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OJHAS Vol. 8, Issue 3: (2009
Jul-Sep) |
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Successful Pregnancy Outcome in a Patient of Chronic Myeloid Leukaemia (CML) Without Any Therapy |
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Joydeb Roychowdhury,
Associate Professor, Dept. of G&O,
Arup Kumar Kundu, Professor, Dept. of General Medicine,
Maitryaee Bhattacharya, Associate professor
Dept. of Haematology,
Nil Ratan Sircar Medical College, 138 AJC Bose Road, Kolkata - 700014, India.
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Address For Correspondence |
Associate Professor,
Dept. of G&O,
Nil Ratan Sircar Medical College,
138 AJC Bose Road,
Kolkata - 700014, India
E-mail:
rcjoydeb@gmail.com |
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Roychowdhury J, Kundu AK, Bhattacharya M. Successful Pregnancy Outcome in a Patient of Chronic Myeloid Leukaemia (CML) Without Any Therapy. Online J Health Allied Scs.
2009;8(3):15 |
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Submitted: Sep 28, 2009; Accepted:
Sep 30, 2009 Published: Nov 15, 2009 |
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| Abstract: |
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The management of cancer during pregnancy may pose
difficulty for patients, their families and physicians. The concomitant occurrence of pregnancy and CML is very
rare since it is a malignancy which is most commonly detected in elderly. A 30 years old female was diagnosed as a
case of CML and prescribed hydroxyurea which she stopped on her own after taking for few months. The patient conceived
one month after stopping hydroxyurea. She did not agree to terminate the pregnancy even on repeated requests. Though the
total leucocyte count was in the range of 150-200X103/ml, she refused to take any form of therapy till delivery.
Antenatal period was uneventful and at term she delivered a male child normally. The mother developed secondary
postpartum hemorrhage which was controlled after exploration and removal of retained bits of placenta. Hydroxyurea
was started 4 weeks after delivery. Both the mother and the child are doing well
till date.
Key Words: Chronic myeloid leukemia, Pregnancy
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The real incidence of leukemia during
gestation is not well known. It is estimated to range from 1 in 75,000 to 100,000 pregnancies.[1] Acute leukemias
are more frequent with pregnancy. CML is very rare and accounts for less than 10% of all cases. The management
of CML during pregnancy is a difficult problem because of the potential effects of therapy on the fetus. In this
circumstance, the physician should not only provide adequate treatment to ensure continued maternal well-being but
also avoid fetal compromise. In this case report, we describe a CML patient with pregnancy who delivered a healthy
baby at term without any therapy.
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A 30 year old woman with chronic myeloid
leukemia attended antenatal clinic of NRS Medical College, Kolkata around 32weeks of pregnancy. The patient
was married for 6 years. She had history of two spontaneous abortions at 12 and 20 weeks of gestation in early
years of her married life. Following these miscarriages, she was suffering from secondary infertility. Old
documents showed that she attended local physician for dragging pain in the left upper abdomen and was found
to have moderate splenomegaly. Subsequent peripheral blood and bone marrow examination confirmed it to be a
case of Philadelphia chromosome positive CML. She was prescribed hydroxyurea, which she took for 5 months and
stopped on her own. She conceived in the next cycle spontaneously. Physical examination showed that she had
mild pallor associated with a huge splenomegaly. Uterus was 28-30 weeks (4 cm above the umbilicus) deviated
to the right and carrying a small, growth-retarded fetus with a heart rate of 140/min. Opinion of the
hematologist was immediately sought for. Complete hemogram showed Hb-9.2 g%, Hct-28.2%, MCV-94.3fl,
MCH-33.4 pg/ml, WBC 175X103/l, platelets-601X103/l, and differential count showed Polymorphs 36, Lymphocytes 12, Monocytes 7 Basophils 4, Eosinophils 2,
with myelocyte 19%, metamyelocyte17%, blast cell 3%. Blood biochemistry revealed normal liver function test,
and blood sugar, urea, creatinine and uric acid levels were 133mg%, 24mg%, 0.8mg%, 11mg% respectively. She was
advised to take hydroxyurea or to undergo leukapheresis till
delivery. She refused to take any sort of therapy till the pregnancy
got over.
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Figure 1: The Chronic Myeloid Leukaemia Patient With
Hepatosplenomegaly |
The patient was kept under close monitoring with weekly blood count and blood
biochemistry. Her Hb% remained around 9g%, WBC count varied between 150 –200 X 103 /ml, blood biochemistry
remained normal except a high uric acid level. She went into labour at 37 weeks and delivered normally a healthy
male child of 2.5 kg. On 8th day of puerperium she developed secondary post partum hemorrhage, which required
exploration under general anesthesia and blood transfusion. After one week she was discharged from the hospital,
and asked to attend haematology out patient department and well baby clinic regularly. She was put on hydroxyurea
as per advice of the haematologist. Both the mother and the baby are doing well after 6 months of follow-up.
The coincidence of CML and pregnancy is an
uncommon event, in part because CML occurs mostly in older age groups. In contrast this patient is a case
of CML presented at young age. Pregnancy and cancer is a complex situation. Often treatment cannot be delayed.
When chemotherapy is needed urgently, this typically requires termination of pregnancy.[2] Many patients with CML
have been reported to have a successful pregnancy. CML has been treated during pregnancy with busulfan,
alpha-interferon, hydroxyurea and leukapheresis. Unfortunately, the potential teratogenic effects of chemotherapy
on the fetus make their use during pregnancy much less attractive. Indeed, congenital malformations have been
associated with busulphan therapy during pregnancy in at least three cases.[3] Teratogenic effects have also been
seen in the offspring of rats given five times the normal human dose of hydroxyurea.[4] Although, alpha-interferon
has not been associated with teratogenicity in either animal studies or in humans receiving the drug during pregnancy,
it has been shown to have abortifacient effects in rhesus monkeys, albeit at doses many times higher than those used
to treat patients.[5] Arguably, there are other reports[6-8] of pregnant patients receiving busulphan, hydroxyurea, or
alpha-interferon without apparent teratogenic or abortifacient effects. However, there is paucity of data regarding
CML patients on imatinib mesylate becoming pregnant and completing pregnancy.[2] Imatinib has been found to be
teratogenic in rats. This patient with two previous fetal loss when conceived after a period of secondary infertility
refused to take any form of therapy when explained about the potential effect of therapy on the fetus. But fortunately
pregnancy without any medication in the antenatal period continued uneventful and had successful outcome. While CML
may not need to be treated immediately, and pregnancy does not appear to affect the course of the disease, there is
still a risk of leukostasis, as well as the risk of placental insufficiency with consequent below-normal fetal birth
weight, increased fetal prematurity, and increased mortality if CML is left untreated through out the pregnancy.[9]
Fortunately, the antenatal and intranatal periods of the patient were uneventful and she delivered a healthy baby.
The secondary postpartum haemorrhage that she experienced was mainly due to the retained bits of placenta and not
related to the disease process.
- Haas JF. Pregnancy in association with a newly diagnosed cancer: a population-based epidemiologic assessment.
Int J Cancer 1984;34:229-235.
- Heartin E, Walkinshaw S, Clark RE. Successful outcome of pregnancy in chronic myeloid leukemia treated with imatinib.
Leuk Lymphoma 2004;45:1307–1308.
- Caligiuri MA, Mayer RJ. Pregnancy and leukemia.
Sem Oncol 1989;16:388–396.
- Asano Y, Okaniwa A. In utero morphological effects of hydroxyurea on the fetal development in Sprague-Dawley rats.
Exp Anim 1987;36:143–149.
- Physicians Desk Reference. 51st Edition. Montvale, NJ. Medical Economics Company, Inc. 1997. p 2308–2311.
- Earll JM, May RL. Busulfan therapy of myelocytic leukemia during pregnancy.
Am J Obstet Gynecol 1965;92:580–581.
- Jackson N, Shukri A, Ali K. Hydroxyurea treatment for chronic myeloid leukaemia during pregnancy.
Br J Haematol 1993;85:203–204
- Crump M, Wang X-H, Sermer M, Keating A. Successful pregnancy and delivery during alpha-interferon therapy for chronic myeloid leukemia.
Am J Hematol 1992;40:238–239.
- Juarez S, Cuadrado Pastor JM, Feliu J, Gonzalez Baron M, Ordonez A, Montero JM. Association of leukemia and pregnancy: clinical and obstetric aspects.
Am J Clin Oncol 1988;11:159–65.
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