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Management of Acute Promyelocytic Leukemia during Pregnancy
Abstract Number: F-59
Abstract Type: Case Report/Case Series
Acute promyelocytic leukemia (APL) is a variant of acute myeloid leukemia with only 600-800 cases diagnosed annually in the United States. APL is considered a medical emergency due to the extremely high risk of bleeding and disseminated intravascular coagulation (DIC). It has a high cure rate with the mainstay of treatment being all-trans-retinoic-acid (ATRA) and arsenic trioxide (ATO). Both drugs, while effective in treating APL, can lead to differentiation syndrome and a systemic inflammatory response with mortality rate as high as 30%. We present the management of a pregnant patient diagnosed with APL in the third trimester and her eventual positive outcome.
A 37 year old G8P7 at 31 weeks gestation presented to her obstetrician with complaints of fatigue and shortness of breath. Laboratory evaluation revealed severe pancytopenia, with a hemoglobin of 3.8 and platelets of 8. She was transferred to UNC where a bone marrow biopsy was consistent with APL. She was admitted to the MICU for monitoring given her high risk of acute deterioration, and dependence on blood and platelet transfusions to keep her at the recommended goals set by hematology. Her treatment with ATRA was complicated by differentiation syndrome based on findings of tachypnea and pulmonary edema on chest x-ray. Intravenous steroids were administered with resolution of her symptoms. Induction of labor was performed at 33 weeks gestation with subsequent spontaneous vaginal delivery. Her hospital course was complicated by postpartum hemorrhage requiring D&C and Bakri balloon placement under general anesthesia. She stabilized and was discharged to the oncology service on PPD 2 to continue her treatment.
Acute leukemia is rare in pregnancy, but the incidence of these complex cases may continue to rise as average maternal age increases. Due to the risk of differentiation syndrome from ATRA treatment, our patient was managed in the medical ICU until she was stable enough to transfer to labor and delivery. This case presented an anesthetic challenge given the patient’s pancytopenia and relative contraindication to neuraxial anesthesia, as well as her potential for DIC and massive hemorrhage. During antepartum consultation, it was decided the patient would not be offered neuraxial anesthesia due to her transfusion dependent thrombocytopenia and risk of bleeding. This rare case of APL highlights the need for a multidisciplinary team approach to caring for complex patients. We believe this played a large role in the patient’s eventual positive outcome despite her course being complicated by differentiation syndrome and postpartum hemorrhage.
1.Giagounidis, A.A.N., et al. Acute promyelocytic leukemia and pregnancy. Eur J of haematology 64.4(2000):267-271.
2.Sanz, Miguel A., et al. Management of acute promyelocytic leukemia: recommendations from an expert panel on behalf of the European LeukemiaNet. Blood 113.9(2009):1875-1891.