Physiologic changes occur during pregnancy, which influence normal haematologic values and impact the diagnosis and management of haematologic disease in pregnancy. Physiologic changes of pregnancy also commonly lead to mimicking symptoms of haematologic disease that may prompt investigations for haematologic disease. The toxicity and radiation associated with the diagnostic imaging and pharmacologic management of both benign and malignant haematological conditions during pregnancy present unique challenges. Strategies for diagnosis and treatment must weigh the benefits and risks to the mother while also taking foetal outcome into consideration. In this review, we highlight the common haematologic diseases encountered by obstetricians and try to provide guidance for the most prevalent diagnostic and therapeutic questions. At the other end of the spectrum, we also comment on less common but very challenging haematologic diseases in pregnancy that require multidisciplinary effort to arrive at difficult individual diagnostic and treatment decisions.
Highlights
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Normal pregnancy symptoms can mimic serious haematological disease.
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Thrombocytopenia is common in pregnancy and has numerous aetiologies.
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Increased risk of thrombosis in pregnancy necessitates accurate diagnosis.
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Thromboprophylaxis in pregnancy and post partum is indicated for high-risk women.
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Multidisciplinary teams are needed for managing haematologic malignancy in pregnancy.
Normal physiologic changes in pregnancy
An understanding of normal physiologic adaptations during pregnancy is essential to identifying and managing haematological disease in pregnancy. By the 6th week of gestation, the plasma volume begins to rise until its peak at the 30th week of gestation leading to a dilutional effect on haemoglobin referred to as the physiological anaemia of pregnancy . The haemostatic system is progressively activated to prepare for the haemostatic challenges of delivery (see Table 1 ). The hypercoagulability of pregnancy gradually returns to the non-pregnant state after the early post-partum period, as evidenced by progressive normalisation of markers of coagulation activation .
| Tests with values that increase during pregnancy |
| Fibrinogen (up to 3× baseline) |
| Leukocytes (WBC) (to 10–16 × 10 9 /L) |
| Factor VIII (55–70% higher) |
| D-dimer (∼2–3× by third trimester) |
| Ferritin |
| von Willebrand Factor (vWF) (∼2–3× by third trimester) |
| Erythrocyte sedimentation rate (ESR) (∼2–3× by third trimester) |
| Tests with values that are unaffected by pregnancy |
| Partial thromboplastin time (PTT) |
| International normalised ratio (INR) Factor IX Factor XI |
| Antithrombin (AT) |
| Protein C |
| Tests with values that decrease during pregnancy |
| Haemoglobin (Hb) (2–3 g/dL drop by second trimester) |
| Platelet count (∼10% decrease) |
| Protein S free (30–54% lower) |
| A disintegrin and metalloproteinase with thrombospondin motifs (ADAMTS) (∼25% drop by second trimester) |
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