How I Treat Series on Hematologic Complications in Pregnancy

Summary

Blood Podcast: How I Treat Series on Hematologic Complications in Pregnancy

Episode Date: January 15, 2026
Host: Dr. Thomas Ortel (Chief of Hematology, Duke University Medical Center)
Guests: Dr. Ware Branch (Obstetrician Gynecologist, MFM specialist, University of Utah), Dr. J.J. Strauss (Adult & Pediatric Hematologist, Director of Adult Sickle Cell Program, Duke University)

---

Episode Overview

This bonus episode of the Blood Podcast spotlights the new "How I Treat" series published in Blood addressing hematologic complications in pregnancy. Dr. Thomas Ortel interviews contributing authors Dr. Ware Branch and Dr. J.J. Strauss, delving into the latest research, clinical guidance, and nuanced considerations for treating pregnant patients facing complex hematologic disorders. The discussion focuses primarily on antiphospholipid syndrome and sickle cell disease in pregnancy, with practical takeaways for both hematologists and maternal fetal medicine (MFM) specialists.

---

Key Discussion Points & Insights

1. Rationale for the New Series

[00:25–02:24]

• Blood previously published a 2020 series on lymphoma, TTP, venous thromboembolism (VTE), and bleeding disorders in pregnancy.
• Recognizing persistent knowledge gaps, the new series covers:
  • Thrombocytopenia in pregnancy (gestational, immune, HELLP)
  • Diagnosis and treatment of antiphospholipid syndrome (APS)
  • Sickle cell disease in pregnancy
  • Myeloproliferative neoplasms (essential thrombocytosis, polycythemia vera)
• The aim: Equip hematologists for consultative roles with obstetric colleagues, addressing common but challenging scenarios.

---

2. Treating Antiphospholipid Syndrome (APS) in Pregnancy

Guest: Dr. Ware Branch
[02:24–06:03]

Key Points:

• Updated Classification:
  • The recent (late 2023) ACR/EULAR classification criteria for APS were designed for research purposes but impact clinical management complexity.
  • Real-world cases don’t always fit the criteria, especially in recurrent miscarriage with borderline antibody findings.
• Individualized Care:
  • Treatment must distinguish between classic APS and probable/possible cases, especially in patients with unexplained pregnancy losses.
• Catastrophic APS:
  • Managing rare, life-threatening catastrophic APS requires specialized protocols, drastically different from mild/moderate cases.

Notable Quote:

“One of the reasons to write this article is to sort of get into the weeds about those kinds of cases.” — Dr. Branch [04:28]

---

3. Sickle Cell Disease in Pregnancy: A Collaborative Approach

Guest: Dr. J.J. Strauss
[03:20–07:44]

Key Points:

• Early, Ongoing Partnership:
  • Hematologists and MFMs must collaborate early to develop comprehensive, individualized care plans.
• Division of Labor:
  • Hematologist: Manages sickle-cell-specific therapies (e.g. blood transfusion, hydroxyurea considerations), VTE prevention strategies.
  • MFM Specialist: Oversees pregnancy monitoring, delivery planning.
• Delivery Planning:
  • Crucial for patients to deliver at centers with sickle cell expertise or with an established MFM-hematology partnership.

Notable Quote:

“I want my maternal fetal medicine partners to see us as partners in the management of this patient." — Dr. Strauss [06:31]

---

4. Neonatal and Pediatric Hematology Considerations

[07:44–10:04]

• Preterm Birth:
  • Both APS and sickle cell disease increase the likelihood of preterm delivery—coordination is required with neonatal teams.
• Transplacental Antibodies:
  • The implications of passively transferred antiphospholipid antibodies remain uncertain in neonates.
• Sickle Cell Neonates:
  • Most babies will not have sickle cell disease but risks include prematurity, small-for-gestational-age status, and cesarean delivery complications.

Notable Quote:

“Prematurity is quite common in people that deliver with sickle cell disease... we think that's the effects of sickle cell disease on the placenta and perhaps the chronic anemia as well that drives that." — Dr. Strauss [09:00]

---

5. Postpartum Management

[10:04–13:41]

Sickle Cell Disease:

• VTE Prevention:
  • Prophylactic anticoagulation for at least six weeks postpartum is standard, regardless of prior thrombosis history.
• Anemia Monitoring:
  • Transfusion support may be needed due to anticipated postpartum anemia.

Antiphospholipid Syndrome:

• Anticoagulation:
  • Continued anticoagulation postpartum (therapeutic or prophylactic, based on history) is best practice.
  • Bridging to warfarin recommended in most cases.
  • Controversy remains regarding the exact duration (typically 6–8 weeks post-delivery).

Hypertension & Thrombocytopenia:

• Additional Risks:
  • Classic APS patients, particularly those with lupus anticoagulant, face higher risk for preeclampsia and HELLP syndrome.
  • Ongoing vigilance for thrombocytopenia, especially if microangiopathy is suspected.

Family Planning:

• Contraception:
  • Sickle cell patients: Avoid estrogen-containing regimens; imperative to counsel on future pregnancy risks and reliable contraception, especially after high-risk pregnancies.

Notable Exchange:

“For people with sickle cell disease... we try to avoid estrogen containing regimens, but I do think it's an important thing to discuss...plan reliable birth control if another pregnancy is not planned.” — Dr. Strauss [13:00]
“Absolutely. A very important point. Thanks for bringing it up.” — Dr. Branch [13:37]

---

6. Challenging Scenarios and Clinical Judgment

[13:49–16:58]

APS Cases with Borderline Results:

• Hematologists frequently encounter patients with recurrent miscarriage and low-positive or IgM-only APS lab findings.
• Shared decision-making, often driven by parental preference, leads to continuation of therapy (e.g., low molecular weight heparin, aspirin) even without definitive APS diagnosis.
• The hematologist’s role includes helping the patient weigh therapy risks and supporting informed choices.

Notable Quote:

“The shared decision making is driven by the patient more than the doctor. And we often end up being a bit passive in the decision making and being willing to go along with it.” — Dr. Branch [15:14]

Sickle Cell Pregnancy as "Engagement Opportunity":

• Pregnancy should prompt referral to a sickle cell comprehensive center or at least remote expert consultation—telemedicine expands access for both hematology and MFM expertise.

Notable Quote:

“Now that we do have the opportunity for telemedicine visits within our state, most people should be able to access someone who has substantial experience in managing people with hemoglobinopathies during pregnancy.” — Dr. Strauss [16:34]

---

Memorable Quotes & Timestamps

• “So we looked at it as this is another series on a topic that is very important to hematologists because we're frequently asked by our obstetric colleagues to weigh in on these types of problems during pregnancy.”
  – Dr. Ortel [01:50]
• “There are patients for whom hematologists will be sought in consultation because it's not sure that they have APS. And one of the reasons to write this article is to sort of get into the weeds about those kinds of cases.”
  – Dr. Branch [04:37]
• “I want my maternal fetal medicine partners to see us as partners in the management of this patient.”
  – Dr. Strauss [06:31]
• “Prematurity is quite common in people that deliver with sickle cell disease...”
  – Dr. Strauss [09:00]
• “The shared decision making is driven by the patient more than the doctor.”
  – Dr. Branch [15:14]

---

Key Takeaways for Clinicians

• Multidisciplinary Collaboration: Early, close partnership between hematology and maternal fetal medicine is essential for optimizing both maternal and neonatal outcomes in complex pregnancies.
• Updated Criteria and Nuance in Diagnosis: Recent APS guidelines favor research clarity over clinical flexibility; effective management often requires nuanced judgment beyond criteria.
• Shared Decision-Making: Patient preferences play a major role in ambiguous APS cases, underlining the importance of patient education and risk-benefit conversations.
• Proactive Postpartum Management: Both APS and sickle cell disease demand attentive postpartum prophylaxis, focusing on VTE, anemia, hypertension, and individualized family planning support.
• Specialist Involvement: Annual/one-off consultations (including via telemedicine) with hematology or sickle cell centers should be standard in management pathways for high-risk pregnancies.

---

Suggested Listening Order (with Timestamps)

• [00:25–02:24] Overview of series topics and rationale
• [02:24–06:03] APS in pregnancy: new criteria, controversies, key management points
• [06:03–07:44] Sickle cell disease: partnership, planning, checklist for MFMs
• [07:44–10:04] Neonatal issues; what pediatric hematologists/neo teams should know
• [10:04–13:41] Postpartum management: VTE, anemia, hypertension, contraception
• [13:49–16:58] Approach to ambiguous APS; optimizing sickle cell care access
• [16:58–17:54] Summary & call to consult series articles in Blood

---

Final Thoughts

This engaging, expert-led discussion provides essential updates and clinical pearls for hematologists and maternal-fetal medicine practitioners jointly caring for pregnant patients with complex hematologic diseases. The emphasis on communication, nuanced management, and evolving standards ensures listeners are well-equipped for common challenges and collaborative practice. For detailed protocols and further reading, listeners are encouraged to review the full articles in Blood.

Transcript

[A]

Welcome to this week's bonus episode of the Blood Podcast, your source for innovative ideas and cutting edge information. In this episode, Associate Editor Dr. Thomas Ortel discusses the How I Treat series on hematologic complications in pregnancy with contributing authors Dr. Ware Branch and Dr. J.J. strauss.

[B]

Hello, my name is Tom Ortel. I am Chief of Hematology at Duke University Medical Center. This is a How I Treat series on the hematologic complications in pregnancy. Blood actually had published a How I Treat series on this topic in 2020, addressing four topics, specifically lymphoma, thrombotic thrombocytopenic purpura, venous thromboembolism, and bleeding disorders such as hemophilia carriers and patients with BWD during pregnancy. We recognized that there were other topics, though, that our colleagues were frequently getting asked about, so we introduced another How I Treat series, again on hematologic complications in pregnancy. The papers in this series include a paper on how I treat thrombocytopenia in pregnancy, looking at it broadly, going from gestational through immune, through help, authored by Drs. Fogarty and Coughter, a paper on diagnosis and treatment of anaphospholipid syndrome in pregnancy, which looks at the new classification criteria, diagnostic versus classification criteria, et cetera, treating these folks, authored by Drs. Branch and Lim at Utah. The third paper is on how I treat sickle cell disease in pregnancy, looking at the variety of sickle cell complications that these patients can get, what's exacerbated during pregnancy, what medications can be pregnancy, et cetera, authored by Drs. James and Strauss. And the fourth paper to round out our series was a paper on treating myeloproliferative neoplasms in pregnancy, such as essential thrombocytosis, polycythemia vera. And that particular paper is authored by Dr. Robinson, Regeb and Harrison. So we looked at it as this is another series on a topic that is very important to hematologists because we're frequently asked by our obstetric colleagues to weigh in on these types of problems during pregnancy.

[C]

I'm Ware Branch and I'm an obstetrician gynecologist who is an MFM specialist as well here at the University of Utah in Salt Lake City. I was invited by Dr. Ortel to write an article about how I treat antiphospholipid syndrome in pregnancy, and I believe the invitation was timely, as Dr. Ortel certainly knows, because recently the classification criteria for this autoimmune condition have changed, that is in late 2023. That's a topic that by itself would be of interest to hematologists. And experience has shown that there's quite a bit of confusion and consternation about the best approach to the variety of patients that get labeled as having antiphospholipid syndrome. And so the article I've written tries to bring out some of the nuances of those different situations.

[D]

Hi, I'm J.J. strauss. I'm an adult and pediatric hematologist at Duke University, where I direct the adult sickle cell program. Our article, which we were very excited to work on, was written By Andy James, Dr. Andy James, and myself to try to outline how we approach the care of pregnant people with sickle cell disease. We all recognize that this is a group that's at substantial risk for complications during pregnancy and the postpartum period, and we wanted to share our experience with how to minimize those complications and make it likely that people could have successful pregnancies and childbirth. Dr.

[B]

Branch, from the perspective of. You wrote a very interesting, very thorough article. If you could boil it down to a couple, two, three key points, keeping in mind that most hematologists don't have a guy like you around that they can turn to and ask questions of. But what would you really like the hematologic community? What important pieces do you think they should know?

[C]

Great question, and a real world question to be sure. I think the first thing to note is that the new classification criteria, referred to as the ACR EULAR classification criteria for aps, was designed in a very, very rigorous fashion under the direction of Doric Erkin, a rheumatologist at HSS in New York. And pointedly, the idea was to create a classification system for identifying patients for research purposes. And so in the real world, that matters a lot for research purposes and to some degree for clinical purposes. But there are patients for whom hematologists will be sought in consultation because it's not sure that they have aps. And one of the reasons to write this article is to sort of get into the weeds about those kinds of cases. So that's one point to be distilled, I think, down. Another point is how I treat the individual cases, whether they have classic syndrome that would qualify them for a research study according to ACR EULAR criteria, or whether they don't. And that's particularly problematic, I should say, confusing, in patients with recurrent early miscarriage. And so a couple of the cases in the article were about that. And finally, I touch on catastrophic APS as something that may be identified in a pregnant patient. And that's really important because the management of that kind of condition is dramatically different.

[B]

Thank you very much for those points, Dr. Strauss, I would ask the converse question. Both you and Dr. Branch had the luxury of having a hematologist and a maternal fetal medicine specialist on your papers. What would you want the maternal fetal medicine specialist to know about sickle cell disease? What 2, 3 points? If you were distilling things out, do you think are most important to share?

[D]

I want my maternal fetal medicine partners to see us as partners in the management of this patient. I probably know more about sickle cell disease than they do, but they know a whole lot more about the care of the pregnant patient and how to achieve that successful delivery. And for that partnership, I want to make sure that it starts early on. So I want to get the person with sickle cell disease when they're pregnant to that maternal fetal medicine specialist and I want them to have the checklist from this article about the things that we need to do in those stages. In general, there's some division of labor. I often take care of the sickle cell disease specific therapies, whether that's transfusion or if we're going to consider restarting hydroxyurea. I see that as my area and also provide advice about venous thromboembolism treatment or prophylaxis, though they often handle the implementation of that since they're usually seeing the person more frequently. And I'd like to work together on a delivery plan, especially if that's going to occur at some place other than the institution where we have boots on the ground for sickle cell care.

[B]

Excellent. I'm also wondering for both of you, do you have anything in particular you'd like to say to your pediatric hematology colleague who's going to be getting that baby handed off to them after a successful pregnancy? Is there anything that they should be aware of and be ready to potentially have to manage? Can start with Dr. Branch, since you're on my left.

[C]

Another good question. I think the most important thing for pediatric folks I get to deal with, and in this kind of situation we're often talking about neonatal intensive care unit colleagues. Most important thing to recognize is that preterm delivery is modestly likely, if not pretty likely in these cases. And so getting everybody on the same page for the time of delivery is a critical issue. There's controversy with regard to whether transposenal passage of antiphospholipid antibodies has important bearing in the neonate, and that's not discussed in my article. I think it's a separate Topic that is not of a critical nature for this conversation.

[B]

Sounds good. Dr. Strauss, anything that you want. I realize you're also in pediatrics, but you're probably not there getting the baby in the neonatal care units.

[D]

I try to avoid this NICU consults these days, though I do have a little bit of PTSD from the NICU as a resident. But I think it is important to recognize that prematurity is quite common in people that deliver with sickle cell disease and also small for gestational age infants. And we think that's the effects of sickle cell disease on the placenta and perhaps the chronic anemia as well that drives that. For the most part, the children will not have sickle cell disease. But we do recommend preconception or during the pregnancy counseling and testing of the father of the baby. For that reason. We don't see, even if the child has sickle cell disease, we generally don't see problems related to that birth. So it's really the prematurity and being small for gestational age that we want people to be aware of. And then also they're more likely to be cesarean section deliveries. In sickle cell disease, 40 to 45% of the pregnancies end in a cesarean section. So potential complications related to that might affect the baby as well.

[B]

And so we've talked about pregnancy, we've talked about the baby. How about any special words that you want to do for postpartum treatment of the mother? I'll turn this time first to Dr. Strauss.

[D]

Much like in people with antiphospholipid antibodies, we worry a lot about thrombosis. So sickle cell disease being a significant thrombophilia that postpartum period. We about worry, worry about thrombosis. And we generally recommend VT prophylaxis even in people without a history of thrombosis for six weeks. And some people might even argue to extend that after cesarean delivery. But both cesarean deliveries and deliveries that are spontaneous or induced vaginal deliveries, we would recommend that VT prophylaxis and we worry more about postpartum anemia. Most of the people are anemic before we try to transfuse them up to a hemoglobin of in between 8 and 10 prior to delivery. But with blood loss, they might need additional transfusion. And those are two areas that I think require a lot of attention in people delivering with sickle cell disease in the postpartum period.

[B]

Thanks, Dr. Branch.

[C]

VTE prophylaxis is critical, of course, in patients with antipostolipid syndrome because of a recognized risk for thrombosis in patients who have previously had thromboembolic events. Event or events. They are typically managed during the pregnancy and afterwards on therapeutic anticoagulation and bridging the patient post delivery. That kind of patient post delivery to warfarin is, I think, a best practice in the majority of cases. I'm sure there are a few exceptions, but in the majority of cases for patients that have never had a blood clot, antepartum thromboprophylaxis is indicated and should be continued, typically with a heparin agent. Low molecular weight heparin agent for six to eight weeks post delivery. The exact timeline of how long one should do that is a matter of controversy in the world of obstetrics, so also very important to manage hypertensive disease in these cases. Classic antiphospholipid syndrome patients, especially those with lupus anticoagulant, are modestly likely to develop preeclampsia and need blood pressure care antenatally around the time of delivery and very often into the days and weeks post delivery. We physicians should be on guard for the possibility of thrombocytopenia in patients with aps. It's a known complication and in cases wherein the picture looks microangiopathic, such as with HELLP syndrome, be on guard for the possibility of a rare case of catastrophic aps.

[B]

Very good.

[D]

Could I add on one thing to that question? Yes, I know that my obstetrics and maternal fetal medicine colleagues are very good about thinking about family planning after someone delivers. For people with sickle cell disease. I think it's important to recognize that we try to avoid estrogen containing regimens, but I do think it's an important thing to discuss, especially if someone has had a very complicated pregnancy and is at high risk for complications, including maternal mortality and future pregnancies. To talk about that in the postpartum period and a plan reliable birth control if another pregnancy is not planned.

[C]

Absolutely. A very important point. Thanks for bringing it up.

[B]

I just wondered, do either of you have any other questions, topics, thoughts, anything you'd like to mention on the podcast?

[C]

Hematologists may be asked to consult on patients who have recurrent early miscarriage and antiphospholipid test results that are low positive or IGM isotype only. This is a pretty common situation out there in the world of possible aps. In the article I have written about an all too frequent type of patient who has been seen by practitioners who with very good intention. After the patient's had a couple of pregnancy losses, the practitioners get antiphospholipid antibody tests. The patient comes back lupus anticoagulant, negative but low positive for, let's say, IgG anticardiolipin antibodies. A thoughtful OBGYN doc, I believe, should send that patient to speak with somebody who has expertise in this condition. Very often that's a hematologist, to get opinion, an informed opinion about whether the patient actually should carry that diagnosis and get an informed opinion about how they should be managed. Not infrequently, I should remind, I will remind my hematology colleagues, not infrequently, the patient is already on a heparin agent and low dose aspirin in the current pregnancy and is not going to stop it. If she's got a live embryo in there and has had miscarriages in the past, she's very likely going to, maybe not insistent, but very much in favor of continuing the low molecular weight heparin treatment in spite of her not having a certain diagnosis of aps. And I just want my hematology colleagues to realize that this is a dilemma wherein, as I've said in the article, the shared decision making is driven by the patient more than the doctor. And we often end up being a bit passive in the decision making and being willing to go along with it. I feel that the task then is, is to make sure the patient understands the importance of the risks associated with low molecular weight heparin in pregnancy. And I think a hematologist can easily help with that kind of conversation.

[D]

I wanted to focus on pregnancy as an opportunity for people to get engaged in high quality sickle cell care and also to have that opportunity to speak to an expert in sickle cell disease and maternal fetal medicine. So I encourage my OB and maternal fetal medicine colleagues to refer to a sickle cell comprehensive center during pregnancy. If someone has not had that before, I think it's a great opportunity to engage them in that care, even if it's a telemedicine visit or a single visit to aid in their long term management. And the same thing for maternal fetal medicine. Now that we do have the opportunity for telemedicine visits within our state, most people should be able to access someone who has substantial experience in managing people with hemoglobinopathies during pregnancy. And I recommend that for people, even if they're at a center working with a maternal fetal medicine, if they don't have that focused expertise, I think it's worth having a one time consult.

[B]

Super. Thank you very much to Dr. Branch, Dr. Strauss who joined me on this podcast. We've really enjoyed talking with you, learning what you know, gaining from your expertise in insights into these hematologic disorders that we frequently see. I also want to thank the listener who's listened in and I hope that your curiosity and interest has been piqued enough that you're going to be going to the journal Blood to look at the original articles. Plus the other two articles that we didn't get to discuss on the podcast. One on thrombocytopenia and pregnancy in general, a common problem problem that we encounter and one on the pregnant patient with a myeloproliferative disorder which is becoming more common as we make those diagnoses earlier and earlier. So thank you everybody and have a good day.

[A]

Thank you for listening to this bonus episode of the Blood Podcast. To read these articles visit bloodjournal.org this episode is copyrighted by the American Society of Hematology.