delivery and prescribe factor concentrate when necessary, but they also involve a genetic counselor and try to determine in advance whether an unborn baby will be affected. James also works with the Duke Sickle Cell Disease Program and Anemia Clinic when treating patients with those conditions.
Duke’s Division of Hematology is currently participating in clinical trials of treatments for ITP, sickle cell disease, venous thromboembolism, and bleeding disorders. “Due to a lack of information on safety for unborn babies, not all of these novel treatments are suitable in pregnancy,” James says. “Our job is to analyze the latest research and incorporate into practice what is safe and appropriate for pregnant women.”