Outcome of Pregnancy and Disease Course among Women with Aplastic Anemia Treated with Immunosuppression

Outcome of Pregnancy and Disease Course among Women with Aplastic Anemia Treated with Immunosuppression

André Tichelli, MD;
Gérard Socié, MD, PhD;
Judith Marsh, MD;
Renée Barge, MD;
Norbert Frickhofen, MD;
Shaun McCann, MD;
Andrea Bacigalupo, MD;
Jill Hows, MD;
Pedro Marin, MD, PhD;
David Nachbaur, MD;
Argiris Symeonidis, MD;
Jakob Passweg, MD;
Hubert Schrezenmeier, MD; and
for the European Group for Blood and Marrow Transplantation Severe Aplastic Anaemia Working Party*

From University Hospitals Basel, Basel, Switzerland; Hôpital St. Louis, Paris, France; St. George's Hospital, London, and Bristol Haematology and Oncology Centre, Bristol, United Kingdom; Dr. Horst-Schmidt-Kliniken, Wiesbaden, and Freien Universität Berlin, Berlin, Germany; St. James Hospital, Trinity College, Dublin, Ireland; Ospedale San Martino, Genoa, Italy; Instituto de Investigaciones Biomédicas Agustí Pi Sunyer, Barcelona, Spain; University Hospital Innsbruck, Innsbruck, Austria; and Patras University Medical School, Patras, Greece.

Abstract

Background: Aplastic anemia may develop during pregnancy and sometimes improves spontaneously after delivery. The effects of pregnancy on aplastic anemia after immunosuppressive treatment and of aplastic anemia on the outcome of pregnancy have not been described.

Objective: To determine the outcome of pregnancy and the disease course among women with aplastic anemia who received immunosuppressive therapy.

Design: Retrospective multicenter study.

Setting: Twelve centers participating in the European Group for Blood and Marrow Transplantation.

Patients: 36 women who received immunosuppressive therapy to treat aplastic anemia.

Measurements: Outcomes of pregnancy and aplastic anemia and blood counts before, during, and after delivery.

Results: The 36 pregnancies resulted in 34 live births (one set of twins), 2 elective abortions, and 1 spontaneous abortion. Of the 36 pregnancies, 22 were uncomplicated and 14 involved medical complications. Seven pregnancies (19%) were complicated by relapse of aplastic anemia, and 5 patients without relapse (14%) needed transfusions during delivery. After delivery, 3 of the 7 patients who had relapse recovered spontaneously and 3 recovered after retreatment. One patient who did not respond to treatment died of aplastic anemia. A woman with aplastic anemia and paroxysmal nocturnal hemoglobinuria had a fatal cerebral thrombosis after delivery. Women with uneventful pregnancies had better prepregnancy remission status (8 complete and 11 partial remissions) and a higher median platelet count (146 × 10⁹ cells/L) than did women with complicated pregnancies (2 complete remissions, 8 partial remissions, and 4 cases of paroxysmal nocturnal hemoglobinuria; median platelet count, 92 × 10⁹ cells/L).

Conclusions: Successful pregnancy with normal outcome is possible in women with aplastic anemia previously treated with immunosuppression. Complications appear to be more likely in patients with low platelet counts and paroxysmal nocturnal hemoglobinuria–associated aplastic anemia.

*For a list of centers that participated in the Study of the European Group for Blood and Marrow Transplantation Severe Aplastic Anaemia Working Party, see Appendix.

Article and Author Information

Acknowledgments: The authors thank the study patients and their referring physicians. They also thank Alois Gratwohl for critical review of the manuscript.
Requests for Single Reprints: André Tichelli, MD, University Hospitals Basel, Hematology, Petersgraben 4, CH-4031 Basel, Switzerland.
Current Author Addresses: Drs. Tichelli and Passweg: University Hospitals Basel, Hematology, Petersgraben 4, CH-4031 Basel, Switzerland.
Dr. Socié: Hôpital St. Louis, Department of Hematology, Bone Marrow Transplantation, 1 Avenue Claude Vellefaux, 75475 Paris Cedex 10, France.
Dr. Marsh: St. George's Hospital, Medical School, Department of Cellular and Molecular Sciences, Division of Haematology, Crammer Terrace, London SW17 ORE, United Kingdom.
Dr. Barge: Bone Marrow Transplantation Centre Leiden, Leiden University Hospital, PO Box 9600, 2300 RC Leiden, the Netherlands.
Dr. Frickhofen: Dr. Horst-Schmidt-Kliniken, Department of Medicine III, Hematology/Oncology, 65199 Wiesbaden, Germany.
Dr. McCann: St. James Hospital, Department of Hematology, Trinity College, James Street, Dublin 8, Ireland.
Dr. Bacigalupo: Ospedale San Martino, Department of Hematology, Viale Benedetto XV, 16132 Genoa, Italy.
Dr. Hows: Bristol Haematology and Oncology Centre, Avon Haematology Unit, Horfield Road, Bristol BS2 8ED, United Kingdom.
Dr. Marin: Instituto de Investigaciones Biomédicas Agustí Pi Sunyer, Hemotherapy and Hemostasis Department, Hospital Clinic, Villarroel 170, 08036 Barcelona, Spain.
Dr. Nachbaur: University Hospital Innsbruck, Division of Hematology and Oncology, Anichstrasse 35, 6020 Innsbruck, Austria.
Dr. Symeonidis: Patras University Medical School, Hematology Division, Department of Internal Medicine, University Hospital, 261 10 Patras, Greece.
Dr. Schrezenmeier: Klinikum Benjamin Franklin, der Freien Universität Berlin, Innere Medizin, Hämatologie/Onkologie, Hindenburgdamm 30, 12200 Berlin, Germany.
Author Contributions: Conception and design: A. Tichelli, G. Socié, J. Passweg, H. Schrezenmeier.
Analysis and interpretation of the data: A. Tichelli.
Drafting of the article: A. Tichelli, G. Socié, J. Passweg, H. Schrezenmeier.
Critical revision of the article for important intellectual content: A. Tichelli, G. Socié, J. Marsh, R. Barge, N. Frickhofen, S. McCann, A. Bacigalupo, J. Hows, P. Marin, D. Nachbaur, A. Symeonidis, J. Passweg, H. Schrezenmeier.
Final approval of the article: A. Tichelli, G. Socié, J. Marsh, R. Barge, N. Frickhofen, S. McCann, A. Bacigalupo, J. Hows, P. Marin, D. Nachbaur, A. Symeonidis, J. Passweg, H. Schrezenmeier.
Provision of study materials or patients: A. Tichelli, G. Socié, J. Marsh, R. Barge, N. Frickhofen, S. McCann, A. Bacigalupo, J. Hows, P. Marin, D. Nachbaur, A. Symeonidis, J. Passweg, H. Schrezenmeier.
Statistical expertise: A. Tichelli, J. Passweg.
Collection and assembly of data: A. Tichelli.