Acute promyelocytic leukemia and pregnancy

Abstract

In acute promyelocytic leukemia (APL), the use of all-trans-retinoic acid (ATRA) as a differentiating agent induces complete remission in a high percentage of patients. In pregnancy, however, this drug bears the risk of severe teratogenicity to the child. We report the case of a 23-yr-old woman at 21 weeks' gestation suffering from APL. She was treated with ATRA (45 mg/m2) for 40 d and two courses of standard chemotherapy. The mother achieved complete remission within 22 d of treatment. Fetal development was normal, and a healthy premature girl was born in the 35th week of pregnancy. In a review of the literature we have identified 14 cases of APL in pregnancy treated with ATRA alone or in combination with chemotherapy. ATRA has been used as early as in the 3rd week of gestation and in no case have malformations or other teratogenic effects occurred. Side-effects, however, ranged from fetal cardiac arrhythmias to induction of labour. Although known to exhibit severe teratogenic effects during the first trimester of pregnancy, ATRA seems to be reasonably safe during the second and third trimesters in the treatment of APL. However, careful obstetric follow-up is mandatory regarding fetal cardiac complications.

Acute promyelocytic leukemia during pregnancy

“…In the literature we can find some examples of babies, born from mothers treated with chemotherapy during pregnancy, with no abnormalities. In the second and third trimesters, pregnant woman can be treated like a nonpregnant one (7)(8)(9)(10). During therapy it is important to control fetal growth and the heart's function, and to monitor and promptly treat the retinoid acid syndrome (5).…”

Guidelines on the diagnosis and treatment for acute promyelocytic leukemia: Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular Guidelines Project: Associação Médica Brasileira - 2013

“…All began treatment soon after diagnosis with varying schemes: ATRA alone, ATRA associated to an anthracycline and/or cytarabine, and/or other systemic chemotherapy or chemotherapy without ATRA (C) 83., 84., 85., 86., 87., 88., 89., 90., 91., 92.…”

“…Of the women diagnosed in the second trimester of pregnancy, 76.2% delivered by C-section or vaginal birth, 4.8% had miscarriages and there were no reports on 19%, with 57.1% having been treated with ATRA in isolation or in association with systemic chemotherapy. Of the pregnant women of third trimester, all 100% had C-sections or normal births and 77.8% were treated with ATRA alone (D) 83., 84., 85., 86., 87., 88., 89., 90., 91., 92.. All women showed significant improvement of the management of bleeding disorders at varying degrees after the first week of treatment, especially those receiving ATRA in isolation or associated with other medications (C) 83., 84., 85., 86., 87., 88., 89., 90., 91., 92.…”

How I Treat Newly Diagnosed Acute Promyelocytic Leukemia

“…The treatment approach depends largely upon the trimester of pregnancy during which APL is diagnosed 54–55…”

“…Therefore, if elective termination of the pregnancy is unacceptable to the patient, the only available treatment option is the administration of chemotherapy alone. If treatment with chemotherapy alone is chosen, daunorubicin may be the preferred anthracycline for pregnant women because there is greater experience with this drug during pregnancy 54–55. If a remission is achieved and the pregnancy continues normally, ATRA may be added during the second or third trimester.…”