Acute myeloid leukemia and pregnancy: clinical experience from a single center and a review of the literature

Abstract

Background: Acute myeloid leukemia (AML) accounts for more than two thirds of leukemia during pregnancy and has an incidence of 1 in 75,000 to 100,000. Its clinical management remains a challenging therapeutic task both for patient and medical team, given to the therapy-attributable risks for mother and fetus and the connected counseling regarding pregnancy continuation.

Methods: We provided a review of updated literature and a comprehensive description of five maternal/fetal outcomes of AML cases diagnosed concomitantly to pregnancy and treated at our Institution from 2006 to 2012.

Results: Median age at AML diagnosis was 32 years (31-39). One diagnosis was performed in first trimester and the patient asked for therapeutic abortion before starting chemotherapy. Three cases were diagnosed in second/third trimester; in one case leukemia was diagnosed concomitantly with intrauterine fetal death, while the remaining two patients continued pregnancy and delivered a healthy baby by cesarean section. In only one of these two cases chemotherapy was performed during pregnancy (at 24 + 5 weeks) and consisted of a combination of daunorubicine and cytarabine. Therapy was well tolerated and daily fetus monitoring was performed. After completion of 30 weeks of gestation a cesarean section was carried out; the newborn had an Apgar score of 5/1'-7/5'-9/10', oxygen therapy was temporarily given and peripheral counts displayed transient mild leukopenia. One patient had diagnosis of myelodysplastic syndrome rapidly progressed to AML after delivery. Four out of the 5 described women are currently alive and disease-free. Three children were born and long-term follow-up has shown normal growth and development.

Conclusions: The treatment of AML occurring during pregnancy is challenging and therapeutic decisions should be taken individually for each patient. Consideration must be given both to the immediate health of mother and fetus and to long-term infant health. Our series confirmed the literature data: fetal toxicity of cytostatic therapy clusters during the first trimester; while chemotherapy can be administered safely during second/third trimester and combination of daunorubicin and cytarabine is recommended for induction.

Keywords: Acute myeloid leukemia; Chemotherapy; Pregnancy.

Fig. 1

a Clinical case 4, acute myeloid leukemia cells limited to intervillous maternal space, which is indicated by the asterisk. Hematoxylin-eosin staining. The area pointed out by the arrow is magnified in Fig. 1(B). b Myeloblasts show mild size variation, have pale to slightly basophilic agranular cytoplasm and uniform large nuclei with condensed chromatin. Blast cells are pointed out by the arrow

Fig. 2

Clinical case 4, immunohistochemical staining for myeloperoxidase highlights myeloblasts in the intervillous maternal space, which is pointed out by the asterisk