Case Presentation: A G4P3 patient in her 30s with a past medical history of sickle cell disease (SCD) complicated by recurrent venous thromboembolism, prior transient ischemic attacks, a splenectomy, and avascular necrosis presented during her second trimester following her second pain crisis of the pregnancy. She had discontinued hydroxyurea and anticoagulation on her own six weeks into her pregnancy, consistent with previous guidance from prior pregnancies. Her previous pregnancies had been largely uncomplicated. Seven weeks after stopping hydroxyurea, she experienced a pain crisis requiring a 7 day hospitalization. Laboratory results revealed a hemoglobin of 8.2 g/dL and a reticulocyte count of 8.3%. Her pain was managed adequately and she was able to be discharged. A few weeks later, during her second trimester, she endured a second pain crisis. Her hemoglobin had fallen to 7.2 g/dL. After five days of hospitalization, her obstetrics team recommended restarting hydroxyurea, citing updated guidelines for high risk pregnancies. The inpatient hematology team advised her to remain without hydroxyurea for the remainder of the pregnancy, referencing their longstanding guidelines. After thorough counseling from both teams, discussing both benefits and risks, the patient elected not to resume hydroxyurea. She had cited concerns from previous pregnancies as her reason for remaining without hydroxyurea for this pregnancy. She continued to be managed by a multidisciplinary team and ultimately underwent cesarean delivery at 36 weeks after a 23 day hospitalization for a late pregnancy pain crisis. The infant required NICU care briefly but was discharged without complications. Postpartum, the patient developed a DVT and was restarted on hydroxyurea and anticoagulation.
Discussion: This case highlights a major area of clinical controversy in hospital medicine: managing pregnant patients with SCD when specialty-specific guidelines conflict. Although hydroxyurea is first-line therapy for reducing vaso-occlusive crises and acute chest syndrome in nonpregnant adults, its safety in pregnancy remains uncertain. Hematology guidelines continue to advise discontinuation due to animal teratogenicity and limited human data, whereas obstetric guidelines now support selective use after the first trimester for patients at high risk of morbidity. Conflicting recommendations created uncertainty for both clinicians and patients, emphasizing the importance of collaborative multidisciplinary evaluation in high-stakes inpatient settings. Because evidence remains observational and confounded by indication, neither guideline offers definitive risk–benefit clarity. In these situations, hospitalists often serve as coordinators of care, facilitating alignment of specialty input, patient values, evolving evidence, and real-time clinical acuity.
Conclusions: When evidence-based guidelines diverge, multidisciplinary collaboration and shared decision-making are essential for safe, patient-centered care. This case demonstrates how hospitalists can bridge specialty disagreements, ensure transparent counseling regarding risks and uncertainties, and support individualized management for complex pregnant patients with SCD.