Pregnancies in patients with inherited bone marrow failure syndromes in the NCI cohort

To the editor:

We read with great interest the recent letter in Blood, by Gansner et al, on the topic of pregnancies in patients with an inherited bone marrow failure syndrome (IBMFS).¹  We agree that these rare patients have reduced numbers and complicated pregnancies, and we think that our experience in this area serves to reinforce the points made by those authors. We have been involved in the care of a larger number of patients, with many more pregnancies, with informative complications and outcomes.

The National Cancer Institute (NCI) IBMFS program opened in 2002; enrollment is biased only by volunteerism, based on self-referral and chart review, with 54% of the patients discussed subsequently seen by the authors at the National Institutes of Health Clinical Center. The protocol was approved by the NCI Institutional Review Board, and all participants signed consent forms (registered at www.clinicaltrials.gov as #NCT00027274). This cohort of women includes >100 who were postmenarchal, of whom 67 were sexually active (Table 1). All diagnoses were confirmed with clinical and syndrome-specific laboratory findings, including genotyping in 78% of the 67.^2,3  Seven patients had undergone HCT: 1 with FA and 1 with DC; each of these had 2 pregnancies. The FA patient had 1 miscarriage and 1 elective abortion; the DC patient had donor egg and IVF for her first pregnancy, and IVF and preimplantation genetic diagnosis for the second, after the gene had been identified. Two dozen patients did not have any pregnancies and were on androgens or using birth control.

There were a total of 102 pregnancies in the 67 women: 25 miscarriages in 13 women, 71 live deliveries of 74 babies (3 sets of twins), 16 preterm births, and 26 C-sections. Infertility was reported frequently in FA, because of POI. Infertility in DC was less frequent, associated with endometriosis or scarred fallopian tubes. AMH was decreased in all the infertile FA and DC women who were tested.^4,5 

Complications were related to hematologic, obstetrical, and fetal circumstances (Table 2). Almost half of the whole group of pregnant women had decreased hematopoiesis in 1 or all lineages, and 20% of the patients received red cell and/or platelet transfusions. The cytopenias may have reflected a combination of the need for expanded hematopoiesis in pregnancy, plus the reduced marrow response because of the IBMFS. Preeclampsia during pregnancy in FA was reported by us earlier⁶  and was now noted in DC as well. The number of primary C-sections appeared unusually high, perhaps related to maternal hematopoietic problems and preeclampsia.

Overall, patients with FA had decreased fertility, increased POI,⁴  and increased premature births and C-sections, as well as decreased hematopoiesis during gestation.^7-9  Those with DC had normal fertility, increased miscarriages, premature infants, and C-sections, as well as decreased hematopoiesis, although less common than in FA. One woman with DC had scarred fallopian tubes but did become pregnant after several attempts, whereas 1 with DBA and scarred fallopian tubes did not become pregnant. Despite the increased maternal and obstetric complications, most of the live-born babies were clinically well, although half of the babies from mothers with a dominant syndrome would be expected to be affected.

The topic of pregnancy in patients with an IBMFS was addressed by us in the past, and the conclusions from those reports,^6,10-13  the Gansner et al letter,¹  and our current analyses remain unchanged. Women with any IBMFS who desire pregnancy or are pregnant would benefit from care provided by a multidisciplinary team of fertility specialists, high-risk maternal-fetal specialists, neonatologists, and hematologists, with expertise in bone marrow failure disorders. The women may have hematologic problems that may worsen during pregnancy, the rate of C-sections may be high, and the fetuses may be premature or have neonatal problems (whether affected with the syndrome or not).¹⁴  In most cases, the maternal hematologic complications will be transient, and the women will return to their prepregnancy hematologic status. However, all individuals with these syndromes have variably increased risks of cancer, and thus, they must receive appropriate counseling and surveillance during pregnancies and beyond.¹⁵