Hematological Complications in Obstetrics, Pregnancy and Gynecology

Obstetric haematology is an important area of medicine which is managed by a variety of medical practitioners. A comprehensive overview would be a useful addition to the library. I enjoyed reading this textbook which is in my specialty area of interest, Obstetric Haematology.

Hematological Complications in Obstetrics, Pregnancy and Gynecology attempts to provide relevant information on the aetiology, pathophysiology, clinical and laboratory diagnosis, and management of a wide range of haematological problems, including bleeding disorders, venous thromboembolic disease, haemolytic disease of the newborn, anaemia and genetic disorders. Obstetric and gynaecological areas range from pregnancy and miscarriage to menorrhagia and gynaecological malignancy. Haematological malignancies in pregnancy, such as acute myeloid leukaemia and essential thrombocytosis, are unfortunately not covered by this book.

The quality of the book rests on each individual chapter because they are written by different authors. Some chapters are outstanding, whereas others are quite disappointing. The highlights are summarized first.

The chapter on Hemolytic disease of the fetus and newborn caused by ABO, Rhesus and other blood group alloantibodies is concise, clear and up to date, providing not only clinically valuable information but a helpful description of the pathophysiology. It provides a good basis for practising obstetricians and registrars who are not routinely working with high-risk patients.

Likewise the chapter on Post partum haemorrhage (PPH) is a good overview with a helpful level of information covering obstetric, haematological and intensive care matters that relate to PPH. It was grounded in useful statistics on morbidity and mortality, and made reference to the variation between developed and developing world practices and outcomes. From a haematology perspective, I would have liked the haemorrhagic diatheses to be stratified according to prevalence, which would emphasize the more common disorders.

The chapter on Hemoglobinopathies in pregnancy summarizes the literature and effectively explains the tertiary level care of managing pregnancy in sickle cell disease. The management of patients with thalassaemia major, however, is not as comprehensive.

Genetic counselling and prenatal diagnosis is another valuable chapter which is clinically relevant, especially for clinicians not routinely involved in genetic disease but requiring this knowledge on a sporadic basis. Clinical genetics has changed dramatically in the last few decades and a useful foundation is provided. My only quibble is the lack of clarification of a non-universal term – haemoglobin fractionation.

The chapter on The rational use of blood and its components is a comprehensive reference text, which provides information that is not readily accessible to the non-haematologist. The detailed overview is a platform to guide clinical practice, understand and explain processes to the patient, and communicate with the blood service. The description of the management of Jehovah's Witnesses could have been expanded in its own subsection covering the clinical approach in patients who refuse the use of blood products.

Coagulation defects as a cause for menstrual disorders is a difficult area as the literature is sparse and data are lacking. Phillips explains concisely why this area is significant and divides the text into relevant and useful subheadings. His focus on von Willebrands disease is appropriate and the considerations for surgery are helpful.

However I have significant concerns about many chapters in this textbook, acknowledging that there is controversy in areas such as recurrent miscarriage, disseminated intravascular coagulopathy and thrombophilias.

The Recurrent miscarriage chapter provides no definition of the problem or its frequency. The chapter focuses on their centre's experience of 351 patients without an appraisal of the available literature or a discussion of possible reasons why there may be a discrepancy between studies. Likewise the Thrombophilia in pregnancy chapter is personal, not succinct and not consistent with published guidelines.^1–3 Similarly in Thromboprophylaxis and treatment of thrombosis in pregnancy there is conflict with published management guidelines – which I feel is misleading.^1–3 It would have been helpful to acknowledge variations in clinical practice and provide insights about these differences.

There are manuscript errors with inaccurate subheadings and disease entities described in incorrect subsections. I suspect that some areas are the special interests of the editors and so appropriate editing of large paragraphs of immense detail has not occurred. I was disappointed that Diagnosis of deep vein thrombosis and pulmonary embolism in pregnancy, despite the title, lacks an emphasis on the impact of the investigations in pregnancy – for example, the radiation dose in CTPA was not discussed.

There is also duplication of information, occasionally conflicting. There is overlap in the chapters on Hereditary and acquired thrombophilia in pregnancy, Thromboprophylaxis and treatment of thrombosis in pregnancy, Diagnosis of deep vein thrombosis and pulmonary embolism, Thrombosis prophylaxis and risk factors for thrombosis in gynecologic oncology and Low molecular weight heparins in pregnancy. There is a boxed warning from 2002 about Lovenox (enoxaparin) use in pregnancy in the Recurrent miscarriage chapter, which is not alluded to in later chapters. The duplication and contradictions detract from the reliability of this textbook.

It is always a challenge when publishing a textbook to write current practice when there is a time lag, compared with publishing papers in journals. Some attempts have been made to focus on pathophysiology, clinical features and principles of management. A reference to refer to current literature, where the data are evolving, would be pertinent.

Anaemia in pregnancy is an important area, especially reversible causes such as iron, B₁₂ and folate deficiencies. This was a large chapter and could be more succinct. Clinically relevant points are lost in the detail. I am concerned by some unorthodox suggestions and poor quality references. Including countries beyond North America would also help with applicability of this chapter, such as where there is no folate fortification of food.

In summary, it is difficult to recommend this text book, because a clinician who is unfamiliar with the field may not be able to discern which chapters are reliable and which chapters do not follow mainstream or evidence-based practice. It is a shame that poor quality material detracts from some exceptional chapters.