#Fetal Health Scan

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The expert sonographers of a 4D Baby Scan Clinic in Hitchin reveals the 5 effective natural ways you can boost your immune system during pregnancy.

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There are many benefits to pelvic scans at an Early Pregnancy Scan Clinic ofAylesbury.With the help of this blog, you will get to know the top 5 benefits of pelvic scans during pregnancy. So go through this blog to know in detail.

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You ought to know the Benefits of Eating Avocado at a Fetal Wellbeing Scan Clinic in Cardiff during Pregnancy.

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A healthy diet is crucial during pregnancy. Pregnant women should aim to eat a balanced diet with a variety of foods from all the food groups. This includes fruits, vegetables, whole grains, lean proteins, and healthy fats. It's also important to stay hydrated by drinking plenty of water throughout the day.

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Miscarriage is one of the most important issues in pregnant women. This blog by Fetal Well Being Scan Clinic of Reading will help you know how you can overcome the chances of miscarriage during pregnancy. So read this blog to know in detail.

[lilleluv]

What Is Viable/ Non-Viable Pregnancy?

Pregnancy is a beautiful phase in a woman’s life. However, not all pregnancies progress to a full-term healthy delivery. In some cases, a pregnancy may not develop normally or may cease to grow, leading to what is known as a non-viable pregnancy. In this article, we will explore what viable and non-viable pregnancies are, what causes them, and how they can be diagnosed and managed. What Is…

[covid-safer-hotties]

Also preserved in our archive

"Just a cold" that increases intercranial abnormalities

By Nikhil Prasad

Medical News: A groundbreaking study conducted at San Marco University Hospital in Catania, Sicily, Italy, has revealed new insights into the potential impacts of SARS-CoV-2 on newborns. Researchers from this hospital and the University of Ferrara carried out an ultrasonographic analysis on newborns exposed to the virus, highlighting a significant incidence of minor intracranial abnormalities compared to unexposed infants. The findings raise important questions about the long-term neurological implications for children born during the COVID-19 pandemic.

The Study at a Glance This Medical News report delves into the research conducted by Bruna Scalia, Marco Andrea Nicola Saporito, and their colleagues, investigating cranial ultrasonography (cUS) findings in infants born to mothers who tested positive for SARS-CoV-2 during pregnancy or at delivery. The team analyzed data from 278 newborns, evenly split between exposed and unexposed cohorts. The study adhered to stringent observational protocols to ensure the reliability of results.

Key Findings Among the 139 newborns exposed to SARS-CoV-2, 23% exhibited intracranial abnormalities on cUS, compared to 16.5% in the unexposed group. Minor abnormalities were most prevalent and included subependymal cysts (SEPCs), choroid plexus cysts (CPCs), frontal horn cysts (FHCs), and lenticulostriate vasculopathy (LV). Major abnormalities, such as cerebellar hemorrhages and arachnoid cysts, were rare but noteworthy.

Interestingly, infants exposed to SARS-CoV-2 during pregnancy had a higher rate of abnormalities (38.4%) than those exposed at birth (19.5%). The second trimester emerged as a particularly critical period, with the majority of abnormalities observed in this subgroup.

Why These Findings Matter The study's results are alarming for public health professionals and expectant mothers. While SARS-CoV-2's immediate risks to newborns have been considered minimal, this research suggests subtle yet significant neurological effects. These abnormalities, although classified as minor, may carry long-term implications for cognitive and behavioral development.

The link between maternal inflammation and fetal development is not new, but the cytokine storm induced by SARS-CoV-2 appears to heighten this risk. The researchers hypothesize that inflammatory markers like interleukin-6 could cross the placenta, affecting the fetal brain and potentially disrupting synaptogenesis.

Methodology Details All newborns in the study underwent cranial ultrasonography within their first week of life. The scans were conducted using standardized equipment by experienced neonatologists. The findings were categorized as normal, minor, or major abnormalities. To exclude confounding factors, the study excluded infants with other infections or genetic disorders.

Demographic factors, such as gestational age and birth weight, were comparable across both groups. However, premature birth and maternal complications, such as gestational diabetes and hypertension, were noted as potential contributors to the observed abnormalities.

Implications for Future Research The findings call for more extensive, longitudinal studies to understand the long-term effects of these abnormalities. Current evidence suggests a potential association between minor abnormalities like SEPCs and neuropsychiatric conditions such as autism and ADHD. Further investigation could clarify whether these cUS findings are precursors to such outcomes.

What Experts Are Saying The study's authors emphasize caution, noting that minor intracranial abnormalities do not necessarily predict adverse outcomes. However, they recommend routine cranial ultrasonography for newborns exposed to SARS-CoV-2 as a precautionary measure. "The cost-effectiveness and non-invasive nature of cUS make it a valuable tool in monitoring these infants," said lead researcher Bruna Scalia.

Limitations and Strengths of the Study One limitation of the study was its relatively small sample size, particularly for subgroups like prenatally exposed infants. Additionally, the lack of serological testing for unexposed mothers could have introduced undetected cases into the control group. However, the study's rigorous methodology and use of a well-matched control group lend credibility to its conclusions.

Study Conclusions The research underscores a statistically significant increase in minor intracranial abnormalities among SARS-CoV-2-exposed newborns. These findings are particularly pronounced in infants exposed during the second trimester of pregnancy. While the abnormalities observed in the study were predominantly minor, their potential impact on long-term neurological outcomes cannot be overlooked. The researchers advocate for the following:

-Routine cUS Screening: Cranial ultrasonography should be performed on all newborns exposed to SARS-CoV-2 to identify abnormalities early.

-Long-Term Follow-Up: Exposed infants should be enrolled in neurodevelopmental follow-up programs to monitor their progress and intervene if necessary.

-Expanded Research: Larger, multicenter studies are needed to confirm these findings and explore the mechanisms behind SARS-CoV-2's impact on fetal brain development.

By highlighting these abnormalities, the study adds a critical layer to our understanding of COVID-19's broader implications, particularly for future generations.

The study findings were published in the peer-reviewed Italian Journal of Pediatrics. link.springer.com/article/10.1186/s13052-024-01826-3

[hashimasims]

TW: Pregnancy Termination mentioned → continue at your own risk

Beginning|Previous|Next

Absalom: Is it too late to end the pregnancy Volkov?

Kristopher: Scans show she is in her second Trimester, possibly almost third, there’s no way to tell how her captivity affected fetal development without extensive tests she will have to sign off on. But at this time, without some underlying health reasons that would risk her carrying to term we can not terminate

Kanaloa: Why would we do that? She'd never forgive you! That is her child!

Absalom: And she was clearly Assaulted if she is pregnant now when she wasn't before she was taken. -to Volkov- there must be something that says it's allowed with these extenuating circumstances, no?

Kristopher: There is no evidence of that happening but if her pregnancy were the result of that then yes, but only if SHE were asking for the procedure. Her Mates can not make that decision for her, not even Human spouses are given that option.

Absalom: It's clearly a result of her captivity!

Kristopher: The Watcher changed the MCCC settings to make pregnancy last closer to their world. The scans that were done in the ER when you first brought her in estimated Conception to be around Winterfest but the newest scans done by the OBs on this floor are guessing closer to New Years. We're thinking that one of the children is larger than the other and that is how there was the disconnect between departments. Her due date could be anywhere from The week before Harvesfest to the day after but they will be here before winter begins.

[justinspoliticalcorner]

Jess Piper at The View from Rural Missouri Substack:

When I scanned the code, it took me straight to a Google drive. I was hesitant immediately. The first folder in the drive is titled, “Arkansas Abortion Amendment Myth vs. Fact” and that was pretty much a dead giveaway; the lady stopping folks headed to an event intent on signing the abortion petition was going to hit them with disinformation first.

Another folder in the Google drive was something called “Decline to Sign.” This graphic included bulleted points. Among them: *No licensing for healthcare professionals at abortion medical facilities. *No ultrasound required before an abortion to determine fetal age and location. *Would make it harder to combat sex trafficking and child abuse. *No health and safety standards imposed on abortion clinics. Wow. That was a lot of weird and incorrect information. I would think a doctor would know the location of a fetus, and forcing a person who has been sex trafficked into delivering a pregnancy is just about the most disgusting and cruel act I can imagine. The rest of the points are at least stretching the truth if not flat out lies. Was the woman standing in that parking lot just some solitary extremist trying to dissuade voters from signing a petition? Some woman who got a crazy idea, created a Google drive, printed up cardstock with a QR code, and decided to lie to folks on their way to sign a petition in a small town in Arkansas?

No. “Decline to Sign” is a coordinated movement and we saw it in Missouri as well. It is well-funded and not at all grassroots. They have signs, sites, and lawmakers who are bought and paid for to do their dirty work. I noticed “Decline to Sign” popping up on social media from Missouri GOP State Senators and Representatives. The messaging was exactly the same. Some Reps even started tweeting out videos of themselves, sitting on the same couch in front of the same bookcase, reading a script about “out of state” folks coming to Missouri to gather signatures and steal identities or allow abortions up to birth. It was creepy because it was so scripted and the deliveries were so automated. The politicians also had those dead eyes you need to straight up lie to someone. I’m not exaggerating when I tell you it is Orwellian. Nearly the exact same words were seeping from the dry mouths of several extremist Missouri lawmakers.

There were nearly a dozen who were recruited for the videos, but here are just three examples: Senator Mary Elizabeth Coleman, Representative Doug Richey and Representative Justin Sparks. Each one took their time to stare into the camera and lie about the abortion petition. The videos gave me chills and let me know we are up against a machine that wants to take away bodily autonomy from everyone, and keep us from fighting back with ballot measures to return bodily autonomy. The good news? Missourians had just over 90 days to gather 180,000 signatures to put abortion on the ballot. Friends, we collected 380,000 signatures! Read that again…we gathered over 200k more signatures than we needed to put the measure on the ballot in November. We still have obstacles to returning bodily autonomy to Missourians, though. The GOP is planning to take away one person, one vote and strip us of the ability to pass Constitutional amendments. They are planning to take away a simple majority vote to pass amendments. That will be a disaster for Missourians and I’ll write more on it in another post.

Jess Piper writes on her Substack the deceptive "decline to sign" movement touted by anti-abortion extremists.

[theivorybilledwoodpecker]

Tennessee��s politicians are passing cruel laws against something they know nothing about − medically essential abortions. I needed one, and it was traumatizing for me and my family that I had to leave Tennessee to get it. Tennesseans must be able to get the care they need at home. A lifelong Tennessean, I became a single mom at age 22, working three jobs to support my daughter while earning my degree. Adalie is 6 now and like me, she’s very social and a little stubborn. About the time she turned 3, I reconnected with a former high school boyfriend and we got married last year. Bryan is such a great stepfather and we both wanted to grow our family. We were ecstatic to learn we were pregnant last November. Each night, at bedtime, Adalie would lie next to me and sing "Twinkle Twinkle Little Star" while rubbing my belly. Early on, we learned we were having a girl. We named her Miley Rose, after the song “Flowers” by Miley Cyrus. At 19 weeks, I brought Adalie along with me to share in what I thought would be a routine anatomy scan. But after the scan, I saw a high-risk maternal fetal medicine specialist who explained that Miley’s kidneys, bladder and stomach had not formed as expected and were not functioning. Two of the four chambers of her heart were also not working. She had little-to-no amniotic fluid. She had stopped growing. There were no signs of lung development. She also had a rare brain condition. We were told she had no chance at life. It was definitive. The doctor suggested there were two options– either terminating the pregnancy, or continuing, knowing she would not survive. Because of Tennessee’s cruel ban on abortion, an essential medical procedure, I could not legally get an abortion in my home state. I would have to travel out of state, and my doctor told me that Tennessee law prevented her from offering me any resources in that effort. Our daughter died, but the risk to me was still great Although there was no way of knowing how much longer Miley Rose would survive inside my womb, the longer she was there, the more risk there was to my health and safety. I made the decision to have an abortion. Instead of being able to grieve for her and the future we dreamed of, I had to scramble and start calling clinics in the states that allowed second trimester abortions, book flights, find hotels and arrange transportation. And figure out how to pay for it all. Thankfully, I found a clinic in New York City that could get me in the following week. After I arrived at the clinic, I learned that Miley Rose’s heart was no longer beating. Completely broken, I had to call Bryan and tell him over the phone that our daughter was gone. But the risk to me was not over. The doctor told me that my body hadn’t recognized that she had died, and that there was about a 2-week window before I would become severely at risk of blood clots and infections, including sepsis. I can honor my daughter Miley Rose through my testimony Within an hour, I went into surgery alone. I sat in recovery alone. I grieved the loss of my daughter alone, in a city I’d never been to, around doctors I’d never met before, far from my family. I am so grateful for the caring professionals who treated me with such dignity, but I should never have had to leave home for humane health care–abortion care. I realized that sharing my experience publicly could be a powerful way to honor Miley Rose. That is why I’m joining the Center for Reproductive Rights’ case against Tennessee; it’s why I documented my heartbreaking experience on TikTok. It’s why I’m going to keep fighting these dangerous laws. The autonomy to make personal medical decisions about our lives and futures and health care must be returned to patients like me and our doctors.

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In this article, you will get to know about oligohydramnios, including their symptoms, causes, prevention, and much more. Read this article by the Fetal Well Being Scan Clinic ofAylesbury in detail to know all about it.

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If you are wondering how to lose your tummy fat after pregnancy delivery, then read this article by the Private Baby Scan Clinic of Cardiff to know in detail.

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This blog, written by the experts of a reliable Baby Scan Clinic in Milton Keynes is all about disclosing some maternity styling tips for would-be mommies.

[alterrune]

Albert: Somethings wrong, be careful, the hospitals layout is shifting!

(The walls and hallways of the hospitals begin to shift around, before a wall blocks off Alter, Violent, Laurence, and Morgana from Kyle, Henry, Ellie, and Teddie)

Albert: The layout has changed, there's stairwells on both of your sides, you'll have to use them to continue moving up the hospital. Again, be aware of traps and shadows, it's becoming much more dangerous here.

(Albert notices some of the signs and painting decorations on the walls after scanning the area)

Albert: These paintings, there all of Lily's memories, the bad ones unfortunately, this entire place are projections of Lily's fear for the worst outcomes because of her after all, so... you might come across more projections of her thoughts. The staircase requires you all solve a puzzle to access it... you might want to take a glace at Lily's memories when you have the chance. Watch over Laurence okay, some of these memories he likely wouldn't want to see,

O-Okay, I can help you. I'm pretty sure you have to go up the stairs with the paintings depicting something that actually happened to her. Lily always told me whenever something bad happened to her, and I remember what they are because I comforted her afterwards.

(We begin climbing up the stairwells. Laurence seems to be becoming less and less stable after each stairwell, but when we get to the last one, it REALLY breaks him...)

No.

No, no, no.

No, no, no, no, no, no!

NO, NO, NO, NO, NO, NO, NO!!!!

(...because it's a depiction of the exact moment Laurence shot Lily. However, Laurence suddenly sprints away and RUNS INTO THE WRONG STAIRWAY ON PURPOSE.)

NO, YOU SICK FUCKING BASTARD OF A SHADOW!!! I REFUSE TO LET THAT BE THE DAMNED ANSWER!!!

(We can't stop him. Luckily, what he did doesn't end up resetting our progress or get us kicked out of the dungeon.)

Guys, I'll get him back here. Stay here and let me handle things.

I'm POSITIVE, Teddie. Laurence needs help, and I'm gonna give it to him.

(I quickly run up and follow Laurence. A fuckload of shadows are surrounding him, as he lies on the floor, crying in fetal positi---wait a minute. Holy fucking shit, he's having a full-on mental breakdown. I have to stop this, and I know just how to do it.)

J-JUST FUCKING KILL ME ALREADY!!! FINISH THE F-FUCKING JOB!!! WHY ARE YOU T-TORMENTING ME BY L-LETTING ME LIVE?!?!

LAURENCE!!!

(Laurence suddenly looks up after I shouted his name, and sees me. I run over to come up close to him.)

K-Kyle...? What are you doing here? This is my punishment.

No it fucking ain't. Listen, Laurence. I know you have PTSD from that whole event. But I know how it feels to have a family member die. In fact, it happened to me twice.

My grandfather passed away due to "health complications" (the details are fuzzy on the specifics), and my step-grandfather passed away due to cancer. I miss both of them, but constantly hanging onto that memory isn't good for you. But at the same time, neither is just trying to just straight-up discard it, either. It'll always come back to you.

Do you know what I do with those memories? Turn them into ways to push myself forward. Instead of constantly grieving over them, I make sure whatever I do, I do it for them. And I'm damn well sure that I've made them proud of me.

And remember, you still have Lily. She's just known as Kynn Lee now, remember? You may be grieving over someone who "died" in your eyes, but she's been essentially reincarnated now. You don't have to grieve over someone who's still alive.

Now, how about you stop being a big ol' ding-dong-dumbass and help me kill these Shadows so we can get the fuck outta this death trap?

(Laurence stands up and gives me a genuine smile.)

You're right, Kyle. Whatever happened then isn't important right now. What matters is what we do right here and now. ORPHEUS!

Alright, now we're talking. MAGATSU-IZANAGI!

(Orpheus and Magatsu-Izanagi stand behind us as we prepare to use a skill that will ensure we get back to the others. That move is...)

MEGIDOLAON!!!

(...the Almighty skill, Megidolaon, of course! We quickly cast it at the same time, leaving no shadows left. It's two Megidolaons going off at the exact same time, do you really expect survivors?)

C'mon, Kyle. Let's head back to the others.

(We quickly head back through the same doorway. Everyone is relieved to see us back.)

Oh thank GOD, you two are alright! We were starting to get worried!

Yeah. What happened when you went the wrong way, anyways?

Turns out the wrong set of stairs had a metric fuckton of shadows behind it.

We managed to fight them off, though.

Actually, thanks to Kyle, I'm better than ever. Let's get the hell off of this never-ending staircase, everyone.

(Laurence then heads up, with everyone following suit. Teddie and Morgana stop me for a moment, however.)

Happy to be of assistance. He already heard that message once before, I just gave him a reminder. Regardless, let's get going.

(Teddie, Morgana, and I then leave out of the final stairwell, ending this never-ending staircase climb once and for all...as well as Laurence coming out of that whole experience feeling leagues better than he did before.)

[jcsmicasereports]

Acute Myeloid Leukemia In Pregnancy: Difficult Journey From Diagnosis To Delivery And Treatment by Vina Kumari in Journal of Clinical Case Reports Medical Images and Health Sciences

Abstract

The incidence of Acute Myeloid Leukemia in pregnancy is about 1 in 75,000 to 1 in 100,000. Owing to the therapy attributable risks to mother and fetus, the management of AML in pregnancy is very challenging, both for the parents and the medical fraternity. Furthermore, the diagnosis of leukemia in pregnancy is very difficult owing to vague presenting symptoms like fatigue and weakness which are confused with physiological changes during pregnancy.

Case Report: Primigravida, 33 weeks 6 days gestation age, with history of weakness and fatigue for 15 days and fever, cough and cold for 3 days was referred to our hospital with blood reports of raised total leucocyte count. The lab reports showed thrombocytopenia, anemia and leukocytosis with increased circulating blasts in the peripheral smear. As she was in her third trimester, plan of induction of labor and delivery followed by chemotherapy was taken. She delivered a live healthy baby. Post-delivery, she was advised chemotherapy. She had an immediate remission after the chemotherapy. The disease relapsed after 10 months and she succumbed to the disease due to unavailability of facilities during the COVID pandemic.

Conclusion: AML during pregnancy is rare. There is no fixed protocol for management of AML during pregnancy .The aim of management should be to take care of the initial concerns regarding fetal well-being according to gestation age and commence chemotherapy as soon as possible. This would give the best survival chances to the mother.

Keywords: Acute myeloid leukemia, pregnancy, chemotherapy.

Introduction

The association of leukemia and pregnancy is very rare, rather under-diagnosed and sparsely reported. The prevalence based on diagnosed and reported cases is one in 75,000 to 100,000 pregnancies. Most of the leukemias diagnosed in pregnancy are myeloblastic.

Acute myeloid leukemia (AML) is characterized by excessive proliferation of blast cells of myeloid lineage. This results in hematopoietic insufficiency like anemia and thrombocytopenia. The symptoms are related to complications of the pancytopenia, such as infections or hemorrhagic diathesis. The mentioned initial symptoms of leukemia in pregnancy are easily attributed to physiological changes related to the pregnancy and hence are either missed or diagnosed late. We report a case of Acute Myeloid Leukemia in a pregnant patient, its management and outcome.

Case Presentation

18-year-old primigravida presented at 33 weeks 6 days gestation. She was referred with history of weakness since 15 days and fever, cough, cold since 3 days associated with raised leucocyte count. She belonged to low socioeconomic status, was unbooked and had two antenatal visits during her pregnancy. She visited the facility when she had symptoms of gross weakness.

Her first trimester was uneventful. She was registered at a local hospital but was not compliant. Dating scan, trisomy screening and anomaly scan was not done.

On examination, her pulse rate was 88, blood pressure 100/60, respiratory rate 20 per minute, and temperature 99 degree Fahrenheit. She was pale but there was no jaundice, icterus or edema. She had angular stomatitis, and glossitis indicating malnutrition. Lymph nodes were not palpable.

On per abdomen examination, Uterus was relaxed, 33-34 weeks size and fetal heart 143/min. Ultrasound showed a single live fetus in cephalic presentation with effective fetal weight of 2.4 kg and liquor 12.7cm. Placenta was in upper posterior position. The fetus had overdistended urinary bladder with hydronephrosis of fetal kidneys suggestive of bladder outlet obstruction. Moderate hepatosplenomegaly was present. She was moderately anemic with hemoglobin of 8.3 gm/dl. The leucocyte count was very high 2,66,000/cu mm with neutrophils 4, lymphocytes 1, eosinophils 1 and basophils 1. The blood picture showed marked leucocytosis with blasts cells predominating 86% and 2 myelocytes and 1 metamyelocyte. The blast cells typically showed large nuclei, opened up chromatin, prominent nucleoli and cytoplasmic blebs. This picture raised the suspicion of Acute Myeloid Leukemia in pregnancy. Her platelet count was 96000/cu mm. LDH was raised 995 U/L signifying cell lysis. Liver enzymes were also borderline raised. Dengue serology was found negative. Her blood group was O negative. Serum Creatinine - 1.05 mg/dl and Serum uric acid - 10.9 mg/dl were also raised. The blood picture thus indicated towards normochromic normocytic anemia, thrombocytopenia and leukocytosis. On further examination of the peripheral blood smear, a leukoerythroblastic formula was noted with the presence of predominant blast population (86%).

Peripheral smear showed mostly Monoblasts (red arrow), promonocytes (green arrow) and few myeloblasts (blue arrow) under the oil immersion object 100 X, Leishman stain.

Monoblasts are large cells with abundant cytoplasm, moderately to intensely basophilic, scattered fine azurophilic granules, round nuclei with lacy chromatin and one or more large nucleoli.

Promonocytes have moderate cytoplasm, less basophilic, granulated with occasional large azurophilic granules. Vacuoles are more irregular. Nuclei are delicately folded.

Myeloblasts have large nuclei, fine chromatin, 3-4 prominent nucleoli and few Auer rods in the cytoplasm.

In view of suspected Acute Myeloid Leukemia, she was advised Bone marrow aspiration, biopsy and immunophenotyping, flow cytometry and translocation (15:17) study by oncologist.

The obstetrical examination was normal. All cardiotocographies were reactive. She was started on IV antibiotics, Inj Ceftriaxone 1 gm IV BD and steroids, Inj Betamethasone was given for fetal lung maturity. In view of malignancy with pregnancy, the case was discussed in tumor board on 10/9/19 and a decision for delivery followed by chemotherapy was taken.

She was induced with one dose of intracervical dinoprostone gel following which she went into labour and delivered live baby 2.8 kg weight with good apgar. The baby was shifted to nursery in view of premature delivery and mother was planned to transfer to medical oncology department for Induction chemotherapy.

Repeat investigations three days after delivery, haemoglobin decreased to 7 g/dl, TLC increased to 3,81,000 cells per cu mm with neutrophils 2, lymphocytes 5 and myelocytes 5. The abnormal blast cells had increased to 88% and platelets decreased to 21000 per cu mm (TABLE 1). Serum creatinine also increased to 1.43 mg/dl and e-GFR decreased to 54 ml/min/1.73 m2, indicating compromised renal function. The peripheral picture showed mostly agranuloblasts with moderate to scanty grey blue vacuolated cytoplasmic nuclei showing convolutions and 1-3 nucleoli occasional myelocytes, metamyelocytes seen, findings in favour of Acute myeloid leukemia (M4/M5). On myeloperoxidase staining, only 40 % took up the stain indicating AML-M4 lineage. She was transfused with one packed cell and one single donor platelet, following which her condition improved. She was transferred to medical oncology ward where she received chemotherapy and had immediate remission of the disease.

Discussion

The Incidence of Acute Myeloid Leukemia is 1 in 75,000 to 100,000 pregnancies with maximum 40% presenting in third trimester and 23% and 37% in first and second trimester respectively. In a population based study by Nolan et al [1], out of total acute leukaemia cases, two thirds are myeloblastic and one third lymphoblastic leukemia.

The rarity of disease during pregnancy, might also be due to very low reporting in view of confusing diagnosis. The symptoms of AML can easily be confused with symptoms of anaemia like malaise, easy fatigueability, low grade fever. Thrombocytopenia and anaemia are relatively common findings in pregnancy. Although, Neutropenia is rare and merits further investigation or close monitoring. But in the developing country like India, it is majorly missed. Thus, whenever there is presence of circulating blasts in a blood film, it suggests a diagnosis of haematological malignancy and is an indication for bone marrow biopsy. The other differential diagnosis that should be kept in mind are Thrombotic microangiopathy, HELLP syndrome and Cytopenias of deficiency or immune origin [2].

The tests to be done before bone marrow aspiration are Full blood count, blood film examination, Vitamin B12, folate and ferritin measurement, Coagulation screen, Renal and liver function tests. All these were done for our patient and further bone marrow aspiration was suggested with studies directed at Immunophenotypic, cytogenetic and molecular analysis for accurate subtyping and understanding of prognostic features.

Once diagnosed, a Multidisciplinary approach comprising of hematologists, obstetricians, anesthetists and neonatologists is the key to appropriate management. Consideration should be given to health of both mother and baby. The woman should be fully informed about the diagnosis, treatment of the disease and possible complications during pregnancy , clearly implying that any treatment delays might result in compromised maternal outcome without improving the outcome for the fetus [3].

The risks of Leukemia, disease per se, to pregnancy is miscarriage, foetal growth restriction, perinatal mortality, premature labour and Intrauterine fetal death [4].

Due to the high risk of the disease, there are different recommendations for management of AML in pregnancy in the three trimesters owing to the urgent need of chemotherapeutic agents and the adverse effects of the drugs involved .

If it is diagnosed in the first trimester, the patient should be counselled for elective abortion, medical/surgical and starting of chemotherapy. Between 13- 24 weeks, the Induction chemotherapy should be started while pregnancy is continued [5]. Preterm termination of pregnancy is indicated after fetal viability. Similar conclusions were derived by Nicola et al and Farhadfar in a single centre study of 5 and 23 case of AML diagnosed during pregnancy respectively [6,7].

Between 24 - 32 weeks, chemotherapy exposure to the fetus must be balanced against risks of prematurity following elective delivery at that stage of gestation (Grade 1C). At gestation age more than 32 weeks, the fetus should be delivered prior to Induction chemotherapy.

Chemotherapy with anthracycline based regimens are favored. According to a meta-analysis done by Natanel A Horowitz et al, anthracycline based regimens were associated with maximum remission but overall maternal survival was very low (30%)[8]. Even in our case, although the mother immediately had remission with chemotherapy. There was a recurrence after disease free 10 months and she succumbed to the disease during the COVID pandemic. Quinolones, tetracyclines and sulphonamides are better avoided in pregnancy(Grade 1B).

In one case report by Abdullah et al, a trial of 5- azacytidine has shown promising results [9]. The antifungal of choice in pregnancy is Amphotericin B or lipid derivatives (Grade 2C). If blood transfusion is needed, the blood should be screened for Cytomegalovirus (Grade 1B). Supportive therapy like a course of Corticosteroids given if delivery is between 24 and 35 weeks gestation (Grade 1A) [10]. Magnesium sulphate should be considered 24 h prior to delivery before 30 weeks gestation (Grade 1A).

Delivery should be planned for a time when the woman is at least 3 weeks post-chemotherapy to minimize risk of neonatal myelosuppresion (Grade 1C). Planned delivery is preferred, like Induction of labour (Grade 2C). Caesarean section is indicated only for obstetric indications. Epidural analgesia is better avoided.

The Dose of chemotherapy is calculated on their actual body weight with dose adjustments for weight gain during pregnancy owing to various pregnancy changes.

The Chemotherapy agents have a MW of 250-400 KDa and hence can cross the placenta resulting in detrimental teratogenic effects on developing fetus.Sunny J. Patel et al have done a comprehensive analysis on outcomes in hospitalized pregnant patients with acute myeloid leukemia and come to conclusion that a multidesciplinary, holistic approach leads to quick remission of the disease [11]

After delivery, histopathologic examination of placenta to rule out placental transfer to fetus is advisable. Cytologic examination should be performed in both maternal and umbilical cord blood and neonates should be clinically examined for palpable skin lesions, organomegaly or other masses. If the baby is found to be healthy, a follow up after every six months for two years is recommended. In each visit, physical examination, chest x-ray and liver function tests should be done.

Conclusion

Acute myeloid leukemia in pregnancy is a Rare diagnosis and even rarely reported. With the trend for delaying pregnancy into the later reproductive years, we expect to see more cases of cancer complicating pregnancy. Presently, there are no clear management guidelines to address timing and dosing of anthracycline/cytarabine based regimens especially in pregnancy. The potential drug toxicity to mother and fetus and transplant considerations in intermediate and highrisk patients during pregnancy has not been addressed.

What we also need today is a National registry for leukemia patients, treated in pregnancy. This will help us to answer many unanswered queries and improve maternal and fetal overall survival rates. Although we have few comprehensive studies, but further studies and references are needed. Finally, a Multidisciplinary team is needed to provide comprehensive care to patients.