Case 51 – summary

Thank you for all of your input this week.

This week we looked at a patient who was diagnosed with AML in the 3rd trimester of pregnancy. She initially presented with a rash which, following a biopsy, was diagnosed as leukaemia cutis.

Following discussion with the patient , haematology team, obstetric, neonatal and anaesthetic team it was decided to deliver the baby prior to starting chemotherapy. Following induction of labour a healthy baby was delivered at 32 weeks gestation following a course of steroids to help with foetal lung maturity.

The patient was started on daunorubicin and cytarabine chemotherapy. On day 6 of chemotherapy the patient developed rash, pure is and myalgia. It was thought that this may be cytarabine syndrome. During this time the patient was started on tazocin, cultures came back negative. 

After 25 days the patient recovered her blood counts and a bone marrow revealed morphological remission with blasts count of 1%. Cytogenetics were normal which puts our patient in an intermediate risk category. The choice of whether allo transplantation or chemotherapy only in patients in the intermediate risk category who go into remission following the first cycle of chemotherapy is a debated area. Following discussion with the transplant team our patient declined an allo transplant and went on to complete a total to 2 cycles of DA and 2 cycles of high dose cytarabine.

When investigating a pregnant patient with cytopenias a fbc, blood film, coagulation screen, u+e, LFT and haematinics should be performed prior to bone marrow investigation.

When AML is diagnosed during pregnancy, a MDT approach to care must always given. When AML is diagnosed in the first trimester a successful outcome is unlikely. AML can increase the risk of foetal growth restriction, miscarriage and perinatal mortality. 

Given the risks of diagnosis in the first trimester an elective termination of pregnancy can be offered. Elective termination is felt to be safer than spontaneous miscarriage as control of blood parameters is better in the elective setting. Chemotherapy given during first trimester has been associated with 10-20% risk of major malformations.

When AML is diagnosed in the 2nd and 3rd trimesters chemotherapy can be given, however there is an increased risk of late miscarriage, prematurity, foetal growth restriction, neonatal neutropenia and sepsis. However it will rarely cause congenital malformations. Delivery at >28 weeks has an at least >90% of foetal survival. Chemotherapy should be avoided at >36 weeks as spontaneous delivery is likely to occur prior to count recovery.

There is debate whether foetal exposure to anthracyclines can cause cardiotoxicity. Cardiomyopathy has been transient my reported in neonates exposed to anthracyclines. Foetal/neonatal u/s can be considered to monitor for this.

If chemotherapy is given during pregnancy a foetal ultrasound should be done every 2 weeks. 

Teams need to be very vigilant for development of sepsis in patients and consideration for antibiotics and the potential effects in the foetus need to be considered. Antifungals may be needed in pregnancy, amphoteracin B is the anti fungal which has been most widely used in pregnancy. Animal studies have shown that azoles can have teratogenic effects.

If a pregnant patient needs transfusing CMV negative component will be needed, however these are not needed during labour. If transfusion is needed urgently then leucodepleted CMV untested components can be used. 

When thinking about delivery a planned delivery is preferred as appropriate blood product support, and timings between chemotherapy can be planned. Neonates can develop myelosupression from maternal chemotherapy, and administration of chemotherapy 2-3 weeks prior to delivery.

Vaginal delivery is preferred to Caesarian as there is a decreased risk of infection and quicker recovery. Anaesthetic team should be involved early to discuss analgesia and factors such as thrombocytopenia may affect choice eg epidural anaesthesia.

As in our case steroids were given 48 hours prior to delivery to aid with foetal lung maturity and reduce the risks of premature delivery.

Mothers are advised that it is not safe to breastfeed while on or 2 or more weeks after chemotherapy.

Assessment of all patients for risk of VTE should be made and LMWH given if indicated and safe following delivery.

Have you got any questions regarding our case this week, would you have done anything differently? Thank you again for all of your input in this weeks case!

About TeamHaem

Online education and discussion about all things haematological
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