Successful Completion of Pregnancy in a Patient With Chronic Myeloid Leukemia Without Active Intervention: A Case Report and Review of the Literature

doi:10.3816/CLM.2009.n.064

Clinical Lymphoma and Myeloma

Volume 9, Issue 4, August 2009, Pages 324-327

https://doi.org/10.3816/CLM.2009.n.064 Get rights and content

Abstract

The management of patients with chronic myeloid leukemia (CML) during pregnancy is a matter of continued debate. We present a 21-year-old woman in whom CML was diagnosed during early pregnancy. Because the patient was asymptomatic and desired to carry the pregnancy to term while minimizing fetal exposure to medication, she was observed with no therapy for the duration of her pregnancy. The white blood cell count showed a slow downward trend throughout her pregnancy. She delivered a healthy baby and breast fed for a time before initiating therapy for CML. We reviewed the published case reports of women who had a pregnancy occur in the setting of treatment with imatinib. Given the adverse effects of fetal exposure to imatinib as treatment for the mother with CML, close observation might be an option for selected patients who are diagnosed with CML while pregnant and who have minimal clinical manifestations of CML.

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Cited by (39)

SOHO State of the Art Updates and Next Questions: Chronic Myeloid Leukemia and Pregnancy: “Per Aspera Ad Astra”
2024, Clinical Lymphoma, Myeloma and Leukemia
Chronic myeloid leukemia (CML) has evolved from an invariably fatal disease to a chronic disorder that can be treated with targeted drugs and allows survival expectations approaching age-matched controls. Thus, pregnancy and conception in CML should not be precluded anymore; however, to ensure the well-being of both the mother and the developing fetus careful planning and management are required. Tyrosine Kinase Inhibitors (TKIs) are not genotoxic or carcinogenic but can pose a risk to the developing fetus, due to their teratogenic potential. The risk depends on the TKI and the stage of fetal development during exposure. Teratogenic risk is high in the first trimester of pregnancy when the baby's organs and structures are forming (5-12 weeks). If a female patient is on therapy it is advisable to stop therapy at the first positive pregnancy test (3-5 weeks) to maximize the length of treatment-free, and ideally to not treat until delivery. If needed, the medication plan during pregnancy may be adjusted. Interferons can be used at any time, imatinib and nilotinib have a reduced placental crossing and could be carefully used after 16 weeks, whereas dasatinib crosses the placenta and can induce problems throughout the whole gestation. Management of pregnancy in CML is complex. This manuscript is an update of the state of the art allowing healthcare providers to be informed of the different situations that can occur and their governance.
CML in pregnancy: A case report using leukapheresis and literature review
2015, Transfusion and Apheresis Science
Chronic myelogenous leukemia (CML) complicating pregnancy is uncommon. Literature search demonstrates only a few case reports and some case series but large studies are lacking due to its uncommon presentation. Management of these patients is particularly challenging due to limited available options as several chemotherapy drugs could potentially lead to adverse outcomes and fetal malformations. Leukapheresis has been used in these situations; however paucity of data exists regarding the outcome and complications associated with the procedure. Using leukapheresis alone for extended period to manage CML during pregnancy is also rare. Here we report a case of CML complicating pregnancy which was successfully managed utilizing leukapheresis, followed by a review of literature addressing this controversial issue.
Outcome of pregnancy in chronic myeloid leukaemia patients treated with tyrosine kinase inhibitors: Short report from a single centre
2015, Leukemia Research
Citation Excerpt :
Overall in 12 newborns (9.6%) foetal abnormalities were identified; 8 live births, 1 stillbirth and 3 terminations. Cole and colleagues reported the largest review of the English language literature on women who became pregnant while taking TKI treatment [27]. They identified a total of 217 reported pregnancy events and of these, 171 carried their pregnancy to term, 24 had spontaneous abortions, but in 62 cases the outcome of pregnancy was unknown.
The aim of this work was to report on the outcome of pregnancy in patients with chronic myeloid leukaemia who were on tyrosine kinase inhibitor treatment.
We report the result of 22 pregnancies in 14 patients (9 female and 5 male) who conceived or their partner conceived while being on tyrosine kinase inhibitors for their CML.
All pregnancies except one were uneventful. 25 newborns were born and except in one case where small atrial septal defect was diagnosed, all infants were healthy and showed normal development after birth.
This small series does indicate that parents can most likely expect an uneventful outcome to a pregnancy despite exposure of either partner to TKIs. There is no consensus or guideline regarding the best practice in case of pregnancy. More reports of similar nature would certainly be beneficial to practitioners and patients alike. As such it is still recommended to practice effective contraception during the period of TKI treatment.
How I treat leukemia during pregnancy
2014, Blood
Citation Excerpt :
A number of distinctive congenital abnormalities have been described after exposure to imatinib in early pregnancy, including skeletal malformations (premature closure of skull sutures, craniosynostosis, absent hemivertebrae, shoulder anomaly, and scoliosis), renal (duplex kidney, renal agenesis), respiratory (hypoplastic lungs), and gastrointestinal (exomphalos, omphalocele) abnormalities (Table 466,70TTTTTTTTTTTTTTTTTTTTTTTT-79).70 TTT-72 In particular, the incidence of exomphalos in these cases is roughly 100-fold greater than expected and a cause for significant concern. In animal studies, imatinib was found to be teratogenic in mice but not in rabbits and these abnormalities are postulated to be as a result of PDGFRA inhibition.80
Leukemia in pregnancy remains a challenging therapeutic prospect. The prevalence is low at ∼1 in 10 000 pregnancies, and as a result data are limited to small retrospective series and case reports, rendering evidence-based recommendations for management strategies difficult. The management of the leukemias in pregnancy requires close collaboration with obstetric and neonatology colleagues as both the maternal and fetal outcomes must be taken into consideration. The decision to introduce or delay chemotherapy must be balanced against the impact on maternal and fetal survival and morbidity. Invariably, acute leukemia diagnosed in the first trimester necessitates intensive chemotherapy that is likely to induce fetal malformations. As delaying treatment in this situation is usually inappropriate, counseling with regard to termination of pregnancy is often essential. For chronic disease and acute leukemia diagnosed after the second trimester, therapeutic termination of the pregnancy is not inevitable and often, standard management approaches similar to those in nongravid patients can be used. Here, the management of the acute and chronic leukemias will be addressed.
Pregnancies in patients with chronic myeloid leukemia treated with tyrosine kinase inhibitor
2013, Leukemia Research
Citation Excerpt :
The patient received imatinib one week after successful delivery. There have been several reports of successful treatment of CML during pregnancy with leukapheresis, as it allows the patients to avoid the undesirable fetal exposure to drugs with potential teratogenic effects and has been suggested to be proper options [18,19]. In some instances, for those pregnant patients with a more stable chronic phase, an approach of no intervention could be considered with very close monitoring of the patients and the baby.
We presented our experience in chronic myeloid leukemia (CML) patients who conceived children and/or became pregnant while receiving tyrosine kinase inhibitor (TKI). Among 7 male patients, 7 pregnancies resulted in the birth of 7 healthy babies. Among 18 female patients, 8 ended in elective abortion; 3 had spontaneous abortion, and 7 carried to term, resulting in the birth of 8 healthy babies. All children have normal growth and development. All patients remain in TKI therapy and in good response. It is suggested that female patients are advised to practice adequate contraception. No special precautions apply for male patients receiving TKI.
Cancer Chemotherapy and Pregnancy
2013, Journal of Obstetrics and Gynaecology Canada

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Case ReportSuccessful Completion of Pregnancy in a Patient With Chronic Myeloid Leukemia Without Active Intervention: A Case Report and Review of the Literature

Abstract

Leuk Res

Ann Oncol

Semin Hematol

Blood

Am J Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

Successful management of a chronic myeloid leukemia with leukopheresis during a twin pregnancy

Neth J Med

Two successful pregnancies in a chronic myeloid leukemia patient treated with imatinib

Haematologica

Pregnancy among patients with chronic myeloid leukemia treated with imatinib

J Clin Oncol

Pregnancies in patients with CML in the era of imatinib

Int J Hematol

Successful outcome of pregnancy in a patient with CML exposed to imatinib during the first trimester

Leuk Lymphoma

Case Report
Successful Completion of Pregnancy in a Patient With Chronic Myeloid Leukemia Without Active Intervention: A Case Report and Review of the Literature