Haematological malignancies in pregnant women are rare, with an incidence of 2 in 10,000 pregnancies. Nonetheless, lymphomas are now the fourth most common malignancy in pregnancy. In the UK, this increase in prevalence is associated with increased maternal age, whereas in the developing world it is associated with AIDS-related non-Hodgkin’s lymphoma. Successful pregnancy has been described with chemotherapy for both acute and chronic leukaemia and lymphoma.
Increasing numbers of patients are surviving childhood or adult treatment of haematological malignancies. However, such treatment can leave both physical and psychological problems associated with chemotherapeutic treatment.
Problems and special considerations
Treatment of haematological malignancies often involves intense periods of chemotherapy or radiotherapy followed by maintenance doses. The most aggressive forms of therapy result in permanent ablation of bone marrow. Bone marrow rescue is achieved by transplantation of stored autologous bone marrow or donated allogeneic bone marrow. Patients may require repeated lumbar punctures to test for disease and to administer chemotherapeutic agents (e.g. methotrexate).
The limiting factor in administration of most chemotherapeutic agents is short- and long-term toxicity. Short-term problems include malaise, nausea and vomiting, anorexia and acute organ impairment, especially of the liver and kidneys. Toxicity may also arise from antimicrobial therapy (e.g. gentamicin and vancomycin). Bone marrow depression may result in anaemia, neutropenia with increased risk of infection and coagulopathy. Long-term toxicity may include neurotoxicity, neuropathies (e.g. vincristine) and arachnoiditis (e.g. methotrexate). Cardiomyopathy may occur as a dose-dependent result of anthra- cycline antibiotics such as daunorubicin. Pulmonary toxicity and fibrosis may follow busulfan and bleomycin administration. Although sterility often occurs following high- dose chemotherapy, many survivors do conceive spontaneously or following infertility treatments. Central and peripheral venous access may be a persisting problem.
The long-term effects of chemotherapy on children exposed in utero is unknown. Although there are concerns regarding neurodevelopment, childhood malignancy and fertility, the current data suggest that chemotherapy exposure in utero does not have significant impact.
The psychological effects of a cancer diagnosis in a young person followed by prolonged periods of therapy and isolation may include flashbacks, phobias or features of a post-traumatic stress syndrome. Frequently, these psychological aspects influence management far more than physical aspects.
Patients with Hodgkin’s lymphoma or who have had a stem cell transplant require irradiated blood, so additional time is required to ensure its availability.
Management options
All patients who have or have had haematological malignancies require a detailed assessment by a multidisciplinary antenatal team. Wherever possible, the treatment records should be obtained, preferably with a haematological summary. The patient may find it distressing to recall details of her treatment or of unpleasant experiences such as general anaesthesia or lumbar puncture, and this may induce unexpected irrational behaviour. A careful sensitive approach is required.
Commonly performed laboratory investigations include renal and liver function tests and a full blood count. Assessment of cardiorespiratory status may require studies such as chest radiography, echocardiography or pulmonary function tests.
The spectrum of such patients varies from some that can be treated as normal to those with significant hepatic, renal and cardiopulmonary disease. In the last group, regional analgesia and anaesthesia are usually recommended, depending on the pattern of disease. Concerns over the introduction of circulating blast cells into the cerebrospinal fluid by a traumatic dural puncture (either intentional or accidental) and subsequent central nervous system involvement may contraindicate the use of regional anaesthesia in some patients. Consultation with the haematologist and oncologist is advised if a regional technique is being considered.
Key points
• Organ impairment may arise from the haematological malignancy itself or from its treatment.
• Regional anaesthesia may not be recommended in some patients.
• Survivors of leukaemia and lymphoma need support and sensitive, carefully planned care.
Further reading
Amit O, Barzilai M, Avivi I. Management of hematologic malignancies: special considerations in pregnant women. Drugs 2015; 75: 1725-38.
Elterman KG, Meserve JR, Wadleigh M, Farber MK, Tsen LC. Management of labor analgesia in a patient with acute myeloid leukemia. A A Case Rep 2014; 3: 104-6.
Lishner M, Avivi I, Apperley JF, et al Hematologic malignancies in pregnancy: management guidelines from an international consensus meeting. J Clin Oncol 2016; 34: 501-8.
Owsiak JN, Bullough AS. Chronic myeloid leukemia in pregnancy: an absolute contraindication to neuraxial anesthesia? Int J Obstet Anesth 2016; 25: 85-8.