Management of Sickle Cell Crisis in the 3rd Trimester of Pregnancy
Pregnant women with sickle cell disease experiencing a crisis in the third trimester should be managed in a specialized obstetric unit with expertise in sickle cell disease, with prompt pain management, adequate hydration, oxygen therapy if hypoxemic, and consideration of transfusion therapy based on clinical severity. 1, 2
Initial Assessment and Management
Immediate Interventions
Pain Management:
- Implement a tiered approach based on pain severity
- For moderate to severe pain: opioid analgesia (e.g., morphine 5-10 mg IV/SC)
- Consider epidural analgesia, particularly if there is lower body pain or opioid tolerance 1
Hydration:
- Administer IV fluids to correct dehydration
- Monitor fluid balance carefully to avoid fluid overload
Oxygen Therapy:
- Provide supplemental oxygen if SpO2 < 94%
- Monitor oxygen saturation continuously
Laboratory Assessment
- Complete blood count to assess baseline hemoglobin and detect worsening anemia
- Reticulocyte count to evaluate bone marrow response
- Comprehensive metabolic panel to assess renal function
- Blood cultures if febrile
- Group and crossmatch for potential transfusion 1
Transfusion Considerations
Indications for Transfusion
- Severe anemia (Hb < 70 g/L)
- Acute chest syndrome
- Stroke or other severe complications
- Worsening clinical status despite supportive care 1
Transfusion Protocol
- For simple transfusion: target Hb of 100 g/L
- For exchange transfusion: aim to reduce HbS percentage to < 30%
- Blood should ideally be < 10 days old for simple transfusion and < 8 days old for exchange transfusion
- Ensure donor red cells are HbS negative and compatible for ABO, Rh, and Kell antigens 1
Management of Specific Complications
Acute Chest Syndrome
- Low threshold for diagnosis (new pulmonary infiltrate + chest pain, fever, tachypnea, wheezing, or cough)
- Broad-spectrum antibiotics
- Consider exchange transfusion
- Early ICU consultation 2
Infection
- Prompt administration of broad-spectrum antibiotics for suspected infection
- Low threshold for hospital admission 2
Obstetric Considerations
Fetal Monitoring
- Continuous electronic fetal monitoring during crisis
- Ultrasound assessment of fetal growth and well-being
- Consider antenatal corticosteroids if preterm delivery is anticipated
Delivery Planning
- Regional anesthesia is preferred for cesarean section if needed
- Avoid general anesthesia when possible due to increased risks
- If general anesthesia is required, ensure effective oxygenation during intubation 1
Postpartum Care
- Continue close monitoring for at least 48 hours after delivery
- Maintain hydration and pain control
- Thromboprophylaxis with low molecular weight heparin
- Early mobilization when pain controlled 1
Common Pitfalls to Avoid
- Delayed pain management: Pain should be treated promptly and adequately to prevent worsening of crisis
- Inadequate hydration: Dehydration can worsen sickling
- Failure to recognize acute chest syndrome: Maintain high index of suspicion for this life-threatening complication
- Overlooking infection: Pregnant women with SCD are at increased risk of infections
- Delaying transfusion when indicated: Early consultation with hematology is essential
Multidisciplinary Approach
- Involve obstetrics, hematology, anesthesiology, and critical care teams
- Clear communication regarding management plan
- Early ICU consultation for severe cases 1, 2
The management of sickle cell crisis in the third trimester requires prompt intervention to reduce maternal and fetal morbidity and mortality. While the Association of Anaesthetists guideline 1 provides comprehensive recommendations for management, the American Society of Hematology 1 notes that transfusion decisions should be individualized based on clinical severity and patient history. With appropriate management in specialized centers, maternal mortality has significantly decreased in recent years 1.