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CASE HISTORY

Case History

image A 28-year-old woman was referred to the Reproductive Medicine clinic having recently married. She had a past medical history of acute lymphoblastic leukaemia (ALL) diagnosed at age 10, for which she received an allogeneic bone marrow transplant (BMT) following conditioning with chemotherapy (vincristine, doxorubicin and cyclophosphamide) and total body irradiation (TBI, 14 Gy). She remained under annual review having experienced multiple late effects of treatment. These included:anthracycline-induced cardiac toxicity, with a left ventricular ejection fraction (LVEF) of 22% at the end of treatment that gradually improved; transient renal toxicity (post-treatment glomerular filtration rate (GFR) 41 ml/min) on a background of urinary reflux; and benign multinodular goitre requiring thyroidectomy and thyroxine replacement.

Since menarche her menstrual periods were infrequent, currently occurring every 2–3 months. Hormone replacement therapy (HRT) had been discussed but not started. She had an unplanned pregnancy aged 20 but this ended in miscarriage 10 weeks’ gestation. Blood sampling during menstruation showed follicle-stimulating hormone (FSH) 21.7 IU/l (normal range <15 IU/l) and thyroid stimulating hormone (TSH) 2.3 mIU/l (normal range 0.3–4.2 mIU/l). Pre-pregnancy medical review showed LVEF 55% and normal renal function. She conceived naturally and was referred for antenatal care.

At 27 weeks she attended her local maternity unit with urinary frequency and a sensation of pressure in the vagina. Examination showed a widely dilated cervix with intact membranes. She was given steroids for fetal lung maturation and nifedipine to suppress labour whilst being transferred to a tertiary neonatal unit. She remained on bedrest until contractions started at 28 weeks and she delivered rapidly. The baby required intensive care. He was discharged at 12 weeks of age and remains under follow-up.

Two years later she conceived again. Antenatal booking investigations showed TSH 6.3 mIU/l, normal renal function and echocardiography. Cervical cerclage was performed at 13 weeks’ gestation. Subsequent serial ultrasounds showed the cervix remained closed and fetal growth was normal. At the 28-week check-up, a random blood sugar was raised, and glucose tolerance test revealed gestational diabetes which was initially controlled by diet. From 32 weeks she developed hypertension requiring treatment with labetalol, and insulin was commenced. As the blood pressure and blood sugar level remained poorly controlled, labour was induced at 36 weeks. She delivered a baby girl weighing 2.4 kg who did well after initial hypoglycaemia.

What is the effect of childhood bone marrow transplantation on fertility in women?

What is the effect of childhood bone marrow transplantation on fertility in men?

What are the common late effects of bone marrow transplantation in childhood?

What pre-pregnancy reviews are advisable for women following bone marrow transplantation?

What is the effect of hypothyroidism on pregnancy outcome?

What are the indications for cervical cerclage?

What is the effect of childhood bone marrow transplantation on fertility in women?

In data collected from seven European centres, fertility impairment was suspected in 83% female patients that had received BMT during childhood and ...

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