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Hematology and Pregnancy: We Can Do Better

November 18, 2022
Amanda Blackmon, DO, MS, and Idoroenyi Amanam, MD

Dr. Amanda Blackmon (@mlblack1_b) returns this year after serving as a Junior Author in 2021. Originally from Gaithersburg, Maryland, she attended the University of Maryland for undergrad, earned her MS at Georgetown University, and attended medical school at the Philadelphia College of Osteopathic Medicine in Philadelphia. After her residency at Pennsylvania Hospital, Dr. Blackmon headed west for fellowships at University of California Irvine, and City of Hope National Medical Center in Duarte. She is currently an assistant professor of leukemia and hematopoietic cell transplantation at City of Hope, where she focuses on leukemia, myelodysplastic syndromes, and transplantation. She lives in Pasadena, where she is “enjoying the craziness of a dual physician family with a toddler.” Her hobbies, conveniently, mirror those of her 2-year-old: “jumping (why not?), dancing, exploring the world, lots of snacking, nap time.” Dr. Blackmon might also have a fallback career in the works. “If I wasn’t a hematologist, my dream would be to be on Broadway. It’s never too late.” True words.

Dr. Blackmon is joined by her Co-Author Dr. Idoroenyi Amanam, who is also based at City of Hope where he is an assistant professor of leukemia and hematopoietic cell transplantation, focusing on leukemia, stem cell transplantation, and myeloproliferative neoplasms. He is a triple-boarded physician with advanced fellowship training utilizing cellular and stem cell therapy to treat malignant conditions. He completed his hematology and oncology training at City of Hope, serving as chief fellow. He was then awarded the prestigious City of Hope Hematopoietic Cell Transplantation and Cellular Therapy Fellowship, with a concentration on acute leukemias and myeloproliferative neoplasms. Dr. Amanam was awarded a Congressional Award in voluntary public service, and he carries this spirit into the clinic. “I believe in treating all my patients with compassion and utilizing intellectual curiosity to tailor my treatment approaches,” he shared. He also believes he was chosen to enter this field as he had a loved one who struggled with cancer and lived years longer than expected thanks to compassionate care by the doctors and nurses.

     

Scrolling through the electronic medical record and seeing that your next consult is pregnant and also has a hematologic disorder may leave many of us intrigued, and terrified. Being asked to write this piece, my initial reaction was that I did not want to take on such a large, important, personal, and emotional topic that I am not entirely comfortable with — which is exactly why this subject needs to be addressed. ASH published a policy statement in June 2022 on “The Right to Maternal Health Care.” According to the statement, maternal deaths have been increasing in the United States since 2000, estimated at 20.1 per 100,000 live births in 2019. That number is doubled for non-Hispanic Black women. “Approximately two-thirds of the 700 pregnancy-related deaths are considered preventable,” the statement reads. It’s time to take a closer look.

Thrombosis and hemorrhage during pregnancy and postpartum are two of the top five causes of death in pregnant women. Women with inherited blood disorders such as sickle cell disease or thalassemia, as well as those with hematologic malignancies, are at higher risk for these complications. These maternal conditions can also impact fetal health. While many hematologists are seeing these patients, only a select few specialize in pregnancy, making this an underserved group with a particular need. We need to talk about prevention and management for these patients to achieve successful pregnancies, and we must talk about access to care when these pregnancies cannot be safely carried to term. Per the ASH policy statement, “Access to evidence-based medical information and lifesaving medical options [procedures and treatments], including termination of a pregnancy, is a maternal right.”

The ASH annual meeting will begin with a “Hematology and Pregnancy” Scientific Workshop on Friday, December 9, which will review the physiologic and hematologic changes during pregnancy and cover topics such as stroke/vascular disorders in those with underlying conditions (including antiphospholipid antibody syndrome or vascular malformations), COVID-19–related long-term complications with placentopathy, and management of platelet disorders in women of reproductive age.

A Special-Interest Session on “Maternal Health in Hematology” held on Monday, December 12, will address current resources and future advocacy. Dr. Mikkael Sekeres, Chief of Hematology at Sylvester Comprehensive Cancer Center, will be one of the speakers. “As physician specialists, we have the privilege of being welcomed into our patients’ lives when they are at their most vulnerable,” he stated. “With that comes the responsibility to also be their health advocates at the individual, regional, and national level. This session provides insight into how that can be accomplished.” Dr. Sekeres will be discussing how to effectively write essays as a form of advocacy, and the impact physician-writers can have in the lay press.

As we delve into the topic, each hematologic malignancy will have nuances in how to manage the disease, as well as dilemmas with treatment and fertility. At this year’s meeting, chronic myeloid leukemia (CML) and pregnancy is highlighted. During the session titled “Chronic Myeloid Leukemia: Clinical and Epidemiological: Longer Term Response, TFR, Pregnancy, and Disparities,” taking place Sunday from 4:30 to 6:00 p.m., Dr. Ekaterina Yu Chelysheva from the National Medical Research Center for Hematology will discuss promising results on outcomes in patients with CML diagnosed during pregnancy from the ELN International Pregnancy Registry. In the Education Program session “Beyond Routine Frontline Therapy of CML,” happening Sunday from 4:30 to 5:45 p.m., Dr. Jane Apperley from Hammersmith Hospital will discuss CML treatment in planned and unplanned pregnancies. “In general, tyrosine kinase inhibitors might harm a developing fetus and should be avoided in the first and second trimesters,” said Dr. Apperley, describing many situations in which those with chronic-phase CML can achieve successful pregnancies. She does acknowledge, however, that many situations are not that easy. “Special consideration should be given to older women who might not want to wait for several years to obtain responses before becoming pregnant and to those who have had problems conceiving in the past.”

This year at the annual meeting, pregnancy and sickle cell disease will be a focal point. Pregnancy in women with sickle cell disease is a life-threatening condition, and the Education Program session “Obstetric Management in Sickle Cell Disease in High and Low Income Countries” (Sunday, 4:30 p.m.-5:45 p.m.) will describe the benefit of multidisciplinary obstetric care and the improvement in mortality seen in this setting. The challenges faced in lower income countries significantly impacted by sickle cell anemia and current management strategies used to reduce morbidity and mortality with limited resources will be discussed. The oral session “Hemoglobinopathies, Excluding Thalassemia: Clinical and Epidemiological: Women's and Clinical Issues” (Monday, 2:45 p.m.-4:15 p.m.) will cover important issues such as management of hypertension in pregnant patients with sickle cell disease, oral contraception in this population, and whether or not sickle cell trait discovered in the 23andMe cohort is associated with venous thromboembolism.

Lastly, the ubiquitous thrombocytopenia consult will be dissected during the Education Program session "Managing Thrombocytopenia in Challenging Situations," which takes place Sunday, from 4:00 p.m. to 5:15 p.m. Dr Allyson Pishko from the University of Pennsylvania will discuss the various etiologies ranging from benign gestational thrombocytopenia to life-threatening conditions. “With many advances in the treatment of classical hematologic disorders like immune thrombocytopenia and thrombotic thrombocytopenic purpura,” she stated, “it has become increasingly important to form strong working relationships with our maternal-fetal medicine colleagues to provide appropriate preconception counseling and support these patients throughout pregnancy.”

The first way to make a change is to become informed, and this year, ASH is helping us do just that.

Dr. Blackmon and Dr. Amanam indicated no relevant conflicts of interest.

About the Authors: Dr. Amanda Blackmon (@mlblack1_b) returns this year after serving as a Junior Author in 2021. Originally from Gaithersburg, Maryland, she attended the University of Maryland for undergrad, earned her MS at Georgetown University, and attended medical school at the Philadelphia College of Osteopathic Medicine in Philadelphia. After her residency at Pennsylvania Hospital, Dr. Blackmon headed west for fellowships at University of California Irvine, and City of Hope National Medical Center in Duarte. She is currently an assistant professor of leukemia and hematopoietic cell transplantation at City of Hope, where she focuses on leukemia, myelodysplastic syndromes, and transplantation. She lives in Pasadena, where she is “enjoying the craziness of a dual physician family with a toddler.” Her hobbies, conveniently, mirror those of her 2-year-old: “jumping (why not?), dancing, exploring the world, lots of snacking, nap time.” Dr. Blackmon might also have a fallback career in the works. “If I wasn’t a hematologist, my dream would be to be on Broadway. It’s never too late.” True words.

Dr. Blackmon is joined by her Co-Author Dr. Idoroenyi Amanam, who is also based at City of Hope where he is an assistant professor of leukemia and hematopoietic cell transplantation, focusing on leukemia, stem cell transplantation, and myeloproliferative neoplasms. He is a triple-boarded physician with advanced fellowship training utilizing cellular and stem cell therapy to treat malignant conditions. He completed his hematology and oncology training at City of Hope, serving as chief fellow. He was then awarded the prestigious City of Hope Hematopoietic Cell Transplantation and Cellular Therapy Fellowship, with a concentration on acute leukemias and myeloproliferative neoplasms. Dr. Amanam was awarded a Congressional Award in voluntary public service, and he carries this spirit into the clinic. “I believe in treating all my patients with compassion and utilizing intellectual curiosity to tailor my treatment approaches,” he shared. He also believes he was chosen to enter this field as he had a loved one who struggled with cancer and lived years longer than expected thanks to compassionate care by the doctors and nurses.

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