Transfusion Management in Pregnancies Complicated by Hemoglobinopathies: Evidence, Guidelines, and Clinical Challenges

Abstract This review examined the evidence and guidelines on transfusion strategies, targets, and complications in pregnant women with hemoglobinopathies through a narrative review of literature published from 2010 to 2025, including randomized trials, observational studies, systematic reviews, and guidance from the American Society of Hematology, the British Society for Haematology (BSH), and International Society of Blood Transfusion, as well as regional recommendations and consensus statements from thalassemia-endemic areas such as China and Southeast Asia. The findings show that pregnancy substantially alters transfusion requirements and risks in this population. In sickle cell disease, prophylactic transfusion strategies targeting hemoglobin levels of 10–11 g/dL and sickle hemoglobin fractions below 30% are associated with reduced vaso-occlusive complications and improved maternal and fetal outcomes (Grade B evidence, supported by BSH, the Society for Maternal-Fetal Medicine, and observational meta-analyses). In β-thalassemia major, transfusion support during pregnancy typically requires intensification to maintain hemoglobin levels between 9.5–10.5 g/dL (Grade B, BSH guideline), particularly because interruption of iron chelation therapy during gestation increases the risk of iron overload and cardiac complications. Chinese and Southeast Asian expert recommendations similarly support maintaining hemoglobin at or above 10 g/dL to promote fetal growth and reduce maternal cardiac stress (Grade C, expert consensus). At the same time, transfusion-related complications, including alloimmunization, delayed hemolytic reactions, circulatory overload, acute lung injury, and iron toxicity, remain important clinical concerns. Overall, transfusion management in pregnancies complicated by hemoglobinopathies requires individualized, evidence-based strategies, careful surveillance for complications, and close multidisciplinary collaboration to optimize maternal and fetal outcomes, while incorporation of global and regional evidence enhances the relevance and applicability of current recommendations.