Prostaglandins safe in pregnant patients with sickle cell disease

Prostaglandins safe in pregnant patients with sickle cell disease | Image Credit: © extender_01 - © extender_01 - stock.adobe.com.

Prostaglandin use to induce labor or treat postpartum hemorrhage (PPH) is safe in patients with sickle-cell disease, according to a cohort study published in Pregnancy.¹

Complications of sickle-cell disease include acute chest syndrome, vaso-occlusive crises, venous or arterial thromboembolisms, and chronic kidney, heart, and chest syndrome. These complications are exacerbated by pregnancy, indicating a need for close monitoring of pregnant patients with the condition.²

“Prostaglandins… are commonly used to induce labor,” wrote investigators.¹ “However, there is concern that prostaglandins may increase the risk of vaso-occlusive crisis.”

Assessing prostaglandin outcomes

The retrospective cohort study was conducted to assess the risk of vaso-occlusive crisis in pregnant patients with sickle cell disease taking prostaglandins. Pregnancies with sickle cell disease between January 1, 2009, and June 30, 2020, in the databases of 10 French centers were included in the analysis.

In the first of 3 analyses, populations exposed to any prostaglandin were compared to those unexposed. In the second analysis, those exposed to labor induction were compared to those unexposed. Finally, those exposed to PPH treatment were compared to controls.

A recorded acute complication was reported as the primary outcome of the analysis, while secondary outcomes included needing intravenous morphine for vaso-occlusive crises and crises leading to intensive care unit admission. Maternal, pregnancy, delivery, and neonatal characteristics were collected alongside sickle-cell disease variables.

Prostaglandins used and patient demographics

PGE2 analog dinoprostone and PGE1 analog misoprostol were common prostaglandins used for the induction of labor. For PPH, the PGE2 analog intravenous sulprostone is recommended by French guidelines.

There were 411 pregnancies included in the final analysis, 61.1% of which were complicated by S/S sickle-cell disease, 27% by S/C, and 11.7% by S/ß-thalassemia. Severe disease was reported in more than 50% of cases, and at least 1 vaso-occlusive crisis in 55.5%.

Morphine was required in 39.4% of cases, transfusion in 60.7%, and hospitalization in intensive care in 11.9%. While no maternal death cases were reported, there were 12 cases of fetal demise and 1 case of neonatal death.

Older age and increased nulliparity prevalence were reported in patients receiving prostaglandins vs those unexposed. However, the odds of prior cesarean delivery, having a thromboembolic event before or during pregnancy, receiving low-dose aspirin, and having preeclampsia were reduced in this population.

No difference in outcomes from prostaglandins

Vaso-occlusive crisis rates did not significantly differ between patients exposed vs unexposed to prostaglandins, at 12.2% vs 11.6%, respectively. Rates of intensive care unit admission and intravenous morphine use also did not significantly differ between groups.

Vaginal deliveries were more common in the exposed group vs the unexposed group, with rates of 56.1% and 31.4%, respectively. Additionally, failed induction was more often the indication for cesarean delivery in these patients, at 20.1% vs 5.4% in unexposed patients. Mean gestational ages at delivery were 37.7 vs 36.7 weeks, respectively.

Sickle-cell disease was the indication for induction of labor in 44.5% of patients. Prostaglandins were used in 57.9% of inductions, but vaso-occlusive crisis rates were similar between exposed and unexposed individuals, at 11.6% vs 7.2%, respectively. Secondary and obstetrical outcomes were also similar between groups.

PPH outcomes and conclusions

PPH was reported in 14.6% of patients, and severe PPH in 5.8%. Sulprostone was provided to 18.3% patients with PPH, and rates of the primary and most secondary outcomes did not differ between those exposed vs unexposed. However, blood transfusions were more common in women receiving sulprostone.

Overall, the results indicated no association between prostaglandin use in pregnancy and severe complications of sickle-cell disease. Investigators concluded prostaglandins are safe for use in pregnant women with sickle-cell disease.

“Further large-scale prospective multicentric studies are necessary to explore the impact of specific prostaglandin drugs, particularly misoprostol,” wrote investigators.

References

1. Gnofam M, Sibiude J, Affo L. Safety of prostaglandins in the peripartum period in case of sickle-cell disease: A multicenter cohort study. Pregnancy. 2025. doi:10.1002/pmf2.70014
2. Society for Maternal-Fetal Medicine; Sinkey RG, Ogunsile FJ, et al. Society for Maternal-Fetal Medicine Consult Series #68: Sickle cell disease in pregnancy. Am J Obstet Gynecol. 2024;230(2):B17-B40. doi:10.1016/j.ajog.2023.10.031