Inr J Gynecol Obsret, 1992, 38: 49-53 International Federation of Gynecology and Obstetrics
49
Letters to the Editor Successful pregnancy in a patient with chronic myeloid leukemia following therapy with cytotoxic drugs To the Editor
January 9th, 1992
A 28-year-old female, a known chronic myeloid leukemia patient, presented at the University, Hospital in 1986 at 28 weeks gestation with a 6-month history of abdominal pain and emaciation. She had defaulted from treatment with myleran ,7 months previously. On examination she was pale, cachectic and showed evidence of hepatic and splenic enlargement. The symphysiofundal height measured 22 cm suggesting intrauterine growth retardation: the hematology results are summarized in Table 1. The leucocyte alkaline phosphatase score of marrow preparation was low. The patient was placed on myleran, paracetamol and diazepam. At 30 weeks gestation, premature
contractions commenced. .These were controlled with bed rest, paracetamol and salbutamol. At 35 weeks gestation, her hemoglobin level dropped to 7.5 g/dl, and 2 units of sedimented red cells were transfused. At 36 weeks, the patient went into spontaneous labor and delivered a live male infant with birthweight 1.95 kg and Apgar score of 617. The immediate postpartum period was uneventful, and the patient was discharged on the seventh day. The baby, however, was discharged 4 weeks later weighting 2.3 kg. At the postnatal visit, the patient’s condition was stable and the baby was thriving well. Transfer to the medical clinic was arranged for further management. In general, pregnancy has no specific effect on [I]. However, because of the leukemia debilitating effect of leukemia on the mother, its
Table 1. Hematological profile during therapy.
PCV WBC NEUT EOS BASO LYMPH MONO
On presentation
One week after admission
During labor
One week after birth
25 131 800 50 2 10 4
23 182 500 52 1 3 0 3
26 137 ooo 45 2 2 8 4
27 163 000 51 3 1 7
4 10 10 10
6 8 32 11
5
12 26 8
4 18 22 8
3
2
2
Blasts Promyels Metamyels Bands Nucleated red cells (“/)
-
Keywords: Live birth; Chemotherapy;
5
Leukemia. Inr J Gynecol Obstet 38
50
Letters to the Editor
management in pregnancy requires good obstetric care as well as specific treatment of the condition. In the case of chronic myeloid leukemia, chemotherapy could be deferred until delivery, because a delay in starting treatment is unlikely to have a serious effect on the clinical course [4]. In this patient, it was necessary to initiate therapy when the condition relapsed during pregnancy. Cytotoxic drug treatment in the first trimester may lead to increased incidence of fetal wastage and congenital malformations, whereas this risk is much less if therapy is started in the second or third trimester [ 21. The eventual delivery of a normal baby by this patient may relate to the fact that chemotherapy was started late in the third trimester. However, it is possible that cytotoxic drug therapy contributed to the premature delivery. Our patient was successfully managed with cytotoxic drugs. This confirms the view of some
authors [3,4] that chemotherapy should be used in the management of cases of chronic myeloid leukemia with the aim of successful outcome for both mother and infant. B.C. Ozumba G.O. Obi
Department of Obstetrics and Gynaecology University of Nigeria Teaching Hospital Enugu, Nigeria
References I
2
3 4
Ask-Upmark: Leukemia in pregnancy. Acta Med Stand I70: 635, 1961. Lilleyman JS, Hill AS, Anderton KS: Consequences of acute myelogenous leukemia in early pregnancy. Cancer 40: 1300, 1971. Moloney WC: Management of leukemia in pregnancy. Ann NY Acad Sci 114: 857, 1964. Dora P, Slatter L, Armentrout S: Successful pregnancy during chemotherapy for acute leukemia. Cancer 47: 845, 1981.
Prerupture of unscarred uterus masked by an epidural analgesia
To the Editor
January 9th, 1992
The use of epidural analgesia during labor may delay or mask the diagnosis of spontaneous uterine rupture, thereby increasing the risk to the mother and newborn [l]. The most common etiologies of rupture of an unscarred uterus during labor are oxytocin stimulation, cephalopelvic disproportion, grand multiparity and abruptio placenta 121. The type of rupture is usually described as complete or incomplete, depending on whether the laceration communicates directly with the peritoneal cavity. A women aged 34 years, at her second pregnancy, came to the delivery room 2 h after spontaneous rupture of membranes during the 41st week of her gestation. Her previous pregnancy had been terminated by a voluntary abortion. The cervix was 80% effaced, and the head was not engaged. She had good uterine contractions. She received 75 mg of pethidine and 25 mg of proKeywords: Unscarred uterus; Prerupture; Epidural analgesia. Int J Gynecol Obstet 38
methazine (phenergan). Seven hours later the cervix was completely effaced and dilated 4 cm. The head was engaged. The parturient asked for an epidural analgesia. After receiving 1000 ml of Ringer’s lactate solution, blood pressure was 1lo/80 mmHg. In the sitting position, a Tuohy epidural needle (Portex) was inserted at the LE3_4 interspace with the loss of resistance technique using air in the special syringe. A test dose of 2 ml of lidocaine 1% was injected through the needle. Then 9 ml of bupivacaine 0.25% and 1 ml of fentanyl 50 pg were injected through the needle. An epidural catheter was introduced into the epidural space uneventfully. Its epidural length was 3 cm. One milliliter of bupivacaine 0.25% was injected through the epidural catheter. Analgesia was obtained within 8 min with the level of T7_s. There was no hypotension, nausea, or vomiting. An oxytocin drip of 5 units within 500 ml of glucose 5%, at a rate of 30 ml/h, was started, with augmentation of 10 ml/h every 30 min. Two hours and forty minutes after the start of the epidural
49
Letters to the Editor Successful pregnancy in a patient with chronic myeloid leukemia following therapy with cytotoxic drugs To the Editor
January 9th, 1992
A 28-year-old female, a known chronic myeloid leukemia patient, presented at the University, Hospital in 1986 at 28 weeks gestation with a 6-month history of abdominal pain and emaciation. She had defaulted from treatment with myleran ,7 months previously. On examination she was pale, cachectic and showed evidence of hepatic and splenic enlargement. The symphysiofundal height measured 22 cm suggesting intrauterine growth retardation: the hematology results are summarized in Table 1. The leucocyte alkaline phosphatase score of marrow preparation was low. The patient was placed on myleran, paracetamol and diazepam. At 30 weeks gestation, premature
contractions commenced. .These were controlled with bed rest, paracetamol and salbutamol. At 35 weeks gestation, her hemoglobin level dropped to 7.5 g/dl, and 2 units of sedimented red cells were transfused. At 36 weeks, the patient went into spontaneous labor and delivered a live male infant with birthweight 1.95 kg and Apgar score of 617. The immediate postpartum period was uneventful, and the patient was discharged on the seventh day. The baby, however, was discharged 4 weeks later weighting 2.3 kg. At the postnatal visit, the patient’s condition was stable and the baby was thriving well. Transfer to the medical clinic was arranged for further management. In general, pregnancy has no specific effect on [I]. However, because of the leukemia debilitating effect of leukemia on the mother, its
Table 1. Hematological profile during therapy.
PCV WBC NEUT EOS BASO LYMPH MONO
On presentation
One week after admission
During labor
One week after birth
25 131 800 50 2 10 4
23 182 500 52 1 3 0 3
26 137 ooo 45 2 2 8 4
27 163 000 51 3 1 7
4 10 10 10
6 8 32 11
5
12 26 8
4 18 22 8
3
2
2
Blasts Promyels Metamyels Bands Nucleated red cells (“/)
-
Keywords: Live birth; Chemotherapy;
5
Leukemia. Inr J Gynecol Obstet 38
50
Letters to the Editor
management in pregnancy requires good obstetric care as well as specific treatment of the condition. In the case of chronic myeloid leukemia, chemotherapy could be deferred until delivery, because a delay in starting treatment is unlikely to have a serious effect on the clinical course [4]. In this patient, it was necessary to initiate therapy when the condition relapsed during pregnancy. Cytotoxic drug treatment in the first trimester may lead to increased incidence of fetal wastage and congenital malformations, whereas this risk is much less if therapy is started in the second or third trimester [ 21. The eventual delivery of a normal baby by this patient may relate to the fact that chemotherapy was started late in the third trimester. However, it is possible that cytotoxic drug therapy contributed to the premature delivery. Our patient was successfully managed with cytotoxic drugs. This confirms the view of some
authors [3,4] that chemotherapy should be used in the management of cases of chronic myeloid leukemia with the aim of successful outcome for both mother and infant. B.C. Ozumba G.O. Obi
Department of Obstetrics and Gynaecology University of Nigeria Teaching Hospital Enugu, Nigeria
References I
2
3 4
Ask-Upmark: Leukemia in pregnancy. Acta Med Stand I70: 635, 1961. Lilleyman JS, Hill AS, Anderton KS: Consequences of acute myelogenous leukemia in early pregnancy. Cancer 40: 1300, 1971. Moloney WC: Management of leukemia in pregnancy. Ann NY Acad Sci 114: 857, 1964. Dora P, Slatter L, Armentrout S: Successful pregnancy during chemotherapy for acute leukemia. Cancer 47: 845, 1981.
Prerupture of unscarred uterus masked by an epidural analgesia
To the Editor
January 9th, 1992
The use of epidural analgesia during labor may delay or mask the diagnosis of spontaneous uterine rupture, thereby increasing the risk to the mother and newborn [l]. The most common etiologies of rupture of an unscarred uterus during labor are oxytocin stimulation, cephalopelvic disproportion, grand multiparity and abruptio placenta 121. The type of rupture is usually described as complete or incomplete, depending on whether the laceration communicates directly with the peritoneal cavity. A women aged 34 years, at her second pregnancy, came to the delivery room 2 h after spontaneous rupture of membranes during the 41st week of her gestation. Her previous pregnancy had been terminated by a voluntary abortion. The cervix was 80% effaced, and the head was not engaged. She had good uterine contractions. She received 75 mg of pethidine and 25 mg of proKeywords: Unscarred uterus; Prerupture; Epidural analgesia. Int J Gynecol Obstet 38
methazine (phenergan). Seven hours later the cervix was completely effaced and dilated 4 cm. The head was engaged. The parturient asked for an epidural analgesia. After receiving 1000 ml of Ringer’s lactate solution, blood pressure was 1lo/80 mmHg. In the sitting position, a Tuohy epidural needle (Portex) was inserted at the LE3_4 interspace with the loss of resistance technique using air in the special syringe. A test dose of 2 ml of lidocaine 1% was injected through the needle. Then 9 ml of bupivacaine 0.25% and 1 ml of fentanyl 50 pg were injected through the needle. An epidural catheter was introduced into the epidural space uneventfully. Its epidural length was 3 cm. One milliliter of bupivacaine 0.25% was injected through the epidural catheter. Analgesia was obtained within 8 min with the level of T7_s. There was no hypotension, nausea, or vomiting. An oxytocin drip of 5 units within 500 ml of glucose 5%, at a rate of 30 ml/h, was started, with augmentation of 10 ml/h every 30 min. Two hours and forty minutes after the start of the epidural
