Outcomes of Pregnant Women with Acute Leukemia Treated for Life-Threatening Complications

Background: Acute leukemia (AL) during pregnancy is a rare event. The incidence of AL in pregnancy has been reported as one in 100 000 [1]. The serious complications may be caused in these women as by pregnancy as by AL and chemotherapy.

Aim: To evaluate the outcomes of pregnant women with AL admitted in ICU due to life-threatening complications before delivery.

Patients (Pts) and Methods: 20 pregnant women with AL admitted in the intensive care unit (ICU) due to the life-threatening complications were included in retrospective study (1996-2016). The reasons for ICU admission, chemotherapy, delivery features and outcomes of mothers and children were assessed.

Results: 14 pts had acute myeloid leukemia (AML), 2 two of them with acute promyelocytic leukemia, 6 pts had acute lymphoblastic leukemia (ALL), age 18-40 yrs., median 30 yrs. Gestation age on ICU admission was 14-36 week, median 32 week. In 19 women AL was manifested during pregnancy, one woman had relapse of AL. 15 pts received induction chemotherapy before ICU admission (7+3, AIDA ALL-2009). 12 pts were severe neutropenic (WBC <0.5*109/l). The reasons for ICU admission were hypoxemic acute respiratory failure (ARF) (13 pts), acute renal failure (4 pts), sepsis (6 pts). ARF developed as result of pneumonia (10), pulmonary edema (2), ATRA syndrome (1). Lung ultrasound was used in pts with ARF to avoid radiation exposure. Bronchoalveolar lavage was done in 6 pts. The most common pathogen causing pneumonia was Pneumocystis jirovecii (4 pts), all of them were treated with trimethoprim/sulfamethoxazole. One woman had cytomegalovirus infection. 2 pts were noninvasive ventilated and 2 patients were mechanically ventilated. 4 pts received noradrenaline. Hemodialysis was required in 1 pregnant woman. All women had anemia (Hb levels from 65 to 114 g/l, median 85 g/l) and thrombocytopenia (from 10*109/l to 140*109/l, median 65*109/l).

1 woman with pneumocystic pneumonia had miscarriage and died 3 days after due to ARF. One woman died due to ARF on the 18-20 weeks of gestation age. Fast improvement was achieved in 3 women and they were discharged from ICU before delivery. Remained 15 women required urgent cesarean section and they delivered in ICU. In total, only 1 woman had vaginal birth, 17 pts required cesarean section. Cesarean sections were performed under general anesthesia in 13 pts and spinal anesthesia in 3 pts. Blood loss was from 200 to 1500 ml, median 803 ml. 16 children were born alive (APGAR scores 6-8), 1 child died 11 days after delivery due to ARF, 1 child was born with Down's syndrome and heart malformation. After delivery all women were discharged from ICU. In all pts the chemotherapy of AL was continued after delivery. The median overall survival of pts with acute leukemia who required ICU admission during pregnancy was 13.9 months.

Conclusion: In the most pregnant pts life-threatening complication were associated with neutropenia. The frequent complication was ARF due to pneumonia, especially caused Pneumocystis jirovecii. Despite life-threatening complications, potentially adverse effect on the fetus of antibiotic therapy and chemotherapy the majority of pregnant women delivered the healthy children.

Reference.

1.Hurley TJ, McKinnell JV, Irani MS. Hematologic malignancies in pregnancy. Obstet Gynecol Clin North Am. 2005; 32: 595-614.