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.