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Background The absence of the red cell antigens P, P1 and Pk , known as 'p', represents an extremely rare red cell phenotype. Individuals with this phenotype spontaneously form anti-PP1Pk isoantibodies, associated with severe haemolytic transfusion reactions, recurrent spontaneous abortion and haemolytic disease of the fetus and newborn (HDFN). Methods We report a series of four successful pregnancies in three women with anti-PP1Pk isoantibodies, one complicated by HDFN, another by intrauterine growth restriction, all managed supportively. We also review the literature regarding the management of pregnancy involving anti-PP1Pk isoimmunization. Results The literature surrounding anti-PP1Pk in pregnancy is limited to a very small number of case reports. The majority report management with therapeutic plasma exchange (TPE) with or without intravenous immunoglobulin. The relationship between titre and risk of pregnancy loss remains unclear, though a history of recurrent pregnancy loss appears important. Although a positive cord blood direct antiglobulin test is frequently noted, clinically significant HDFN appears uncommon, though possible. Conclusion Early initiation of TPE in high risk patients should be strongly considered. If possible, pregnancies should be managed in a high-risk obstetric or maternal fetal medicine service. The fetus should be monitored closely with interval fetal ultrasound and middle cerebral artery peak systolic volume Doppler to screen for fetal anaemia. Timely sourcing of compatible blood products is likely to be highly challenging, and both directed and autologous donation should be contemplated where appropriate. The International Red Cell Donor Panel may also provide access to compatible products.

To describe the characteristics and outcomes of women with inherited bleeding disorder during pregnancy and birth.Retrospective cohort study.Tertiary care hospitals, New South Wales and Victoria, Australia.One hundred women with inherited bleeding disorders, who birthed 134 live infants from 132 pregnancies.Data were retrospectively obtained from the patient and neonatal medical records. Descriptive analysis was used to report maternal and pregnancy characteristics and birth and neonatal outcomes.Factor replacement, neuraxial analgesia use and complications, postpartum haemorrhage (PPH) and neonatal complications.PPH occurred in 22% of deliveries with primary PPH occurring in 20% and secondary PPH in 2% of births; 48% of PPH were classified as major. PPH occurred across the spectrum of inherited bleeding disorders and was evenly distributed between women who had ‘normalised’ (46%) their factor levels in pregnancy compared with those requiring factor at the time of birth (50%). An obstetric cause was identified in almost half of PPH (46%). Neuraxial analgesia was administered in 40% of births without complication and refused in 3% of births despite documented adequate haemostatic potential.Women with inherited bleeding disorders can deliver safely and receive neuraxial analgesia without complication when best practices are adhered to. PPH appears to occur at higher rates than in the general population despite adequate factor levels or planned replacement. Although an obstetric cause was demonstrable in the many cases, these findings raise concern over the current definition of ‘adequate’ factor levels at the time of birth.Women with inherited bleeding disorders can deliver without complication when best practices are maintained.

Thrombocytopenia in pregnancy is a common occurrence, affecting up to 10% of women by the time of birth. These recommendations aim to provide pragmatic guidance on the investigation, diagnosis and management of thrombocytopenia in pregnancy; including safety of neuraxial anaesthesia and precautions required for birth. Management of neonatal thrombocytopenia is also addressed. The authors are clinicians representing haematology, obstetric medicine, maternal-fetal medicine, and anaesthesia. Each author conducted a detailed literature review then worked collaboratively to produce a series of unanimous recommendations. The recommendation strength is limited by the lack of high-quality clinical trial data, and represents level C evidence.

In this clinical review we highlight aspects of the diagnosis and management of pulmonary embolism (PE) in pregnancy and post-partum and how this may impact on antenatal and postnatal management. Investigation for PE in pregnancy is challenging and includes appropriate patient selection and knowledge of the risks and benefits of pulmonary imaging modalities. The complete Society of Obstetric Medicine of Australia and New Zealand Position Statement on Pulmonary Embolism in Pregnancy and Post-Partum comprehensively reviews all aspects of diagnosis, investigation and management and is accessible at https://www.somanz.org/guidelines.asp. It includes a summary of all recommendations and a guide to developing a management plan for birth in women on anticoagulation.

Key content Thrombophilias, whether inherited or acquired, have been linked to adverse pregnancy outcomes, such as pre-eclampsia, placental abruption, fetal growth restriction, stillbirth, thrombosis and recurrent pregnancy loss in many but not all case–control studies. Prospective cohort studies have confirmed that the majority of women who carry inherited thrombophilias do not experience adverse pregnancy outcomes. Thrombophilia testing is expensive and the positive yield of such investigations, in particular with respect to informing management in a subsequent pregnancy, is low. This review critically evaluates the benefit of thrombophilia testing in the obstetric setting and provides guidance with respect to care of women in a subsequent pregnancy following an adverse outcome. Learning objectives To understand the relationship between the various thrombophilias and pregnancy complications. To appreciate the appropriate role of screening for and treating thrombophilias in the context of such pregnancy complications. Ethical issues Should thrombophilia testing following adverse pregnancy outcome be informed by specific factors in the clinical history? Can placental histopathology help guide selection of women requiring further assessment? Thrombophilias may be associated with thromboembolic complications in later life – is it therefore ethical to withhold testing in women with a history of adverse pregnancy outcomes?

The recombinant human keratinocyte growth factor, palifermin, offers a potential means of reducing or preventing mucositis in patient undergoing intensive cancer treatments. This case report details the development of acral erythrodysaesthesia in one patient who underwent palifermin treatment prior to high-intensity re-induction chemotherapy for acute myeloid leukaemia.

The recombinant human keratinocyte growth factor, palifermin, offers a potential means of reducing or preventing mucositis in patient undergoing intensive cancer treatments. This case report details the development of acral erythrodysaesthesia in one patient who underwent palifermin treatment prior to high-intensity re-induction chemotherapy for acute myeloid leukaemia.