A Life-Saving, Multidisciplinary Approach to Treating Pregnant Women With Sickle Cell Disease in Ghana

Pregnant women with sickle cell disease (SCD) living in Ghana have a high maternal mortality rate of 8,300 deaths per 100,000 live births – more than 10 times higher than in Ghanaian women without SCD (690 per 100,000) and more than 500 times higher than in U.S. women with SCD (14 per 100,000). Using a multidisciplinary approach to care for these patients, and establishing dedicated wards for pregnant women with SCD, can decrease the rates of maternal and perinatal mortality, according to the results of a prospective study presented at the 2016 ASH Annual Meeting.

“We saw a dramatic drop – close to a 90 percent reduction – in maternal deaths, which is really remarkable,” said lead study author and presenter Eugenia Vicky Naa Kwarley Asare, MD, MBChB, BSc, from the Ghana Institute of Clinical Genetics at the Korle Bu Teaching Hospital in Accra, Ghana, adding that these reductions were seen after just 13 months of the program’s implementation.

In 2015, Dr. Asare and colleagues formed an obstetric SCD team that included obstetricians, hematologists, pulmonologists, and nurses to improve care and outcomes for pregnant women living with SCD. Other efforts of this intervention included:

  • requiring regular team meetings among the obstetric team members to discuss complex patient cases
  • admitting women to two designated wards to provide more coordinated care
  • implementing simple protocols for preventing and treating acute chest syndrome (ACS)
  • purchasing balloons as a less expensive substitute for incentive
  • spirometry devices to be used routinely during the management of acute pain episodes and after surgery
  • integrating multiple pulse oximetry machines into routine clinical practice to monitor oxygen desaturation
  • monitoring maternal and fetal progress more closely

The researchers assessed mortality outcomes of 158 patients during a 16-month, pre-intervention period (January 2014 to April 2015), then compared those with outcomes from 90 patients in a 12-month, post-intervention period (May 2015 to May 2016) until six weeks post-partum.
The median patient age was 29 years for both the pre-intervention (range = 18-43 years) and post-intervention (range = 18-41 years) periods, and the median gestational age at delivery was 38 weeks (range = 26-41 weeks).

Prior to the intervention, pregnant women with SCD received standard of care (mostly from their obstetrician) and were admitted to multiple wards throughout the hospital. During the intervention period, women received integrated, multidisciplinary care under the protocols outlined above. Members of the multidisciplinary team evaluated patients at enrollment, during outpatient visits, and during acute illnesses (including both inpatient and outpatient).

Prior to the intervention, pregnant women with SCD received standard of care (mostly from their obstetrician) and were admitted to multiple wards throughout the hospital. During the intervention period, women received integrated, multidisciplinary care under the protocols outlined above. Members of the multidisciplinary team evaluated patients at enrollment, during outpatient visits, and during acute illnesses (including both inpatient and outpatient).

After just 13 months, both maternal and perinatal mortality rates decreased significantly, compared with the pre-intervention period:

  • maternal mortality: 9.5% (15 deaths and 139 live births) versus 1.1% (1 maternal death and 85 live births), representing an 89.1% decrease (p value not reported)
  • perinatal mortality: 60.8% (9 perinatal deaths and 148 births) versus 23% (2 perinatal deaths and 87 births), representing a 62.2% decrease (p value not reported)

The most common cause of death before the multidisciplinary intervention was cardiopulmonary disease (60%), followed by preeclampsia (6.67%), acute kidney injury (6.67%), severe anemia (20%), and hypovolemic shock (6.67%). The one death that occurred in the post-intervention period was caused by a massive pulmonary embolism.

Although the comparison between the pre- and post-intervention periods is limited by incomplete data prior to the multidisciplinary care team intervention, Dr. Asare and researchers concluded that this approach is promising for SCD patients in sub-Saharan Africa and even in areas of the United States where such clinics are not the norm.

“Sickle cell disease has acute and chronic complications, and to manage it well, especially in the context of pregnancy and childbirth, you need to have a number of specialists on board, including a hematologist,” Dr. Asare said. Though this strategy led to substantial reductions in SCD-related maternal and perinatal mortality, she added that “further strategies are needed to decrease the SCD-related maternal and perinatal mortality rates to levels expected in the non-SCD population and to implement multidisciplinary SCD obstetric teams in other regions.”

The researchers hope to expand their approach to decrease maternal and perinatal mortality in other hospitals in Accra, Ghana.


Reference
Asare EVNK, Adomakoh Y, Olayemi E, et al. Prospective implementation of multi-disciplinary obstetric team decreases the mortality rate of pregnant women with sickle cell disease in Ghana. Abstract #1017. Presented at the ASH Annual Meeting and Exhibition, December 5, 2016; San Diego, CA.

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