Pregnancy and blood diseases

Hemoblastosis

The term "hemoblastosis" combines numerous tumors formed from blood-forming cells and organs. These include leukemia (acute and chronic), lymphogranulomatosis, and non-Hodgkin's lymphomas.

Acute lymphoblastic leukemia and acute myeloblastic leukemia are hematopoietic tumors that are characterized by bone marrow infiltration by immature blast cells without a tendency to differentiate into blood cells.

Pregnant women are very rare. Sometimes pregnancy occurs in patients with acute lymphocytic leukemia, who became ill in childhood and who, thanks to treatment, achieved remission. Acute myeloid leukemia is mainly affected by adults, so this form of the disease is more common in pregnant women, although in general it is also a rare phenomenon. Sometimes leukemia first manifests during pregnancy.

The etiology is unknown. At the heart of the disease are gene mutations, probably caused by ionizing radiation, toxicants of a chemical nature, viruses or due to heredity.

Diagnosis is based on a cytomorphological study of blood smears and punctate bone marrow.

Pregnancy and childbirth usually aggravate the course of leukemia, can serve as a cause of relapse in patients with prolonged remission. Significant deterioration of the condition, often maternal death most often occur after childbirth. Leukemia adversely affects the course of pregnancy. The frequency of spontaneous abortions, premature births, cases of intrauterine growth retardation, and perinatal mortality has been significantly increased. Fetal death is usually associated with the death of the mother. In general, the pregnancy outcome forecast for the mother is unfavorable.

The tactics of managing pregnancy with acute leukemia are not definitively determined. In our opinion, pregnancy is subject to interruption both in early and late terms. Only in the case of detection of the disease after 28 weeks. Justification can be prolongation of pregnancy before the viability of the fetus. We consider the chemotherapy of the underlying disease during pregnancy unacceptable.

There is another point of view according to which chemotherapy should be prescribed during pregnancy, except for 1 trimester.

Interruption of pregnancy and childbirth should be carried out conservatively, with careful prevention of bleeding and purulent-inflammatory complications.

Chronic leukemias are bone marrow tumors with differentiation of mature blood cells.

Chronic myelogenous leukemia is characterized by an alternation of remissions and exacerbations in the form of blast crises. A specific marker of the disease is the so-called Philadelphia chromosome present in all leukemia cells.

Pregnancy is contraindicated: the frequency of arbitrary termination of pregnancy, premature birth and perinatal mortality is high.

Specific treatment with busulfan in pregnant women is contraindicated, therefore, if it is necessary to promptly appoint it, pregnancy should be interrupted. Expectant tactics and careful observation are possible only in the case of persistent remission of the disease, as well as in late pregnancy, when it comes to the viability of the fetus.

The method of delivery is determined by the condition of the spleen: patients with spenomegaly (the vast majority of cases) should perform a cesarean section, with small spleen sizes, delivery through natural birth can be possible.

In all cases of hemoblastosis, lactation is contraindicated.

Lymphogranulomatosis (Hodgkin's disease)

Lymphogranulomatosis (Hodgkin's disease) is an extraosternal hemoblastosis that affects the lymph nodes and lymphoid tissue of internal organs. It usually develops in people of reproductive age. Among pregnant women is much more common than leukemia.

Etiology and pathogenesis have not been fully determined. Granulomas are formed in the lymph nodes, which contain giant (up to 80 microns) diameter multinucleated Berezovsky-Sternberg cells and specific large single-nucleated Hodgkin cells. Violated immunity, mainly the cellular link.

The international classification of lymphogranulomatosis is based on the number and location of the affected lymph nodes, the presence of general clinical symptoms:

• I stage - lesion of one lymph node or one group of lymph nodes; 
• II stage - the defeat of more than one group of lymph nodes located on one side of the diaphragm;
• Stage III - lymph node involvement on either side of the diaphragm or supra-diaphragmatic lymph nodes and spleen;
• IV stage - involvement of lymph nodes of internal organs (liver, kidneys, lungs, etc.) and bone marrow.

In each stage, subgroup A is given (no common manifestations of the disease) or B (there is an increase in body temperature, night sweating, a decrease in body weight in half a year by 10% or more).

Diagnosis is based on the histological examination of biopsies of affected lymph nodes with the detection of pathognomonic Berezovsky-Sternberg cells.

Pregnancy has little effect on the course of lymphogranulomatosis, just as the latter has little effect on its course.

Given, however, the urgent need for early initiation of a specific treatment (radiation or chemotherapy), pregnancy is only permissible in the case of persistent remission (or even cure) of the disease. In the case of primary detection of lymphogranulomatosis or during its relapse, abortion is indicated both in the period of up to 12 weeks, and in later terms. If the disease is detected in the period after 22 weeks. Against a background of a satisfactory general condition of a woman, prolongation of pregnancy can be postponed, postponing the initiation of treatment for the postpartum period. Regardless of the stage and period (remission or relapse) of the disease, lactation should be discontinued.

The delivery is through natural birth canals.

Children of women with lymphogranulomatosis are born healthy and later develop normally.

Thrombocytopenia

Thrombocytopenia - a decrease in the number of platelets in the peripheral blood below 150 * 10 ⁹ / l due to the limitation of the production or enhancement of platelet destruction.

In the vast majority of cases, thrombocytopenia is an acquired and conditioned autoimmune process, the effect of certain drugs (thiazide diuretics, estrogens, heparin, trimethoprim / sulfamethoxazole, antineoplastic agents) or ethanol, massive blood transfusion, and artificial circulation. Approximately 3-5% of healthy women during pregnancy experience moderate thrombocytopenia (thrombocytopenia of pregnant women), which usually does not cause serious complications in the mother and fetus.

The greatest clinical significance is chronic idiopathic thrombocytopenic purpura - an autoimmune disease, which most often develops in women of reproductive age.

Prevalence in pregnant women is 0.01-0.02%.

The basis of etiology and pathogenesis is the production of antiplatelet antibodies in the body, which, when linked to platelets, contribute to their elimination from the blood and the destruction of the spleen by macrophages. Diagnosis is based on anamnesis (development of the disease before pregnancy), exclusion of other causes that may lead to the development of thrombocytopenia. Antiplatelet antibodies, as well as antibodies to cardiolipin, are often detected.

Pregnancy has little effect on the course of idiopathic thrombocytopenia, although cases of exacerbation of the disease during pregnancy are not uncommon. Most often, an exacerbation occurs in the second half of gestation. Life-threatening bleeding, as a rule, is not observed. It is often during pregnancy that a complete clinical-hematologic remission occurs.

Antiplatelet antibodies can penetrate the placenta and cause thrombocytopenia in the fetus. Nevertheless, there was no correlation between the number of platelets in the mother's blood, the level of antiplatelet antibodies, and the degree of thrombocytopenia in the fetus and the newborn. Perinatal mortality in idiopathic thrombocytopenia is significantly higher than general population, however its causes are not always associated with hemorrhagic complications.

Idiopathic thrombocytopenic purpura is not a contraindication to pregnancy, and its aggravation in no case requires the interruption of pregnancy or early delivery. On the contrary, the exacerbation of the disease should be considered as a contraindication to active interventions, including birth control.

Tactics of management of pregnant women consists in careful dynamic clinical and laboratory observation, treatment, waiting for the spontaneous onset of labor, the desire to conduct labor through the natural birth canal. In the absence of hemorrhagic syndrome (petechiae, bruises on the skin, bleeding from the nose or gums, etc.) and the number of platelets in the peripheral blood more than 50-10 ⁹ / l, special prenatal preparation is not performed.

Treatment. The presence of hemorrhagic manifestations or a decrease in the level of platelets less than 50 * 10 ⁹ / L (even with complete absence of hemorrhages) requires the appointment of corticosteroids.

Usually, prednisolone regos is prescribed in a dose of 50-60 mg / day. After increasing the number of platelets to 150 * 10 ⁹ / L, the dose of prednisolone is gradually reduced to maintenance (10-20 mg / day). Splenectomy during pregnancy is very rare and only in the case of ineffectiveness of glucocorticoid therapy. In life-threatening hemorrhage, platelet concentrate is administered. To prevent bleeding, aminocaproic acid, freshly frozen (antihemophilic) plasma, sodium ethazylate is used. Prophylactic administration of platelet concentrate is shown in rare cases when by the time of delivery it is not possible to achieve a significant increase in platelet count in the blood. The question is solved by the hematologist in each case individually.

Thrombocytopathy

Thrombocytopathy - a violation of hemostasis, due to the quality of inferiority or platelet dysfunction with a normal or slightly reduced their number. Features of thrombocytopathy are a stable violation of platelet properties, inconsistency of the severity of hemorrhagic syndrome, the number of platelets in the peripheral blood, a frequent combination with other hereditary defects.

Distinguish congenital (hereditary) and acquired thrombocytopathy. The first include disaggregation forms of pathology, a deficiency or a decrease in the availability of factor III (without a significant violation of platelet adhesion and aggregation), complex platelet function disorders in combination with other congenital anomalies. Acquired (symptomatic) thrombocytopathies are observed with hemoblastosis, B ₁₂ -deficiency anemia, uremia, DIC-syndrome and fibrinolysis activation, liver cirrhosis or chronic hepatitis, and the like.

Pregnancy, as a rule, proceeds favorably, but labor can be complicated by bleeding.

Diagnosis is based on the study of adhesion-aggregation properties of platelets, the release reaction of intra-platelet substances, the number and morphological features of platelets, the activity of thromboplastin.

Treatment is symptomatic. Apply aminocaproic acid, ATP, magnesium sulfate, riboxin. In case of life-threatening bleeding, the means of choice is platelet concentrate (to avoid isosensitization, the patient donor should be selected according to the HLA system). If the bleeding could not be stopped, resort to extirpation of the uterus.