Chronic Myeloid Leukemia during Pregnancy: Report of Management and Outcome in Seven Patients.

Abstract

The occurrence of leukemia during pregnancy is very rare with an estimated incidence of one per 100,000 pregnancies annually. It has been estimated that during pregnancy most leukemias are acute: two thirds are myeloid (AML) and one third are lymphoid (ALL). Chronic myeloid leukemia (CML) is found in less than 10% of leukemias during pregnancy and chronic lymphocytic leukemia (CLL) is extremely rare. The management of CML during pregnancy is a difficult problem because of the potential effects of the therapy on the mother and fetus. Since the disease has an initial chronic phase, it is usually managed conservatively during pregnancy, while an aggressive approach, such as bone marrow transplantation, may be considered after delivery. A limited number of cases described successful treatment modalities of CML during pregnancy including leukapheresis, hydroxyurea (HU) and interferon (IFN). We report nine cases of pregnancy in seven chronic myeloid leukemia patients, giving birth healthy children in a single institution from 1979 to 2005. In four cases the diagnosis of CML was made on prebirth period in routine blood testing, and five pregnancies developed during the course of disease. Four of the pregnancies were found in the first trimester, four in the second and one in the third. Median age of patients was 21 years (range 18–30years). All patients were Ph1 positive and the leucocyte count ranged between 45 to 336 x 109 /L. Table 1 shows treatment performed in patients before and during pregnancy. Patients 4 and 7 had a subsequent pregnancy despite the use of contraceptive methods, both diagnosed in the first trimester. Hydroxyurea was stopped during pregnancy. Delivery was performed by caesarean section in 5 cases and by spontaneous vaginal delivery in 4 cases. All infants’ examination and blood counts were normal and there were no perinatal or maternal complications. In june 2005, two new cases of pregnant CML patients were seen at our institution. One of them was being treated with imatinib, and the other without treatment at the moment of pregnancy. They will be managed only with leukapheresis. Our data suggest that exposure to IFN and HU during pregnancy is probably not associated with a significantly increased risk for malformations, however leukapheresis can be considered for treatment of CML during pregnancy because of the lack of teratogenic and other adverse effects in patients who tolerate and respond to the procedure. Cases Age (years) CML diagnosis Pregnancy diagnosis Trimester of pregnancy Treatment before pregnancy Treatment during pregnancy 1 18 Sep/1993 Oct/1993 First None HU 2 30 Dec/1996 Jan/1997 Third None Leukapheresis 3 18 Dec/1993 Nov/1995 First IFN stopped IFN 4 21 Sep/1995 Sep/1995 Second None HU 5 21 Jul/1994 Aug/1994 Second HU stopped HU 6 27 Jan/1979 Jan/1979 Second None Busulphan - 2 months 7 18 Dec/1995 Oct/1996 Second HU HU