91¹ú²ú¾«Æ·

Maternal deaths have been increasing in the United States since 2000. According to the Centers for Disease Control and Prevention (CDC), the maternal mortality rate was 20.1 per 100,000 live births in the United States in 2019. The corresponding number for non-Hispanic Black women was more than double that rate, at 44 deaths per 100,000. (1) Nearly two-thirds of the 700 pregnancy-related deaths that occur are considered preventable.

There is a close connection between hematology and maternal health, given the risks of hematologic complications of pregnancy for all women. Hemorrhage and venous thromboembolism are two of the top five causes of death in pregnant women. (2) Postpartum hemorrhage is a leading cause of morbidity and mortality in the United States, (3) and women on anticoagulants or with anemia are at high risk of postpartum hemorrhage. (4) Furthermore, women with inherited bleeding disorders have a risk of having a child with a bleeding disorder which impacts both their own care during delivery (mode of delivery) and may carry long-term implications for their child if affected. (5)

Additionally, women with anemia, women on blood thinners to control blood clots, women with blood cancer, and women with sickle cell disease (SCD) are especially at high risk of pregnancy related complications including death. In fact, women with SCD are 10 times more likely to die in childbirth than Black women without SCD. (6,7)

It is in this light that the 91¹ú²ú¾«Æ· (ASH) makes the following statement in support of the right to maternal life and well-being:

• Maternal health can be adversely impacted by hematologic diseases and disorders
• Termination of a pregnancy is an important clinical consideration when the mother is at risk for serious health complications and/or death
• Access to evidence-based medical information and lifesaving medical options [procedures and treatments], including termination of a pregnancy, is a maternal right

The following clinical cases in hematology are some of the diverse reasons that women may need access to medical abortion and demonstrate the right to maternal health in hematology:

• SCD is a high-risk maternal condition. Some patients may not be able to safely continue pregnancy due to complications of SCD such as severe alloimmunization, strokes, or heart failure. In these cases, it is important for the hematologist to be able to discuss and to offer medically necessary termination of a pregnancy with the individual. 
• Individuals with SCD are at extremely high risk of hypertensive pregnancy complications (i.e. eclampsia). Such conditions may further worsen underlying kidney disease and lead to kidney failure, a leading cause of death in people with SCD. Termination of a pregnancy can help preserve kidney function and the life of the mother. 
• Blood cancers, such as acute leukemia or lymphoma are highly curable cancers. When they are diagnosed during pregnancy, these diseases represent a profound risk to maternal health. Chemotherapy given in the first trimester is associated with fetal abnormalities and pregnancy loss that poses a significant risk of life-threatening infection and/or hemorrhage to the mother. (8,9) Termination of the pregnancy allows a woman to proceed with potentially lifesaving cancer therapy. For women with acute leukemia in the first trimester, termination of a pregnancy is recommended. (10)

Clinical consultations with evidence-based information to prevent severe, lasting hematologic complications and to protect the life of the mother are critical. The relationship between the physician and patient, including the ability for physicians to offer medically appropriate and life-saving treatments, including termination of a pregnancy, must be protected and preserved.

Finally, ASH understands the importance of having individuals with diverse perspectives and experiences in all areas of the field and has a long-standing commitment to combating inequities in hematology, supporting scientists and clinicians from backgrounds underrepresented in medicine, and embracing diverse voices across the patient and health care communities. This includes our own members in hematology, who may have children later in life. These women face higher infertility and secondary risk of pregnancy complications, as upwards of 24% of physicians are affected by infertility, double the national average. (11,12) In situations where fertility procedures are required, selective reduction is often performed for safety of mother and child.

No woman should face legal ramifications for childbearing decisions. The right to maternal life and well-being for our members and the patients they serve, must not be denied.

References

1) Hoyert DL. Maternal mortality rates in the United States, 2019. NCHS Health E-Stats. 2021. doi: 10.15620/cdc:103855.

2) Main, E. K., McCain, C. L., Morton, C. H., Holtby, S., & Lawton, E. S. (2015). Pregnancy-related mortality in California: causes, characteristics, and improvement opportunities. Obstetrics and gynecology, 125(4), 938–947. https://doi.org/10.1097/AOG.0000000000000746

3) Reale, S. C., Easter, S. R., Xu, X., Bateman, B. T., & Farber, M. K. (2020). Trends in Postpartum Hemorrhage in the United States From 2010 to 2014. Anesthesia and analgesia, 130(5), e119–e122. https://doi.org/10.1213/ANE.0000000000004424

4) Nyfløt, L. T., Sandven, I., Stray-Pedersen, B., Pettersen, S., Al-Zirqi, I., Rosenberg, M., Jacobsen, A. F., & Vangen, S. (2017). Risk factors for severe postpartum hemorrhage: a case-control study. BMC pregnancy and childbirth, 17(1), 17. https://doi.org/10.1186/s12884-016-1217-0

5) James AH, Jamison MG. Bleeding events and other complications during pregnancy and childbirth in women with von Willebrand disease. J Thromb Haemost. 2007;5(6):1165-1169. doi:10.1111/j.1538-7836.2007.02563.x

6) Oteng-Ntim E, Meeks D, Seed PT, et al. Adverse maternal and perinatal outcomes in pregnant women with sickle cell disease: systematic review and meta-analysis. Blood. 2015 May 21;125(21):3316-3325. doi: 10.1182/blood-2014-11-607317. ePub 2015 Mar 23. PMID: 25800049.

7) Villers MS, Jamison MG, De Castro LM, James AH. Morbidity associated with sickle cell disease in pregnancy. Am J Obstet Gynecol. 2008 Aug;199(2):125.e1-e5. doi: 10.1016/j.ajog.2008.04.016. ePub 2008 Jun 4. PMID: 18533123.

8) Farhadfar, N., Cerquozzi, S., Hessenauer, M. R., Litzow, M. R., Hogan, W. J., Letendre, L., Patnaik, M. M., Tefferi, A., & Gangat, N. (2017). Acute leukemia in pregnancy: a single institution experience with 23 patients. Leukemia & lymphoma, 58(5), 1052–1060. https://doi.org/10.1080/10428194.2016.1222379

9) Sanz, M. A., Grimwade, D., Tallman, M. S., Lowenberg, B., Fenaux, P., Estey, E. H., Naoe, T., Lengfelder, E., Büchner, T., Döhner, H., Burnett, A. K., & Lo-Coco, F. (2009). Management of acute promyelocytic leukemia: recommendations from an expert panel on behalf of the European LeukemiaNet. Blood, 113(9), 1875–1891. https://doi.org/10.1182/blood-2008-04-150250

10) Shapira, T., Pereg, D., & Lishner, M. (2008). How I treat acute and chronic leukemia in pregnancy. Blood reviews, 22(5), 247–259. https://doi.org/10.1016/j.blre.2008.03.006

11) R. Fertility and Childbearing Among American Female Physicians. J Womens Health (Larchmt). 2016 Oct;25(10):1059-1065. doi: 10.1089/jwh.2015.5638. Epub 2016 Jun 27. PMID: 27347614.

12) Marshall, Ariela L. MD; Arora, Vineet M. MD, MAPP; Salles, Arghavan MD, PhD Physician Fertility: A Call to Action, Academic Medicine: May 2020 - Volume 95 - Issue 5 - p 679-681 doi: 10.1097/ACM.0000000000003079