with rituximab are given (Cohen, 2011; Rizack, 2009). In one follow-up of 55 individuals at 6 to 29 years after exposure to chemotherapy in utero during maternal lymphoma treatment, no congenital, neurological, or psychological abnormalities were noted (Aviles, 2001).
Burkitt lymphoma is an aggressive B-cell tumor associ ated with Epstein-Barr virus infection. Prognosis is poor, and treatment is given with multiagent chemotherapy. In a review of 19 women whose pregnancies were complicated by this lymphoma, 17 died within a year of diagnosis (Barnes, 1998).
In general, these malignancies arise either from lymphoid tissues-lymphoblastic or lymphocytic leukemias, or from bone marrow-myeloid leukemias. hey can be acute or chronic. Although adult leukemias are more prevalent after age 40, they still are among the most common malignancies of young women (see Fig. 63-1). Leukemia was diagnosed in 1 in 40,000 pregnancies reported to the California Cancer Registry (Smith, 2003). In a review of 72 pregnancies complicated by leukemia from 1975 until 1988, 44 had acute myelogenous leukemia; 20 had acute lymphocytic leukemia; and eight had one of the chronic leukemias (Caligiuri, 1989).
Acute leukemias almost always cause marked peripheral blood count abnormalities, and often the white blood cell count is elevated with readily recognizable circulating blast cells. The diagnosis is made from bone marrow biopsy.
With current multiagent chemotherapy, remission during pregnancy is common, compared with an almost 100-percent mortality rate before 1970. Pregnancy termination does not further improve the prognosis, however, abortion is a consideration in early pregnancy to avoid potential chemotherapy teratogenesis. One example of the latter is treatment of acute promyelocytic leukemia with all-trans-retinoic acid, also known as tretinoin (Carradice, 2002; Sanz, 2015). This potent teratogen causes retinoic acid syndrome (Chap. 12, p. 245). In another example, acute myeloid leukemia is treated with tyrosine kinase inhibitors, another teratogen group (Palani, 2015). In other cases, pregnancy termination before viability may simpliY management of an acutely ill woman.
Other than these caveats, treatment of gravidas with leukemia is similar to that for nonpregnant women. Acute myeloid leukemia is treated without delay (Ali, 2015). After induction chemotherapy, postremission maintenance therapy is mandatory to prevent a relapse, which is then usually treated with stem-cell transplantation. If allogeneic stem-cell transplantation is indicated, early delivery is considered. With some chronic leukemias, it may be possible to delay therapy until after delivery (Fey, 2008). As with lymphoma, infection and hemorrhage are signiicant complications that should be anticipated in women with active disease.
Most descriptions of leukemia treatment in pregnancy are single cases or small series (Routledge, 2016; Sanz, 2015). In an earlier review of 58 cases, 75 percent were diagnosed after the irst trimester (Reynoso, 1987). Half were acute myelogenous leukemia, which had a remission rate of 75 percent with chemotherapy. Only 40 percent of these pregnancies resulted in liveborn neonates (Caligiuri, 1989).