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CASE HISTORY

Case History

image A 29-year-old woman presented 6 weeks post-partum seeking fertility preservation (FP) because of a diagnosis of myelodysplastic syndrome (subtype: refractory anaemia with excess blasts (RAEB) type 2). She had no other medical or surgical history.

While pregnant with her first baby, the patient was noted to be anaemic, requiring monthly blood transfusions. The diagnosis of RAEB was established after 32 weeks. No plan for early delivery was made as the patient remained stable. However, she had spontaneous rupture of amniotic membranes at 34 weeks and labour was induced, as standard obstetric management, because of the risk of infection. This resulted in an uneventful vaginal delivery. She breastfed for 2 weeks. She was reviewed in the post-partum period and the multidisciplinary team (MDT) recommended chemotherapy. At 6 weeks post-partum, she was referred for fertility preservation.

At her fertility assessment, she had not yet had a menstrual period, and her ovarian reserve markers showed an antral follicle count (AFC) 11 and anti-müllerian hormone (AMH) level of 3.3 pmol/l. After discussing the case with MDT, it was felt that a cycle of controlled ovarian stimulation (COS) could be attempted as long as her condition remained stable. Stimulation with 300 IU of follicle stimulating hormone (FSH) was commenced. However, by day 8 of stimulation, her blood count started deteriorating and stimulation was abandoned. One week later, she was admitted to the hospital with signs of sepsis accompanied by vulval and right leg oedema. She was found to have non-occlusive thrombus in the inferior vena cava extending into the right external iliac vein. In the course of the following week, it was confirmed that her disease had evolved into acute myelocytic leukaemia.

What are the challenges of diagnosing cancer in pregnancy?

What are the challenges of fertility preservation (FP) in the early post-partum period:

  1. Are traditional markers of ovarian reserve robust enough post-partum?

  2. How efficient is controlled ovarian hyperstimulation (COS) in the post-partum period?

  3. Are there any additional risks of FP in the postpartum period?

What are the challenges of FP for patients with myelodysplastic syndromes (MDS)?

What are the challenges of diagnosing cancer in pregnancy?

Cancers in pregnancy are a rare event with an estimated occurrence of 1 in 1000 pregnancies per annum. The most common types of cancer in this group of women are melanoma, breast cancer, cervical cancer, lymphoma, and leukaemia.1 Physiological changes in pregnancy may delay the diagnosis of some types of cancer. Common cancer symptoms such as fatigue, shortness of breath or weight change are also common in pregnancy. Skin pigmentation and skin lesions may become more or less pronounced. Plasma volume expansion and increased demand for iron often lead to anaemia. Thrombocytopenia is also common and may be associated with pre-eclampsia. Changes to the ectocervix render cervical smears ineffective in diagnosing cervical in-situ malignancies, and colposcopy should be the first line diagnostic tool for suspected cervical cancer. Glandular ...

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