Unusual Presentation of CML in Pregnancy

A 30 year old primigravida was admitted to our hospital with antepartum haemorrhage at 33 weeks of gestation. On examination she was anaemic and had a blood pressure of 160/100mmHg. Abdominal examination revealed massive splenomegaly and live intrauterine foetus with fundal height corresponding to 32 weeks with a tense and tender uterus classical of abruption and she was in active labour. Her peripheral smear revealed a haemoglobin of 4.5gm/dL with marked leukocytosis with 54% neutrophils, (6% blasts, 4% promyelocytes, 15% myelocytes, 10% metamyelocytes) and 8% basophils; a picture suggestive of chronic myelogenous leukaemia (CML). Her liver and renal function tests were normal. She had an INR of 2.94 at admission which was corrected with fresh frozen plasma transfusion. Her anaemic status was corrected with 2 units of packed cell transfusion. With oxytocin augmentation she delivered a live, preterm baby of 30 weeks maturity weighing 1.54 kg which was shifted to nursery for preterm care. Her postnatal period was complicated by the development of an infralevator hematoma which was drained. Her blood pressure in the post natal period was controlled with calcium channel blockers. She otherwise remained stable. Bone marrow aspiration and biopsy were carried out on the fifth post natal day. It showed a hypercellular marrow with florid myeloid hyperplasia. Myeloid to erythroid ratio was found to be 30:1. This picture was consistent with the diagnosis of CML. She was started on Imatinib and is being followed up in our hematology clinic.

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