Pregnancy Outcomes in Women with Sickle Cell Disease in Ireland: A Retrospective Review

Background: Sickle cell disease (SCD) is one of the most common single gene disorders worldwide and is characterised by significant morbidity and early mortality.[1] Pregnancy in SCD is associated with an increased risk of maternal and foetal complications.[2,3] The 2011 RCOG and the 2021 BSH guidelines[5,6] on the management of pregnancy in SCD have provided the basis for best practice care in the UK over the past decade and is the guidance which we follow in Ireland. To date, there is no published data on outcomes for pregnant women with SCD in Ireland. The number of Irish patients with SCD has risen over the past 20 years. Without a national database, the exact prevalence is not known but currently there are at least 600 adults and children with SCD in Ireland, whose population is just over 5 million.[4] Aims: Our study assesses outcomes of pregnant patients with SCD from 2015 to 2022. Our aims were to: * Assess adherence to current guidelines * Assess pregnancy outcomes and maternal complications * Assess transfusion rates amongst our patient cohort. Method(s): This is a retrospective cohort study. We do not have a directly matched cohort, but have compared our findings to published data on Irish pregnancy outcomes from the Irish Maternity Indicator System National Report and have correlated our findings with studies of women with SCD who were managed in UK centres.[8,9,10] Results: We reviewed outcomes of 29 pregnancies in 19 women over a 7-year period. The median age was 29 (range 20-41) and the predominant maternal sickle genotype was HbSS (65.5%). Before conception, 55.2% of cases had pre-existing complications of SCD, including acute chest syndrome (ACS), pulmonary hypertension (PHTN) and prior stroke. In accordance with current guidelines, 100% of women (n=29) were prescribed folic acid, penicillin, and aspirin prophylaxis. 51.7% (n=15) of women had documented maternal complications during pregnancy, including ACS (34%), vaso-occlusive crisis (34%), gestational diabetes (10%), VTE (3%) and UTI (3%). Two women (7%) developed Covid-19 pneumonitis despite vaccination. There was one case of maternal bacteraemia (3%). 65.5% of cases (n=19) required blood transfusion during pregnancy. One woman was already on a blood transfusion programme for disease modification prior to pregnancy. In 6 cases (20.6%), a transfusion programme was commenced during pregnancy due to prior pregnancy complications or intrauterine growth restriction. During pregnancy, 27.6% (n=8) of women required emergency red cell exchange for ACS. Prior studies have suggested that between 30% and 70% of pregnant women with SCD require at least one blood transfusion during pregnancy.[8,9,10] By comparison, only 2.6% of the Irish general obstetric population required transfusion during pregnancy.[7] 20.6% (n=6) of births were preterm at <37 weeks' gestation. There was one live preterm birth (3%) at <34 weeks and one intrauterine death (3%) at 23 weeks' gestation. Similar to UK data[9], 31% of women required critical care stay (n=9) during pregnancy, in comparison with 1.44% nationwide in 2020.[7] Conclusion(s): It is well established that pregnancy in SCD is high risk, and despite adherence to current guidelines, we have shown very high rates of critical care admission, significant transfusion requirement and hospital admissions. Our findings are comparable to published UK outcomes and they further support the need for a comprehensive specialist care setting for this patient cohort.

Conclusion: Building a Resilient State and Inclusive Society

There are several global historical lessons that South African policymakers can deploy as a framework for shaping the future economic policy and growth trajectory. The most significant lesson is that the state has a central role to play in tackling health and economic crises, and in laying the foundation for post-crisis reconstruction. The South African government can exploit the COVID-19 emergency to enact long-delayed structural reforms to reverse the country’s economic stagnation and propel a new post-COVID-19 growth path. To do this, however, will require significant improvements in state capacities across the different spheres of government. There are policy options that are open to the South African state today in the realms of public health, national innovation, institutional capabilities, economic reform as well as community interventions. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

The Digital Divide in South Africa: Insights from the COVID-19 Experience and Beyond

The COVID-19 pandemic has placed digitalization firmly on the development agenda. Although the pandemic has caused enormous social and economic devastation, it presents developing countries—particularly in Africa—with an opportunity to fast-track their plans toward a digital transition. There are binding constraints that make it harder for many developing countries to undertake this transition. These include lack of infrastructure, networks, technologies, and related skills. South Africa also finds itself in a similar bind. The digital uptake is driven by several factors such as affordability, digital literacy, and fit for purpose content as discussed in the chapter. These factors impact the pace of progress in South Africa’s digitalization efforts. The assessment of South Africa’s internet users’ profile also provides insights on why the factors impact uptake. The chapter concludes by laying out recommendations for increased connectivity and onboarding onto the broadband platforms. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Introduction: Responding to Pandemics and Economic Challenges: Policy Choices Post Covid-19

This research project was initiated at the beginning of the COVID-19 pandemic, a time marked by significant economic and social dislocations around the world. The project considers public policy responses to the social and economic dislocations spawned by the pandemic, and identifiers opportunities for implementation of reforms that will shape the future economic policy and growth trajectory. It studies the pandemic closely and does so through a socio-economic lens that draws on history, approaches to state-market relations, and public policy perspectives. International historical experience has shown that countries and societies that have gone through tough economic times, either as a consequence of wars or economic depressions, have enacted unpopular policy measures based on difficult trade-offs, and which yielded innovation. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.