Treatment of Acute Promyelocytic Leukemia During Pregnancy

Abstract

Management of the pregnant patient with acute promyelocytic leukemia (APL) is a challenge. Immediate treatment of APL is critical, as it is an oncologic emergency, with a high risk of morbidity and mortality associated with disseminated intravascular coagulation. However, administration of chemotherapy and differentiating agents in pregnancy is controversial because of potential teratogenic effects. In addition, complications associated with APL, including retinoic acid syndrome, add to the complexity of management. To better understand how to manage this complex patient care situation, we searched the PubMed database (January 1972-May 2008) for English-language articles about maternal and fetal outcomes resulting from APL treatment during pregnancy. A total of 42 cases from 35 articles were identified: 12 first-trimester, 21 second-trimester, and 9 third-trimester cases. The most commonly administered agents were all-trans-retinoic acid (ATRA), anthracyclines, and antimetabolites. Complete remission was reported in 35 (83%) of 42 patients. Administration of ATRA or chemotherapy in the first trimester was associated with an increased risk of fetal malformations and spontaneous abortion, whereas administration in the second and third trimesters was associated with relatively favorable fetal outcomes. The overall treatment of the pregnant patient with APL should include a discussion about pregnancy termination, especially if APL is diagnosed in the first trimester. If the pregnancy is to continue, then the appropriate chemotherapy regimen needs to be determined. Frequent fetal monitoring, along with aggressive management of potential APL-related complications, is necessary to allow for optimal maternal and fetal outcomes.

How I treat leukemia during pregnancy

“…Standard management in addition to blood and coagulation support for disseminated intravascular coagulation, includes ATRA and the anthracycline idarubicin, but both of these drugs are problematic in pregnancy. 28 ATRA remains pivotal to APL treatment, but if given between 3 and 5 weeks of gestation is associated with a high incidence of fetal malformation, in particular skeletal defects and abnormalities of the neural tube, thymus, heart, and kidneys ( Table 1). The European Leukaemia Net recommends avoidance of ATRA in the first trimester, and women should be counseled to consider termination.…”

Acute Promyelocytic Leukemia in a Pregnant

“…Therefore, treatment of APL during pregnancy is not easy. ATRA is not recommended at the first trimester of pregnancy for the proper development of the fetus, but treatment during second or third trimester are supposedly safe [4][5][6]. Additionally, chemotherapy is reasonably safe in the last period of pregnancy [6].…”

Acute myeloid leukemia in the pregnant patient

“…Combined with chemotherapy, ATRA results in an excellent long-term outcome in APL patients. However, ATRA is associated with substantial toxic effects when used during the first trimester of gestation, including neurological and cardiovascular malformations (56).…”