Early Treatment of Acute Leukemia in Pregnancy Linked to Promising Outcomes

From a study that analyzed the therapeutic dilemma of treating acute leukemia (AL) during pregnancy and the delicate balance of improving maternal and fetal outcomes, investigators determined that favorable outcomes on both fronts are likely among patients with acute promyelocytic leukemia (APL), also known as AML-M3, who are treated early.

APL is a highly curable but potentially life-threatening subtype of acute myeloid leukemia (AML) evidenced by abnormal white blood cells in the bone marrow due to a genetic mutation.¹

This recent study was published in Annals of Medicine.²

Also considered a rare blood cancer, AL can be an especially devastating diagnosis when it coincides with pregnancy, the study authors noted. The estimated incidence during pregnancy is between 1 in 75,000 and 1 in 100,000,^3,4 making it an uncommon occurrence that is difficult to study, they added. The 2 conditions also have overlapping symptoms that include fatigue, nausea, and dizziness, so a diagnosis of leukemia is often delayed. Managing simultaneous cases of pregnancy and leukemia, therefore, requires a delicate balance between the urgency of starting aggressive antileukemia treatment and the need to protect the developing fetus from toxic therapies.

This retrospective study focused on 23 pregnant women—16 cases of AML and 7 cases of acute lymphoblastic leukemia (ALL)—diagnosed at Xiangya Hospital in China between May 2012 and March 2022. Their median age was 32 years (range, 19-42), and the median gestation at diagnosis was 23 weeks (range, 3-41 weeks + 1 day). There were 7 cases of anemia before AL diagnosis, and 20 of the 23 patients conceived naturally; the remaining 3 pregnancies were achieved via in vitro fertilization. Diagnosis timing was spread across the stages of pregnancy: 43.4% were diagnosed in the third trimester, 30.4% in the second trimester, and 26.1% in the first trimester. Overall survival was measured from diagnosis to death from any cause or through January 2024 for patients still alive.

Data from the patients’ electronic medical records enabled tracking of variables such as gestational age at diagnosis, leukemia subtype, treatment regimens, and the ultimate outcomes for the mothers and their babies. The researchers also performed a meta-analysis of 17 clinical studies involving AL and pregnancy to see if their findings aligned with broader global trends, specifically analyzing a subset of Chinese studies to compare treatment strategies, such as starting chemotherapy immediately vs waiting until after delivery or an abortion.

Key Findings on Response Rates and Treatment Timing

The overall response rate for these patients was 77.3%, which the authors noted is similar to the response rates seen in the general population of nonpregnant patients who have leukemia, making it an encouraging finding. There were distinct management patterns based on when the mother was diagnosed:

• Most patients diagnosed early in pregnancy tended to receive chemotherapy only after an abortion or intrauterine fetal death
• Every patient diagnosed in the third trimester chose to postpone antileukemia therapy until after delivery

Importantly, the researchers found that the median time from diagnosis to treatment was 22 days (range, 7-40), indicating that “a short delay in initiating antileukemia treatment is not associated with a negative impact on prognosis.”

Because AML-M3 is considered a hematological emergency, they found that using all-trans retinoic acid (ATRA)–based regimens was relatively safe and effective for patients in their second or third trimesters, provided that arsenic trioxide was avoided, as it is known to be highly toxic to the fetus.

Of the 9 live-born infants, 6 were born premature and 3 were delivered at full term, with higher birth weights (median, 2350 vs 2000 g) and later gestational ages (34 vs 27 + 4 weeks) seen among those not exposed to chemotherapy while in the womb. Despite these differences, the long-term outlook for the children was positive. At a median follow-up of 55 months (range, 28-134), all 9 infants were alive and healthy, showing no signs of cancer, blood diseases, or intellectual disabilities.

Real-World Implications

The study underscores that managing AL during pregnancy is not a “one-size-fits-all” scenario and that there is great need for intense collaboration between hematologists and obstetricians to tailor treatment based on a mother’s health and her pregnancy-related wishes. For patients diagnosed after the 30th week of pregnancy, the findings suggest that deferring chemotherapy until after delivery is a safe and viable strategy and that for patients with AML-M3, early intervention with ATRA can lead to favorable outcomes for mother and child.

Ultimately, this research suggests that maternal survival and healthy fetal development are achievable goals with modern supportive care and careful timing as well as provides a roadmap for clinicians facing these rare but critical cases.

Potential limitations on the investigators’ findings are their lack of experience treating chemotherapy-exposed fetuses and combining patients with ALL and AML into 1 cohort instead of comparing outcomes between the 2 leukemia types. Focusing only on assessing treatment of AL during pregnancy could also limit generalizability.

References

1. Acute promyelocytic leukemia. Cleveland Clinic. Updated April 2, 2024. Accessed March 10, 2026. https://my.clevelandclinic.org/health/diseases/acute-promyelocytic-leukemia
2. Liw W, Guo J, Gai D, et al. Acute leukemia during pregnancy: a single center experience with 23 cases, 2012-2022 and literature review. Ann Med. 2026;58(1):2626141. doi:10.1080/07853890.2026.2626141
3. Ali S, Jones GL, Culligan DJ, et al. Guidelines for the diagnosis and management of acute myeloid leukaemia in pregnancy. Br J Haematol. 2015;170(4):487-495. doi:10.1111/bjh.13554
4. Brenner B, Avivi I, Lishner M. Haematological cancers in pregnancy. Lancet. 2012;379(9815):580-587. doi:10.1016/S0140-6736(11)61348-2