Update on Leukemia in Pregnancy Khalid

Leukemia is a rare event in pregnancy. Acute leukemia represents 90% of leukemias occurring during pregnancy with AML accounting for two thirds of these cases. During the first trimester of pregnancy, standard chemotherapy has a teratogenicity rate of up to 20% depending on the specific agent employed. Exposure to cytotoxic agents during the second and third trimesters is not teratogenic but may predispose the fetus to growth retardation, premature delivery and bone marrow suppression. Additionally, the mother and the fetus are at risk of thromboembolism and sepsis. Only absolutely necessary radiologic work-up is justified during the first trimester of pregnancy as exposure to radiation during the first 2 weeks of pregnancy is usually lethal. Thereafter, radiation predisposes to congenital malformations, growth retardation and malignancy in the newborn. Although most infants exposed to multiagent chemotherapy seem to suffer no long-term detrimental consequences, studies have shown that: (1) cytotoxic chemotherapy can cross the placenta and cause teratogenicity, (2) there is a potential risk of adult cancer after intrauterine exposure to radiation, and (3) cytotoxic chemotherapy and radiotherapy increase genetic defects in germ cells. In the first trimester, the termination of pregnancy should seriously be considered if the disease is aggressive and if intensive chemotherapy is needed. In the second and third trimesters, standard chemotherapy can safely be administered without resorting to pregnancy termination. The choice of specific regimens depends upon several factors that include: the gestational age, the clinical status of the patient, the specific type of leukemia and the anticipated toxicity of the cytotoxic agents employed. The decision is often difficult and confounded by several concerns, but the management of each pregnant patient with leukemia has to be individualized and should have a multidisciplinary approach. Vaginal delivery is preferable while caesarean section is reserved for certain obstetric complications. It is preferable to time delivery between 32 and 36 weeks of gestation to ensure optimal © 2015 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. fetal maturation and it is recommended to avoid maternal bone marrow suppression prior to delivery. The management of chronic leukemia in pregnancy is generally easier than that of acute leukemia. However, certain precautions should be taken as some targeted therapies need to be avoided and they may need to be replaced by alternative therapies that are less effective in controlling chronic leukemia. Pregnancy in patients with chronic myeloid leukemia on tyrosine kinase inhibitors requires proper planning as it is essential to have optimal control of the disease for 2 to 3 years prior to having pregnancy in order to avoid acceleration of the disease during pregnancy. Leukemia diagnosed during pregnancy can be considered a poor clinical prognostic factor owing to the less than average long-term disease-free survival due to high relapse rates and high incidence of refractoriness to chemotherapy. Countries should have registries for mothers and children exposed to chemotherapy and radiotherapy and it is essential to have guidelines on the management of various types of leukemia during pregnancy.