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Key words: chronic myeloid leukemia; pregnancy; tyrosine kinase inhibitor; interferon
A27-year-old Australian-born woman named Mrs. B presented to her general practitioner in December 2010 with a three-month history of excessive tiredness. She has a supportive husband, and they have four children aged four months to five years old. Mrs. B was breastfeeding her youngest child and had initially attributed her fatigue to her busy home life. A blood test revealed an elevated white blood cell count (WBC) of 43.7 x 109/L (reference range: 4-11 x 109/L); hemoglobin and platelets were within normal range. Mrs. B was subsequently referred to a specialist hematology service.
Mrs. B had no significant past medical history. She denied a history of fevers, infections, night sweats, or unintentional weight loss. Her vital observations on examination were unremarkable. No palpable lymphadenopathy or hepatosplenomegaly were noted. A repeat complete blood count (CBC) and film assessment confirmed high WBC of 55.3 x 109/L with a marked left shift in the myeloid series in addition to basophilia and eosinophila, raising suspicion of chronic myeloid leukemia (CML). Mrs. B was told to wean her child from breastfeeding in preparation for treatment. A bone marrow biopsy confirmed a diagnosis of chronic phase CML with 100% cytogenetic evidence of the Philadelphia chromosome. She was prescribed imatinib 400 mg daily and was educated on the management of potential side effects and importance of adherence. During this time, Mrs. B discussed her desire to have more children. She was counseled about the potential teratogenic risk associated with treatment, the need to use adequate contraception, and the risk of blast phase transformation in poorly managed CML. Mrs. B was advised to attain at least a major molecular response (MMR) (BCRABL transcript < 0.1%) for two years before considering pregnancy.
Mrs. B attained hematologic remission (HR) with normalization of CBC within four weeks of starting imatinib. She initially experienced issues with fatigue and nausea. At three and six months after starting imatinib, Mrs. B was achieving an ideal molecular response with BCR-ABL transcripts of 2.9% and 0.12%, respectively.
In August 2011, Mrs. B admitted during clinic review that she had stopped imatinib therapy six weeks earlier with the goal of becoming pregnant. Her hematologist and nurse reiterated the potential loss of...