Re: Sickle cell disease and β-thalassaemia major in pregnancy


Dear Sir

We read with interest, the article on sickle cell disease and β-thalassaemia major in pregnancy.[1] We would like to comment on the information under contraceptive problems.

The authors state that two thirds of pregnancies in women with sickle cell disease were unplanned and contraceptive advice is lacking for these women. Also there was a comment in this article that the majority of women with sickle cell disease receive either confused advice or none at all. This is a sad reflection on lack of communication with the College's Faculty of Sexual and Reproductive Healthcare whose members can ensure that these women are seen in specialised contraceptive and sexual health clinics for contraceptive advice. They can then be started on a safe, reliable and effective contraceptive method.

The combined oral contraceptive pill (COC; also the patch or ring) is UKMEC[2] Category 2 for this condition (a condition where the advantages of using the method generally outweighs the theoretical or proven risk – in this condition, the theoretical risk of thromboembolism) and can be prescribed as a method of contraception. However, progestogen-only contraceptive methods are UKMEC Category 1 (a condition for which there is no restriction for the use of the contraceptive method) and can also be considered as methods of contraception.

It was stated that the efficacy of the contraceptive pill may be compromised by the use of broad spectrum antibiotics during a sickling episode. The latest guidance from FSRH on drug interactions with hormonal contraception[3] recommends no additional contraceptive precautions during or after courses of antibiotics other than those that induce liver enzymes. Overall the evidence does not generally support reduced COC efficacy with non-enzyme inducing antibiotics.

The authors of this article suggest that clinicians are reluctant to advise use of the intrauterine contraceptive device (IUD) because of the potential complication of menorrhagia, exacerbating the anaemia and infection, provoking acute sickling crises. It is true that the use of the copper IUD can cause heavy or prolonged bleeding but it does not in itself increase the risk of pelvic infection. Pelvic inflammatory disease (PID) among IUD users is most strongly related to the insertion procedure and to the background risk of sexually transmitted infections.[4] There may be an increased risk of pelvic infection in the 20 days following insertion of intrauterine contraception but the risk is the same as the non-IUD-using population thereafter. This method of contraception for women with these haemoglobinopathies is UKMEC Category 2 (a condition where the advantages of using the method generally outweigh the theoretical or proven risk – in this condition the theoretical risk of heavy or prolonged bleeding causing anaemia). The IUS (progestogen-releasing intrauterine system) can safely be used as a method of contraception; this method can lead to light bleeding or amenorrhoea.

When these women are seen in specialist contraception clinics, clinicians are able to work with the woman and offer all the methods of contraception that are safe, reliable and effective. It is entirely up to these women to make an informed choice and decide the contraceptive method that suits their lifestyle.

The authors acknowledge the importance of contraception for these women to prevent unplanned pregnancy – can we work together to ensure that better use is made of the college's expertise?