Pregnancy-associated aplastic anemia: a case-based review

ABSTRACT

Introduction: Pregnancy-associated aplastic anemia (pAA) occurs when aplastic anemia (AA) is diagnosed for the first time during pregnancy and it is a rare but serious condition leading to severe maternal and fetal complications. It is unknown whether pregnancy triggers bone marrow failure or if this state is unrelated to the pathogenesis of pAA.

Areas covered: In this review, three new cases of pAA are presented and its controversial etiologic relationship with pregnancy, its atypical presentation, and management are also discussed. Furthermore, a literature review of pAA cases between 1975 and 2020 was performed in PubMed, accessed via the National Library of Medicine PubMed interface. Keywords included ‘aplastic anemia’ AND ‘pregnancy’. We found 54 cases reported in the literature with a clear diagnosis of pAA.

Expert opinion: The diagnosis of pAA is challenging since pregnancy is associated with physiologic hematological changes in the complete blood count which can mask the disease. Meticulous monitoring and adequate support therapy given by a trained multidisciplinary team have the potential to improve outcomes for women and their neonates. All women should receive frequent assessments to optimize their care during pregnancy and after delivery, definitive treatment should be offered.

KEYWORDS:

• Aplastic anemia
• bone marrow failure
• pregnancy
• pancytopenia
• bicytopenia
• supportive care

Article highlights

• Aplastic anemia can occasionally be diagnosed during pregnancy and its etiologic relationship is controversial; pregnancy-associated factors, such as a hormone imbalance, might trigger the disease.

• Pregnancy is associated with physiologic hematological changes in the complete blood count which can mask the disease.

• The mainstay of treatment is aggressive transfusion support and treatment of infectious complications with good fetal and maternal outcomes.

• After delivery, the patient should continue hematologic follow-up and an individualized assessment must be performed to select a definitive treatment for aplastic anemia.

• There is a need for larger prospective studies of pregnancy-associated aplastic anemia to define its etiologic association, atypical clinical presentation, in which bicytopenia/pancytopenia scenarios in pregnancy is adequate to perform a bone marrow aspirate and biopsy, and its optimal management.

• In-depth studies exploring proposed pregnancy-related immune mechanisms involved in triggering or exacerbating aplastic anemia can help to understand its pathophysiology and provide better therapeutic strategies for these women.

Acknowledgments

The authors wish to thank Sergio Lozano-Rodriguez, MD, for his critical review of the manuscript.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.