ACUTE MYELOID LEUKEMIA IN PREGNANCY: DIFFICULT JOURNEY FROM DIAGNOSIS TO DELIVERY AND TREATMENT
Obstetrics and Gynaecology, Tata Main Hospital, Jamshedpur, IND
*Vina Kumari, Obstetrics and Gynaecology, Tata Main Hospital, Jamshedpur, IND.
Peripheral smear showed mostly Monoblasts (red arrow), promonocytes (green arrow) and few myeloblasts (blue arrow) under the oil immersion object 100 X, Leishman stain.
Monoblasts are large cells with abundant cytoplasm, moderately to intensely basophilic, scattered fine azurophilic granules, round nuclei with lacy chromatin and one or more large nucleoli.
Promonocytes have moderate cytoplasm, less basophilic, granulated with occasional large azurophilic granules. Vacuoles are more irregular. Nuclei are delicately folded.
Myeloblasts have large nuclei, fine chromatin, 3-4 prominent nucleoli and few Auer rods in the cytoplasm.
In view of suspected Acute Myeloid Leukemia, she was advised Bone marrow aspiration, biopsy and immunophenotyping, flow cytometry and translocation (15:17) study by oncologist.
The obstetrical examination was normal. All cardiotocographies were reactive. She was started on IV antibiotics, Inj Ceftriaxone 1 gm IV BD and steroids, Inj Betamethasone was given for fetal lung maturity. In view of malignancy with pregnancy, the case was discussed in tumor board on 10/9/19 and a decision for delivery followed by chemotherapy was taken.
She was induced with one dose of intracervical dinoprostone gel following which she went into labour and delivered live baby 2.8 kg weight with good apgar. The baby was shifted to nursery in view of premature delivery and mother was planned to transfer to medical oncology department for Induction chemotherapy.
Repeat investigations three days after delivery, haemoglobin decreased to 7 g/dl, TLC increased to 3,81,000 cells per cu mm with neutrophils 2, lymphocytes 5 and myelocytes 5. The abnormal blast cells had increased to 88% and platelets decreased to 21000 per cu mm (TABLE 1). Serum creatinine also increased to 1.43 mg/dl and e-GFR decreased to 54 ml/min/1.73 m2, indicating compromised renal function. The peripheral picture showed mostly agranuloblasts with moderate to scanty grey blue vacuolated cytoplasmic nuclei showing convolutions and 1-3 nucleoli occasional myelocytes, metamyelocytes seen, findings in favour of Acute myeloid leukemia (M4/M5). On myeloperoxidase staining, only 40 % took up the stain indicating AML-M4 lineage. She was transfused with one packed cell and one single donor platelet, following which her condition improved. She was transferred to medical oncology ward where she received chemotherapy and had immediate remission of the disease.
Table 1: Sequential Investigation Reports during hospital stay
- Nolan, N. Czuzoj-Shulman, H. Abenhaim: Obstetrical and newborn outcomes among women with acute leukemias in pregnancy: a population-based study. The Journal of Maternal-Fetal & Neonatal Medicine. 2019, 10.1080/14767058.2019.1579188
- Ali S, Jones GL, Culligan DJ, et al.: Guidelines for the diagnosis and management of acute myeloid leukaemia in pregnancy. British Journal of Haematology. 2015, 170(4):487-95. 1111/bjh.13554
- Greenlund L.J, Letendre L , Tefferi A: Acute leukemia during pregnancy: a single institutional experience with 17 cases. Leukemia and lymphoma. 2001, 41(5-6):571-7. 3109/10428190109060347
- Garofalo S, Degennaro VA,Salvi S, et al.: Perinatal outcome in pregnant women with cancer: are there any effects of chemotherapy?. European Journal Cancer Care (England) . 2017 NOV, 6:26. 1111/ecc.12564
- Yuka Y, Kuniko, Kentaro N, et al.: Successful delivery after chemotherapy for acute myeloid leukemia diagnosed in the second trimester. Rinsho Ketsueki . 2020, 61(3):228-233. 11406/rinketsu.61.228
- Fracchiolla NS, Sciumè M, Dambrosi F, et al.: Acute myeloid leukemia and pregnancy: clinical experience from a single center and a review of the literature. BMC Cancer . 2017 jun, 17(1):442. 1186/s12885-017-3436-9
- Farhadfar N, Cerquozzi S, Hessenauer MR, et al.: Acute leukemia in pregnancy: a single institution experience with 23 patients. Leuk Lymphoma.. 2017 may, 58(5):1052-1060. 1080/10428194.2016.1222379
- Horowitz NA, Henig I, Henig O, et al.: Acute myeloid leukemia during pregnancy: a systematic review and meta-analysis. Epub . 2017, jul:13. 1080/10428194.2017.1347651
- Alrajhi AM, Alhazzani SA, Alajaji NM, et al.: The use of 5-azacytidine in pregnant patient with Acute Myeloid Leukemia (AML): a case report. BMC Pregnancy Childbirth . 2019, 19:394 . 1186/s12884-019-2522-1
- Patel SJ, Ajebo G, Kota V, Guddati AK: Analysis of outcomes in hospitalized pregnant patients with acute myeloid leukemia. Am J Blood. 2020, 10(4):68-75.
- McGregor AK, Das-Gupta E. : Acute myeloid leukaemia in pregnancy. Br J Haematol. 2015 aug, 4:441-2. 1111/bjh.13550