The occurrence of acute leukemia during pregnancy is rare and acute myeloblastic leukemia complicates less than one of 75,000 pregnancies; 1 however, successful management of both remains a major therapeutic challenge. There has been much concern about the short-term and long-term ill effects of chemotherapeutic agents used in pregnant patients on the fetus. Retrospective studies have failed to confirm adverse effects on the offspring of patients treated with cytotoxic agents during the second and third trimesters of pregnancy. [2][3][4][5][6][7] We report a case of twin pregnancy associated with acute myeloblastic leukemia with successful obstetric and hematological outcome. We also report lack of chromosomal abnormalities attributable to in vitro chemotherapeutic exposure in the newborns.
Case ReportIn October 1991G, a 25-year-old multigravida presented with progressive pallor, generalized weakness, and amenorrhea. There was no history of bleeding, fever, or weight loss. Examination revealed pallor, no mucocutaneous bleeding, gum hypertrophy or bone tenderness, no hepatosplenomegaly and a uterine fundal height of 24 weeks' gestation. Investigations revealed Hb 61 g/L, platelets 242x10 9 /L, WBC 0.8x10 9 /L with peripheral blood showing prolymphocytes 9%, monocytes 1%, lymphocytes 81%, and 9% blasts. Bone marrow examination revealed infiltration by 74% myeloblasts and monoblasts and some promonocytes cytochemically. The majority of the blasts were Sudan black B positive, while nonspecific esterase was positive in 25% cells, periodic-acid-Schiff s stain was weak, diffusely positive in some blasts, and a diagnosis of acute myeloblastic leukemia (FAB AML M4) was established. Cytogenetic studies revealed normal karyotype. Serum chemistry and coagulation profile were normal. Ultrasonography confirmed pregnancy. She was treated with combination chemotherapy consisting of daunorubicin 45 mg/m 2 intravenously on days 1, 3, and 5; cytosine arabinoside 100 mg/m 2 IV infusion over three hours on days 1 to 7; and 6-thioguanine 100 mg/m 2 p.o. on days 1 to 7. Therapy was attended by severe myelosuppression requiring multiple packed red cell and platelet transfusions and a febrile episode which responded to amikacin, piperacillin, and ceftazidime. She achieved complete hematological recovery on day 27 and complete remission was documented by bone marrow examination. On day 29, she was administered the second course of combination chemotherapy consisting of the same drugs as used for the remission induction and this was attended by severe myelosuppression and a febrile neutropenic episode that responded to appropriate therapy. She achieved complete hematological recovery and repeat sonography showed a 32 week pregnancy and fetal normalcy. Further chemotherapy was deferred. At 38 weeks' gestation, she delivered twins by vaginal route, a female weighing 2.3 kg and a male weighing 2.2 kg, with no physical abnormalities detected. She received two additional courses of intensified chemotherapy consisting of daunorubicin 45 mg/m 2 ...