World Health Organization · 1st edition, 2025 · 80 pages
First WHO clinical guideline for managing sickle-cell disease across the maternity continuum, addressing medication, pain, monitoring, and birth for women and clinicians worldwide.
- Issuer
- World Health Organization
- Edition
- 1st edition, 2025
- Audience
- Health-care providers developing national/local protocols, maternal health programme managers, policy-makers, obstetricians, midwives, nurses, general practitioners, professional societies, NGOs
- Evidence
- GRADE and GRADE-CERQual methodology; recommendations based primarily on indirect evidence (physiological understanding, non-pregnant SCD populations, general pregnant population) due to paucity of trials; no strength grading assigned
- Reviewed
- 14 Oct 2026 · GMJ
What this guideline says
GMJ summary
This is the first WHO guideline specifically addressing sickle-cell disease (SCD) in pregnancy, a condition affecting 7.74 million people globally with highest burden in sub-Saharan Africa and other historically malaria-endemic regions. Maternal mortality is 4- to 11-fold higher in women with SCD compared to those without, with even higher rates in low-income countries. The guideline provides 21 recommendations covering medication management (folic acid, iron, hydroxycarbamide, prophylactic transfusion), pain management, fluid management during hospitalisation, thromboprophylaxis, fetal monitoring, timing and mode of birth, and interpregnancy care.
Key management principles include: continuing or initiating folic acid supplementation up to 5 mg daily (except 400 µg when taking sulfadoxine-pyrimethamine for malaria); avoiding routine iron supplementation unless iron deficiency is confirmed; considering continuation of hydroxycarbamide after the first trimester based on shared decision-making; offering prophylactic transfusion for women with severe intractable crises; and implementing thromboprophylaxis for hospitalised women unless contraindicated. The guideline emphasises individualised pain-management plans, frequent monitoring for fluid overload, growth scans every 4 weeks from 24–32 weeks then every 3 weeks until birth, and decisions about timing and mode of birth based on individual circumstances and woman’s preferences.
Developed using GRADE methodology, the recommendations are based primarily on indirect evidence due to paucity of trials in pregnant women with SCD, drawing on physiological understanding, evidence from non-pregnant SCD populations, and the general pregnant population. The guideline adopts a life-course approach, recognising that improving outcomes requires integration of noncommunicable disease care with sexual, reproductive, maternal and newborn health services, and addressing the stigma and health inequities faced by people with SCD.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Folic acid: Continue or initiate up to 5 mg daily (or 400 µg if taking sulfadoxine-pyrimethamine for malaria prophylaxis)
- Iron: Supplement only if iron deficiency confirmed (use ferritin >70 µg/L threshold under inflammatory conditions); avoid routine supplementation due to iron overload risk from transfusions
- Hydroxycarbamide (hydroxyurea): Consider continuation/recommencement after first trimester via shared decision-making with multidisciplinary team, based on symptom severity and woman's preferences
- Prophylactic transfusion: Consider for women with history of severe intractable crises or previous benefit from prophylaxis
- Pain management: Offer timely optimal relief with paracetamol, NSAIDs (lowest dose, avoid after 30 weeks), or opioids (lowest effective dose, shortest duration); develop individualised pain-management plans early in pregnancy
- Thromboprophylaxis: Offer to all hospitalised pregnant women with SCD unless contraindicated; for non-hospitalised women, consider additional VTE risk factors and follow local recommendations
- Fetal monitoring: Growth/biometric scans every 4 weeks from 24–32 weeks, then every 3 weeks until birth for uncomplicated pregnancies; intensive individualised monitoring if complications present
- Birth: Individualise timing based on balance of fetal maturation benefits versus maternal/neonatal morbidity risks; vaginal birth preferable in absence of medical/obstetric indications for caesarean
Recommendations on medication management for women with SCD presenting for antenatal care
Table extracted from the guideline
| Medication | Recommendation |
|---|---|
| Folic acid (outside malaria areas) | Continue or initiate daily supplementation up to 5 mg |
| Folic acid (with IpTp-SP) | 400 µg daily only (higher doses counteract antimalarial efficacy) |
| Iron | Not needed unless iron deficiency confirmed; if deficient, supplement as for general pregnant population |
| Prophylactic transfusion | Consider for severe intractable crises or previous benefit from prophylaxis |
| Hydroxycarbamide | Consider continuation/recommencement after first trimester via shared decision-making |
| Thromboprophylaxis (not hospitalised) | Consider additional VTE risk factors; follow local recommendations |
| Infection prophylaxis | Advise against routine prophylaxis; implement frequent screening with low diagnostic threshold |
Source: World Health Organization, Recommendations on the management of sickle-cell disease during pregnancy, childbirth and the interpregnancy period. Reproduced in summary form.
From the guideline
Verbatim
“Maternal mortality is 4- to 11-fold higher in women with SCD than in those without SCD, and is even higher in LICs.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As someone who has worked closely with WHO on health system strengthening in Georgia and the region, I recognise that while sickle-cell disease prevalence is lower here than in sub-Saharan Africa, this guideline addresses critical gaps for our migrant populations and provides a model for integrated chronic disease management in pregnancy. The recommendation I would particularly stress to Georgian clinicians is the need for confirmed iron deficiency before supplementation—our tendency toward routine iron supplementation in all anaemic pregnant women could cause harm in SCD patients already at risk of iron overload from transfusions. The realistic implementation challenge for Georgia and neighbouring countries will be establishing the specialist multidisciplinary teams (haematologist, obstetrician, neonatologist) required for optimal care; these may only be feasible in tertiary centres like the National Center for Disease Control or Tbilisi teaching hospitals, requiring robust referral pathways from primary care where most antenatal care occurs. The guideline's emphasis on shared decision-making and individualised care, particularly around hydroxycarbamide continuation, aligns well with Georgia's 2013 patient rights framework but will require training our providers who may lack experience with this rare condition.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 14 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia and the South Caucasus region have lower prevalence of sickle-cell disease compared to sub-Saharan Africa, but the condition is present in populations with migration from endemic regions and in some local populations. National programmes would need to consider: integrating SCD screening into existing antenatal care protocols; ensuring availability of folic acid at appropriate doses (5 mg formulations); establishing diagnostic capacity for iron deficiency (ferritin testing with inflammation-adjusted thresholds); developing referral pathways to haematology specialists; ensuring blood transfusion services can provide screened products; and training primary care providers to recognise and manage SCD complications in pregnancy. The recommendation for thromboprophylaxis with LMWH may face cost barriers in lower-resource settings where unfractionated heparin could be considered as alternative. Integration with existing maternal health services under Georgia’s UHC programme would facilitate implementation, but specialist multidisciplinary teams (obstetrician, haematologist, neonatologist) may be concentrated in tertiary centres, requiring clear referral protocols.
Questions this guideline answers
Quick answers
What dose of folic acid should pregnant women with SCD receive?
Up to 5 mg daily for women living outside malaria-endemic areas. For women taking sulfadoxine-pyrimethamine for malaria prevention, only 400 µg daily as higher doses counteract the antimalarial's efficacy. This is higher than the 400 µg recommended for the general pregnant population due to increased folate requirements from chronic haemolytic anaemia.
Should all pregnant women with SCD receive iron supplementation?
No. Iron supplementation should only be given if iron deficiency is confirmed, as women with SCD receiving blood transfusions are at risk of iron overload. Use ferritin concentrations to assess iron stores, with a higher threshold (70 µg/L) recommended under conditions of infection and inflammation. Ferritin >500 µg/L may indicate risk of iron overload requiring further evaluation.
Can hydroxycarbamide be continued during pregnancy?
Consider continuation or recommencement after the first trimester through shared decision-making involving the woman and multidisciplinary team including SCD and pregnancy experts. Base the decision on the woman's symptom severity, stage of pregnancy, and her views and preferences. While historically contraindicated due to animal studies, recent non-randomised studies suggest teratogenicity odds may not be increased, though links with miscarriage, stillbirth and low birthweight have been reported.
How often should fetal growth be monitored in pregnant women with SCD?
For women without complications: offer growth/biometric scans every 4 weeks from 24 until 32 weeks' gestation, then every 3 weeks until birth to identify fetal growth restriction. For women with complications (SCD-related or obstetric): offer individualised intensive monitoring considering the woman's preferences and availability of equipment and skilled staff. This is more frequent than standard care due to increased risk of placental insufficiency (69% have placental pathology, 40% have maternal vascular malperfusion).
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- Issuer
- World Health Organization
- Type
- Guideline
- Edition
- 1st edition, 2025
- Status
- Current
- Published
- 2025-06-17
- Languages
- English; translations into UN official languages planned
- Scope
- Management of sickle-cell disease during pregnancy, childbirth and interpregnancy period; medication management, pain management, hospitalised care, fetal monitoring, birth timing/mode, postnatal/interpregnancy care
- Audience
- Health-care providers developing national/local protocols, maternal health programme managers, policy-makers, obstetricians, midwives, nurses, general practitioners, professional societies, NGOs
- Pages
- 80
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- GRADE and GRADE-CERQual methodology; recommendations based primarily on indirect evidence (physiological understanding, non-pregnant SCD populations, general pregnant population) due to paucity of trials; no strength grading assigned
- Next review
- Not specified; to be determined by WHO Maternal and Perinatal Health Guideline Technical Advisory Group
- Record history
- Created 14 Oct 2026 · updated 14 Oct 2026 · next check Apr 2027
WHO recommendations on the management of sickle-cell disease during pregnancy, childbirth and the interpregnancy period. Geneva: World Health Organization; 2025.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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